Nurse’s Role in Influencing the Legislative Process Essay Paper.

Nurse’s Role in Influencing the Legislative Process Essay Paper.

In a brief paper (no more than 2 typed pages, 1 inch margins, 12 font Times New Roman or Courier New), answer the questions below. Write each question as a new topic area and then follow with a paragraph or two to answer the question. You may find it necessary to search for answers to the questions outside of the assigned reading. Be sure to use APA guidelines for writing style, spelling and grammar, and citation of sources.

Answer the following questions:

· What parts of the lawmaking process does a nurse have an opportunity to influence the final bill passage?

· List at least two ways that this influence can take place. In your opinion, would one way be preferable over the other?

· Reviewing the social determinants of health, select one to respond to this question: Nurse’s Role in Influencing the Legislative Process Essay Paper.

o What role can nurses play in promoting health status through policy changes directly affecting this social determinant?

Submission Details:

· Submit your response in a 2-page Microsoft Word document (500 words).

Access to Coverage
Access to Coverage Does Not Necessarily Mean Access to Care, Nor Does It Ensure a Healthy Population
“Frameworks for Action in Policy and Politics” chapter of our course textbook beautifully describes the crux of policy and political issues regarding access, coverage, delivery, and outcomes of health care in the United States. Your course textbook says it perfectly that “. . . access to coverage does not necessarily mean access to care, nor does it ensure a healthy population.”
In the United States, our health care system is philosophically built upon an assumption that if we build an excellent (and expensive) health care system delivered by the highest credentialed professionals, we will have the best outcomes. Our population will be the healthiest in the world, and our citizens will live the longest.
We know that that is not true. And, this chapter is replete with data to support that truth. And, why is that? We have not paid sufficient attention to what our authors write as the “upstream factors,” or the social determinants of health. Heiman and Artiga (2015) define the social determinants of health as “the structural determinants and conditions in which people are born, grow, live, work, and age" (p. 2). They include such factors as socioeconomic status, education, the physical environment, employment, and social support networks. Policies that address the social determinants of health are the ones that promote:
Safe environments
Adequate housing
Economically thriving communities with employment opportunities
Access to affordable and healthful foods
Models for addressing conflict, such as trauma-informed approaches
The social determinants of health are powerful predictors of an individual’s health and wellness. Poverty, lack of transportation, unsafe living environments, inability to find healthy food, lack of educational opportunities, and inability to find useful employment—all of these factors are associated with poor health outcomes. All the technologically advanced medical treatments cannot heal an individual who cannot find healthy food, lives on the street, and has no job or transportation to get to a place of employment.
Social Determinants of Health
Review each factor to know more.
Transportation Lack of Public Transportation Systems to Aid the Poor in Employment and Educational Opportunities and Obtaining Health Care
Federal, state, and local funding and building of mass transportation systems within cities

Food Food Deserts and Food Insecurity Contributing to Adoption of Poor Eating Habits, Obesity, and Malnutrition
State and local funding for farmers' markets and tax-break incentives for the building of supermarkets in economically disadvantaged areas in cities and in rural areas

Lack of Affordable Housing and Services for People with Mental Health Conditions and Substance Use Disorder
Federal, state, and local funding and policies for supportive housing and wrap-around services for homeless individuals and funding for addiction treatment services

Lack of Health-Care Services in Underserved Areas
Federal, state, and local support for federally qualified health centers, health professions educational payback grants for professionals who serve in underserved areas, and expansion of Medicaid for childless adults between nineteen and sixty-five years, making less than 133% of the federal poverty level
Federal, state, and local funding and building of mass transportation systems within cities

One cannot improve each of the social determinants of health absent consideration of the political aspects. We discussed political philosophies in our first lecture this week. Refer to Box 1-1 (Political Aspects of the Social Determinants of Health) from your course textbook for the list. Several keywords emerge in this list: inequities, poor and disadvantaged, evidence, and political will. In the previous week, we also looked at the policy process (Longest). We can use the policy process to determine how to go about addressing the social determinants of health and thus improve the health status of those who live in the zip codes that reflect poor health outcomes.
In the “Frameworks for Action in Policy and Politics” chapter, focus on the following sections: politics, policy analysis and analysts, interest groups and lobbyists, the media, science and research, and the use of power. The Heiman and Artiga reading further elucidates the social determinants of health. And, the Substance Abuse and Mental Health Services Administration (SAMHSA) brief describes an approach on trauma-informed care that creates a model for delivery of services for those with the poorest health indicators.
Heiman, H. J., & Artiga, S. (2015). Beyond health care: The role of social determinants in promoting health and health equity. Retrieved from

Health Policy Brief
Improving Care Transitions
Rachel Burton
An example of a well-written policy brief is presented here. It was developed by Health Affairs and the Robert Wood Johnson Foundation. Website resource: policybriefs/brief.php?brief_id=76.
Improving Care Transitions: Better Coordination of Patient Transfers among Care Sites and the Community Could Save Money and Improve the Quality of Care1
What's the Issue?
The term care transition describes a continuous process in which a patient's care shifts from being provided in one setting of care to another, such as from a hospital to a patient's home or to a skilled nursing facility and sometimes back to the hospital. Poorly managed transitions can diminish health and increase costs. Researchers have estimated that inadequate care coordination, including inadequate management of care transitions, was responsible for $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions.
Several new federal initiatives aim to encourage more effective care transitions. In addition, debate continues over how to restructure fee-for-service payments to motivate providers across care settings to work as a team to make transitions smoother.
This brief examines the factors contributing to poor care transitions, describes the elements of effective approaches to improving patient and family experience with transitions, and explores policy issues surrounding payment reforms designed to address the problem.
What is the Background?
For years, health policy experts have identified poor care transitions as a major contributor to poor quality and waste. The 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, described the U.S. system as decentralized, complicated, and poorly organized, specifically noting “layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful.”
The IOM noted that, upon leaving one setting for another, patients receive little information on how to care for themselves, when to resume activities, what medication side effects to look out for, and how to get answers to questions. As a result, the conditions of many patients worsen and they may end up being readmitted to the hospital. For example, nearly one fifth of fee-for-service Medicare beneficiaries discharged from the hospital are readmitted within 30 days; three quarters of these 74readmissions, costing an estimated $12 billion a year, are considered potentially preventable, especially with improved care transitions.
Root Causes.
There are several root causes of poor care coordination. Differences in computer systems often make it difficult to transmit medical records between hospitals and physician practices. In addition, hospitals face few consequences for failing to send medical records to patients' outpatient physicians upon discharge. As a result, physicians often do not know when their patients have been released and need follow-up care. Finally, current payment policies create disincentives for hospitals to invest in smoother care transitions. For example, although Medicare does not allow hospitals to bill for readmissions that occur within 24 hours of discharge, it does pay full price for most readmissions that occur after that time. This means that the prevailing financial incentive for hospitals is to not expend resources on improving care transitions because a poor transition often leads to readmission, which generates additional revenue.
Moreover, some analysts believe that Medicare and Medicaid payment policies have unintentionally created incentives to unnecessarily transfer patients back and forth between hospitals and nursing homes. Their suspicion is that nursing homes, which are primarily paid by Medicaid with generally low payment rates, unnecessarily transfer patients to hospitals to qualify for more generous Medicare payment rates when their patients return to them after discharge.
Lending credence to this claim, researchers have found that states with lower rates of Medicaid spending on dual-eligible patients under age 65 (people who are eligible for both Medicaid and Medicare) have higher rates of Medicare spending on these patients, and vice versa, suggesting that providers are gaming the system.
Transition to Primary Care.
As mentioned, one of the biggest barriers to smoother care transitions is the fact that primary care physicians often have little or no information about their patients' hospitalizations. A review of the literature published in the Journal of the American Medical Association in 2007 found that physicians had received a hospital discharge summary about their patients, and had it on hand, in only 12% to 34% of first postdischarge visits. Even when discharge summaries are received, they often lack key information, such as test results, treatment course, discharge medications, and follow-up plans. The situation is even worse for those patients who have no usual source of care.
Patients often do not consistently receive follow-up care after leaving the hospital. Among Medicare beneficiaries readmitted to the hospital within 30 days of a discharge, half have no contact with a physician between their first hospitalization and their readmission. (Figure 8-1 shows 30-day hospital readmissions under Medicare as a percentage of admissions, by state.)

FIGURE 8-1 Medicare 30-day hospital readmissions as a percentage of admissions, 2009. (From Commonwealth Fund [2009, October]. Medicare 30-day hospital readmissions as a percent of admissions: National metrics. Washington, DC: Commonwealth Fund.)
This problem may be worsening because of an ongoing shift in practice patterns. Increasingly, outpatient primary care physicians are no longer visiting their patients when hospitalized, and hospitalized patients' care is now being managed by hospitalists, physicians who only treat patients in the hospital. Although hospitalists are generally believed to have improved the quality and coordination of patients' in-hospital care, their presence, and the removal of patients' outpatient primary care physicians from the hospital, has led to an increased need for care coordination among providers that doesn't always occur.
Care Transition Models.
Several models for improving transitions after hospitalization have been developed and rigorously tested. One of the most widely disseminated is the Care Transitions Intervention developed by Eric Coleman at the University of Colorado. This approach involves transitions coaches, primarily nurses, and social workers, who first meet patients in the hospital and then follow up through home visits and phone calls over a 4-week period.
The coaches promote development of patients' skills in four key self-care areas: managing medications; scheduling and preparing for follow-up care; recognizing and responding to red flags that could indicate a worsening condition, such as the onset of a fever or worsening breathing problems; and taking ownership of a core set of personal health 75information by having patients brainstorm and ask their providers questions about their conditions or self-care routine. In a large integrated delivery system in Colorado, the Care Transitions Intervention reduced 30-day hospital readmissions by 30%, reduced 180-day hospital readmissions by 17%, and cut average costs per patient by nearly 20%. The intervention has been adopted by more than 700 organizations nationwide.
Another rigorously tested transitional care model, developed by Mary Naylor and her colleagues at the University of Pennsylvania, involves a longer period of intervention targeted at a high-risk, high-cost subset of older adult patients, such as those hospitalized for heart failure. In six academic and community hospitals in Philadelphia, this approach reduced readmissions by 36% and costs by 39% per patient (nearly $5000) during the 12 months following hospitalization. Under the Naylor model, an advanced practice nurse not only coaches patients and their caregivers to better manage their care but also coordinates a follow-up care plan with patients' physicians and provides regular home visits with 7-day-a-week telephone availability.
What is in the Law?
The Affordable Care Act contains several provisions that could improve care transitions. These include both carrots (financial incentives) and sticks (financial penalties).
Among the carrot approaches, starting October 1, 2012, hospitals can receive increases to their Medicare payments if they achieve or exceed performance targets for certain quality measures, including whether they told patients about symptoms or problems to look out for postdischarge; whether they asked patients if they would have the help they needed at home; and whether they provided heart failure patients with discharge instructions. (See the Health Policy Brief published on April 15, 2011, for more information on improving quality and safety:
Among the stick approaches, also beginning October 1, 2012, the Centers for Medicare and Medicaid Services (CMS) can reduce payments by 1% to hospitals whose readmission rates for patients with heart failure, acute myocardial infarction, or pneumonia exceed a particular target. According to a recent analysis by the Kaiser Family Foundation, 76more than 2200 hospitals will forfeit about $280 million in Medicare payments over the next year because of these readmissions penalties.
Medical Homes.
The law also authorizes paying providers for care transition services as part of payments to primary care practices that operate as medical homes, practices that closely manage and coordinate the care of patients with chronic conditions. One demonstration project, which predates the Affordable Care Act, is the Multi-Payer Advanced Primary Care Practice Demonstration in which Medicare offers practices that have been formally recognized as medical homes in eight states up to $10 per beneficiary per month to cover the cost of medical home services, which include care transition planning.
Another demonstration, the Comprehensive Primary Care Initiative, offers monthly payments to practices that average $20 per beneficiary in the first 2 years and then transitions to $15 plus the opportunity to earn shared savings in the last 2 years. Again, a portion of these programs are intended to compensate practices for the costs of care coordination and care transitions planning.
In addition, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration will pay $6 per beneficiary per month to health centers that adopt the medical home model and apply for Level 3 medical home recognition, having the most stringent requirements, from the National Committee for Quality Assurance (NCQA) by the end of the 3-year demonstration. NCQA's medical home standards ask practices to establish processes to identify patients admitted to the hospital, share clinical information with the admitting hospital, obtain patient discharge summaries from the hospital, and contact patients for follow-up care, among many other expectations.
Medicaid and Medicare.
State Medicaid agencies can now offer providers enhanced reimbursement, such as through monthly care management payments, to cover the cost of “comprehensive transitional care” and other services if the practice qualifies as a “health home”; a practice that cares not only for Medicaid patients' physical conditions but also helps them obtain such other services as behavioral health care and long-term care services and supports.
Also, a 5-year, $500 million Community-Based Care Transitions Program pays organizations that partner with hospitals with high readmission rates to provide care transition services for high-risk Medicare beneficiaries. All-inclusive payments cover the cost of care transition services provided to individual beneficiaries in the 180 days following an eligible discharge plus the cost of systemic changes made by partner hospitals to improve care transitions. So far 47 awardees have been announced, and applications continue to be accepted. Participating organizations initially enter into 2-year agreements, which can be extended annually through the end of 2015.
Incentives in New Payment Models.
The Medicare Shared Savings Program for accountable care organizations (ACOs) will give groups of providers an incentive to coordinate care more closely to keep patients healthy and out of the hospital because they will be eligible to share in the savings they are able to generate relative to a spending benchmark. The quality metrics that must be met by ACOs to benefit financially under the program include six that pertain to care coordination, including preventing unnecessary hospital readmissions. (See Health Policy Brief published on January 31, 2012, for more information on ACOs:
The Affordable Care Act also authorizes 5-year bundled payment pilots in Medicare and Medicaid to test whether making a single payment to one entity for services provided by several providers for an episode of care, such as a knee replacement, will give providers an incentive to work together to ensure that patients receive all the services they need, including hospital and follow-up care, in a more efficient manner. Managing care transitions to prevent costly hospital readmissions will be particularly important because, in the Medicare pilot, at least, the bundled payment will cover services beginning 3 days before a hospital admission for an 77eligible condition and extending 30 days after hospital discharge.
Signaling the importance of care transitions to the success of these efforts, the Medicare pilot requires bundled payments to cover the cost of transitional care services. CMS's new Innovation Center has begun accepting applications from providers interested in piloting four bundled payment models through a separate Bundled Payments for Care Improvement initiative. The Medicaid pilot, meanwhile, requires participating hospitals to have “robust discharge planning programs.”
In addition, a new Medicare-Medicaid Coordination Office in CMS is charged with better integrating benefits for dual-eligible beneficiaries. It also works to ensure “safe and effective care transitions,” among other goals. This office has awarded contracts of up to $1 million each to 15 states to design models to coordinate primary, acute, behavioral, and long-term care for Medicare-Medicaid enrollees. CMS has also invited proposals from states to test two new payment models to better integrate care for this population and allow states to share in savings from these improvements. Twenty-six states, including the 15 states awarded demonstration design contracts, have developed proposals for this demonstration. The new payment and delivery system models are likely to focus on improving care transitions, among other strategies. (See the Health Policy Brief published on June 13, 2012, for more information on dual eligibles:
Physicians and Nurses.
The Affordable Care Act also requires the Department of Health and Human Services to develop and implement a plan by 2013 that would lead to reporting physician-level quality measure data on the new Physician Compare website (, including measures of the quality of care transitions. CMS has until 2019 to decide whether to conduct a demonstration giving Medicare beneficiaries financial incentives to seek care from physicians who score highly on these measures.
The law also creates a $200 million, 4-year workforce development demonstration aimed at increasing the number of advanced practice registered nurses trained in care transition services, chronic care management, preventive care, primary care, and other services appropriate for Medicare beneficiaries.
Mixed Messages.
Taken as a whole, the inclusion in the Affordable Care Act of these carrots and sticks aimed at different types of providers suggests a tension over whom to pay and how to pay them to improve care transitions. On the one hand, the payment cuts that high-readmission hospitals nationwide will soon face create an expectation that hospitals take responsibility for improving care transitions using existing resources. But the fact that another program will provide new care transitions payments to hospitals and community-based organizations suggests that they may require additional resources to provide these services.
And although physicians' performance on care transitions quality measures will be reported on Physician Compare, no provision in the Affordable Care Act requires hospitals to alert physicians when their patients are discharged, typically the needed first step before a physician can become involved in a care transition.
Other Policy Options
If these Affordable Care Act provisions fail to improve care transitions or if CMS decides to pursue other policies, the agency's statutory authority gives it some additional options, as follows:
• Pay physicians for care transition services. Under the Medicare physician fee schedule, CMS could create a new billing code that would enable physicians to bill for delivery of care transition services. In a proposed rule issued in July 2012, CMS would create a code to bill for care transition services delivered to Medicare beneficiaries in the 30 days following a discharge from a hospital, skilled nursing facility, or community mental health center. The code would apply to Medicare patients whose medical or psychosocial problems, or both, require moderate or high complexity medical decision making.
To qualify for the new payment, physicians would have to obtain and review a patient's hospital discharge summary, update the patient's medical records to reflect changes in health conditions and ongoing treatments, and establish or adjust a patient's care plan. Physicians would be required to communicate with a beneficiary or their caregiver within 2 business days of discharge to resolve medication discrepancies and inform them about possible complications. Whether physicians will consider the payment level assigned to this billing code adequate for the effort required, however, remains unclear.
• Track whether hospitals transmit records to physicians. Another policy option would be to add a care transitions measure to Medicare's Hospital Inpatient Quality Reporting program, a pay-for-reporting program. Adding such a measure would create a modest incentive for hospitals to better communicate with physicians about patients' hospitalizations, especially if CMS chose to include that measure in the subset that is displayed on the Hospital Compare website (
If CMS wanted to further elevate hospitals' focus on this measure, it could include it in the subset of measures it uses in the Hospital Value-Based Purchasing Program, the new pay-for-performance program for hospitals created in the Affordable Care Act and scheduled to go into effect in October 2012.
A hospital-related care transitions measure has been developed by a group of physician specialty societies and endorsed by the National Quality Forum, a nonprofit organization that works with providers, consumer groups, and governments to establish and build consensus for specific health care quality and efficiency measures. This indicator, called Timely Transmission of Transition Record (measure no. 0648), measures how often a hospital sends a transition record to a patient's physician within 24 hours of discharge. Having this information would allow primary care physicians to identify which patients needed follow-up care.
However, hospitals may not welcome this additional reporting burden because transmittal of such records to outpatient physicians is not a billable hospital service, which means claims data cannot be used to easily calculate how often such transmittals occur. Instead, for hospitals that don't have good electronic health record systems, labor-intensive chart reviews would be required to calculate such a measure.
If CMS were to pay hospitals to develop discharge plans, discuss them with patients, and transmit them to outpatient physicians for follow-up care, the hospitals would have a greater incentive to perform these crucial activities. CMS could also then use the hospitals' billing records for these services to calculate quality measures assessing how often the hospitals performed these important services.
However, in the current strained federal fiscal environment, offering a new carrot to hospitals may have little appeal for policymakers. Indeed, because Medicare already gives hospitals lump-sum payments to cover all the costs associated with a hospitalization and because Medicare's conditions of participation require hospitals to have a discharge planning process in place, policymakers may feel hospitals are already being paid for care transition services but are simply not performing them as routinely as they should be.
• Strengthen hospital do-not-pay policies. Another policy stick would be to further limit payment for hospital readmissions. For example, CMS could extend its current policy of not paying for Medicare readmissions that occur within 24 hours of a hospital discharge for the same condition to 72 hours, or even 15 or 30 days, postdischarge. Doing so would require carefully defining which readmissions would be ineligible for payments and how to account for co-occurring conditions. Already, hospitals as a group are upset about CMS's decision to penalize them for certain planned readmissions because they do not think it adequately distinguishes between readmissions that are truly necessary compared to readmissions that are truly preventable.
What's Next?
Given the current budgetary environment and the fact that Medicare is estimated to spend $12 billion per year on potentially preventable hospital readmissions, interest in improving care transitions to reduce Medicare spending is likely only to grow.
Although some care transitions interventions have generated cost savings, uncertainty remains over how best to encourage providers to use these approaches. Evaluation of the changes brought about by the Affordable Care Act will begin filling gaps in our knowledge. And if the health care law's approaches fail to make a strong enough case for providers to pay attention to care transitions, policymakers may want to explore bigger carrots and sticks.
Bubolz T, Emerson C, Skinner J. State spending on dual eligibles under age 65 shows variations, evidence of cost shifting from Medicaid to Medicare. Health Affairs. 2012;31(5):939–947.
Coleman EA. Falling through the cracks: Challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society. 2003;51(4):549–555.
Hackbarth G. Report to the Congress: Promoting greater efficiency in Medicare. Medicare Payment Advisory Commission: Washington, DC; 2007, June.
Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA. 2007;297(8):831–841.
Kronick R, Gilmer TP. Medicare and Medicaid spending variations are strongly linked within hospital regions but not at overall state level. Health Affairs. 2012;31(5):948–955.
Naylor MD, Aiken LH, Kurtzman E, Olds DM, Hirschman KB. The importance of transitional care in achieving health reform. Health Affairs. 2011;30(4):746–754.
Pham HH, Grossman JM, Cohen G, Bodenheimer T. Hospitalists and care transitions: The divorce of inpatient and outpatient care. Health Affairs. 2008;27(5):1315–1327.
Tilson S, Hoffman GJ. Addressing Medicare hospital readmissions. Congressional Research Service: Washington, DC; 2012.
Online Resources
The Women's and Children's Health Policy Center.

1Health Policy Brief: Care Transitions, Health Affairs, September 13, 2012. Written by Rachel Burton, Research Associate, Urban Institute. Editorial review by Eric Coleman, Division Head Health Care Policy and Research, University of Colorado Medical Campus; Debra J. Lipson, Senior Researcher, Mathematica Policy Research; Ted Agres, Senior Editor for Special Content, Health Affairs; Anne Schwartz, Deputy Editor, Health Affairs; and Susan Dentzer, Editor-in-Chief, Health Affairs. Health Policy Briefs are produced under a partnership of Health Affairs and the Robert Wood Johnson Foundation. Reprinted with permission.
Political Analysis and Strategies
Kathleen M. White 1
“The difficult can be done immediately, the impossible takes a little longer.”
Unknown author, Army Corps of Engineers motto, World War II
The knowledge and expertise of nurses regarding health and health care are critical to the political process and the development of health policy. However, the word politics often evokes negative emotions and many nurses may not feel inclined to get involved. Nonetheless, nurses have the skills to be active participants in the political arena for a number of reasons. First, nurses are skilled at assessment, and being engaged in the political process involves analysis of the relevant issues and their background and importance. Second, nurses understand people and, in order to understand an issue, it is critical to know who is affected and who is involved in trying to solve the problem. Finally, nurses are relationship builders and the political process involves the development of partnerships and networks to solve problems. As skilled communicators, nurses have the ability to work with other professionals, patients, families, and their communities to solve health care problems that affect their patients and the health care system. Nurses have much to offer in the political process and need to develop skills in political analysis and strategy to truly make a difference.
What is Political Analysis?
Political analysis is the process of examining an issue and understanding the key factors and people that might potentially influence a policy goal. It involves the analysis of government and organizations, both public and private; people and their behavior; and the social, political, historical, and economic factors surrounding the policy. It also includes the identification and development of strategies to attain or defeat a policy goal. Political analysis involves nine components.
Identification of the Issue
The first step in conducting a political analysis is to identify and describe the issue or problem. Identifying and framing the issue involves asking who, what, when, where, and how questions to gather sufficient information to lay the groundwork for developing an appropriate response to the issue. Start with what you know about the issue:
• What is the issue?
• Is it my issue and can I solve it?
• When did the issue first occur, is it a new or old problem?
• Is this the real issue, or merely a symptom of a larger one?
• Does it need an immediate solution, or can it wait?
• Is it likely to go away by itself?
• Can I risk ignoring it?
Beware of issue rhetoric (Bardach, 2012) that is either too narrowly defining an issue in a technical way, or defining the issue too broadly in a societal way. Decide what is missing from what you know about the issue and gather additional information:
• Why does the problem exist?
• Who is causing the problem?
• Who is affected by the issue?
• How significant is the issue?
• What additional information is needed?
• What are the gaps in existing data?
Don't cut corners or overlook the importance of this step in the political analysis, as a well-defined issue is important to the whole process, as is identifying and defining the right issue. The way a problem is defined has considerable impact on the number and type of proposed solutions (Fairclough, 2013). The challenge for those seeking to get policymakers to address particular issues (e.g., poverty, the underinsured, or unacceptable working conditions) is to define the issue in ways that will prompt decision makers to take action. This requires careful crafting of messages so that calls for solutions are clearly justified. This is known as framing the issue. In the workplace, framing may entail linking the problem to one of the institution's priorities or to a potential threat to its reputation, public safety, or financial standing. For example, inadequate nurse staffing could be linked to increases in rates of morbidity and mortality, outcomes that can increase costs and jeopardize an institution's reputation and future business.
It is important not to confuse symptoms, causes, or solutions with issues. Sometimes what appears to be an issue is not. For example, proposed mandatory continuing-education for nurses is not an issue; rather, it is a possible solution to the challenge of ensuring the competency of nurses. After an analysis of the issue of clinician competence, one might establish a goal that includes legislating mandatory continuing-education. The danger of framing issues as solutions is that it can limit creative thinking about the underlying issue and leave the best solutions uncovered.
Context of the Issue
The second part in the political analysis process is to do a situational analysis by examining the context of the problem. This analysis should include, at a minimum, an examination of the social, cultural, ethical, political, historical, and economic contexts of the problem. Several questions can guide you in analyzing the background of the issue:
• What are the social, cultural, ethical, political, historical, and economic factors that are creating or contributing to this problem?
• What are the background and root causes of each of these factors?
• Are these factors constraining or facilitating a solution to the problem?
• Are there other environmental obstacles affecting this issue?
It is important to be as thorough as possible at this stage and to consider whether the source of the information is verifiable and impartial. It is also important to understand any opposing views.
When assessing the political context, nurses need to clarify which level of government (federal, state, or local) or organization is responsible for a particular issue. Scope of practice is a good example. Although typically defined by the states, there are examples where the federal government has superseded the state's authority, such as in the Veteran's Administration and the Indian Health Service. Nurses also need to know which branch of government (legislative, executive, or judicial) has primary jurisdiction over the issue at a given time. Although there is often overlap among these branches, nurses will find that a particular issue falls predominantly within one branch.
Knowledge of past history of an issue can provide insight into the positions of key public officials so that communications with those individuals and strategies for advancing an issue can be developed accordingly. For example, if it is known that a particular legislator has always questioned the ability of advanced practice registered nurses (APRNs) to practice independently, then that individual may need stronger emphasis on the evidence about the quality and value of APRNs to support legislation allowing direct billing of APRNs under Medicare.
This type of context analysis is also applicable to the workplace or community organization. Regardless of the setting, assessing the history of the issue would include identifying who has responsibility for decision making for a particular issue; which committees, boards, or panels have addressed the issue in the past; the organizational structure; and the chain of command. Nurse’s Role in Influencing the Legislative Process Essay Paper.
At an institutional level, once the relevant political forces in play have been identified, the formal and informal structures and the functioning of those structures need to be analyzed. The formal 82dimensions of the entity can often be assessed through documents related to the organization's mission, goals, objectives, organizational structure, bylaws, annual reports (including financial statement), long-range plans, governing body, committees, and individuals with jurisdiction. The informal dimensions of the organization, such as personal relationships and personal communication networks that could be positive or negative, are more difficult to analyze but need to be understood to get a full picture of the context of the issue. Nurse’s Role in Influencing the Legislative Process Essay Paper.
One final example in the analysis of the context of the issue is worth mentioning. Does the entity use parliamentary procedure? Parliamentary procedure provides a democratic process that carefully balances the rights of individuals, subgroups within an organization, and the membership of an assembly. The basic rules are outlined in Robert's Rules of Order ( Whether in a legislative session or the policymaking body of large organizations, one must know parliamentary procedure to develop a political strategy to get an issue passed or rejected.Nurse’s Role in Influencing the Legislative Process Essay Paper. There have been many issues that have failed or passed because of insufficient knowledge of rule-making.
Political Feasibility
The third part of a political analysis is to analyze the political feasibility of solving an issue. There are several ways to conduct a political feasibility analysis. A simple analysis is conducting a force field analysis (Lewin, 1951) to identify the barriers and facilitators to making change to solve the issue. The force field analysis asks you to think critically about the issue and the forces affecting it by creating a two-column chart. One column lists the restraining forces, or all of the reasons that preserve the status quo and any reasons why the issue should stay the same. The second column lists the driving forces, or forces that are pushing the issue to change. This exercise requires that the whole picture is considered and provides a list of the important factors that surround the issue.
A second option is to use John Kingdon's (2010) model of public policymaking (see Chapter 7). Kingdon proposes three streams or processes that affect whether an issue gets on the political agenda; the problem stream is where people agree on an issue or problem, collect data about the issue, and share the definition of problem; the policy stream is characterized by discussion and proposal of policy solutions for the issue; and the political stream is when public mood and political will exists to want to address the issue. Kingdon's model explains that an issue gets on the political agenda only when the three streams couple or converge and a window of opportunity is thereby created. This analysis provides consideration of what needs to happen for the issue to advance to the public policy agenda, including an analysis of the policy and political factors. Nurse’s Role in Influencing the Legislative Process Essay Paper.
The Stakeholders
Stakeholders are those parties who have influence over the issue, are directly influenced by it, or could be mobilized to care about it. In some cases, the stakeholders are obvious. For example, nurses are stakeholders on issues such as staffing ratios. In other situations, one can develop potential stakeholders by helping them to see the connections between the issue and their interests. Other individuals and organizations can be stakeholders when it comes to staffing ratios. Among them are employers (i.e., hospitals, nursing homes), payers (i.e., insurance companies), legislators, other health care professionals, and consumers. Nurse’s Role in Influencing the Legislative Process Essay Paper.
The role of consumers cannot be underestimated. In the political arena, these are the constituents and therefore the voters, and they can wield tremendous power over an issue and its solution. In many cases, nurses are advocates and work on behalf of stakeholders such as the patients who are affected by the care they receive. Nursing has increasingly realized the potential of consumer power in moving forward nursing and health care issues. For example, a consumer advocacy organization such as AARP possesses significant lobbying power. When nurses wanted to advance the idea of a Medicare Graduate Nursing Education (GNE) benefit, similar to the Medicare Graduate Medical Education funding to hospitals for the clinical training of interns and residents, AARP championed the proposal because it views the nursing shortage as a threat to its members' ability to access health care. GNE was included in the ACA as a pilot project. Nurse’s Role in Influencing the Legislative Process Essay Paper.
In commencing a stakeholder analysis it is important to evaluate the relationships you, or others in your group, have with key stakeholders. Look at the connections with possible stakeholders throughout your organization, community, places of worship, or businesses. Consider the following when doing a stakeholder analysis:
• Who are the stakeholders on this issue?
• Which of these stakeholders are potential supporters or opponents?
• Can any of the opponents be converted to supporters?
• What are the values, priorities, and concerns of the stakeholders?
• How can these be tapped in planning political strategy? Nurse’s Role in Influencing the Legislative Process Essay Paper.
• Do the supportive stakeholders reflect the constituency that will be affected by the issue?
For example, as states expand coverage of health services through the state's Medicaid program, it is vital to have those who now qualify let their policymakers know how important the issue is for them and to share their personal stories of how this insurance coverage has made a difference. Yet stakeholders who are recipients of the services are too often not identified as vital for moving an issue forward. Nurses, as direct caregivers, have an important role in ensuring that recipients of services are included as stakeholders; especially when bringing issues to elected officials.
Economics and Resources
An effective political strategy must take into account the resources that will be needed to address an issue successfully. Nurse’s Role in Influencing the Legislative Process Essay Paper.Resources include money, time, connections, and intangible resources, such as creative solutions. The most obvious resource is money, which must be considered when defining the issue and getting it recognized or on the public agenda. Thus, before launching an initiative to champion an issue, it is necessary to determine the resources that will be necessary, how much it will cost, who will bear those costs, the source of the money, and what value will be achieved from the outlay of the resources. Nurse’s Role in Influencing the Legislative Process Essay Paper.It is critical to fully examine, despite the initial financial outlay, the potential for cost savings it may produce. Nurse’s Role in Influencing the Legislative Process Essay Paper.It could be helpful to know how budgets are formulated for a given organization, professional group, or government agency. What is the budget process? How much money is allocated to a particular cost center or budget line? Who decides how the funds will be used? How is the use of funds evaluated? How might an individual or group influence the budget process?
Money is not the only resource to evaluate. Sharing available resources, such as space, people, expertise, and in-kind services, may be best accomplished through a coalition. It may require a mechanism for each entity to contribute a specific amount or to tally their in-kind contributions such as office space for meetings; use of a photocopier, telephone or other equipment; and use of staff to assist with production of brochures and other communications. Other cost considerations include publicity efforts such as printing materials, paying for postage, and accessing electronic communications.
Values Assessment
Every political issue should prompt discussions about values. Values underlie the responsibility of public policymakers to be involved in the regulation of health care. In particular, calls for extending the reach of government in the regulation of health care facilities imply that one accepts this as a proper role for public officials, rather than as a role of market forces and the private sector. Thus, electoral politics affect the policies that may be implemented. An analysis that acknowledges how congruent nurses' values are with those of individuals in power can affect the success of advancing an issue. There are issues that would be considered morality issues−those that primarily revolve around ideology and values, rather than costs and distribution of resources. Among well-publicized morality issues are abortion, stem cell research, and immigration. However, most issues that are not classified as morality issues still require an assessment of the values of supporters and their opponents.
Any call for government support of health care programs implies a certain prioritization of values: Is health more important than education, or jobs, or military action in the Middle East? Elected officials must always make choices among competing demands. And their choices reflect their values, the 84needs and interests of their constituents, and their financial supporters such as large corporations. Similarly, nurses' choice of issues on the political agenda reflects the profession's values, political priorities, and ways to improve health care.
Although nurses may value a range of health and social programs, legislators review issues within the context of demands from all of their constituencies. When an issue is discussed, it is critical to link the issue to the problem it may solve. It is also important to make sure issues are framed to show how they will help the public at large and not just the nursing profession. For example, when a request for increased funding for nursing education is made, linking this request to the need to alleviate the nursing shortage or to increase the number of nurses necessary for successful implementation of health care reform would be important.
Networks and/or Coalitions
Although individuals develop political skill and expertise, it is the influence of networks and coalitions, or like-minded groups that wield power most effectively. It is critical to the political analysis process to evaluate what networks or coalitions exist that are involved with the issue.
Too often nurses become concerned about a particular issue and try to change it without help from others. In the public arena particularly, an individual is rarely able to exert adequate influence to create long-term policy change. For instance, many advanced practice registered nurses (APRNs) have tried to change state Nurse Practice Acts to expand their authority. As well intentioned as the policy solutions may be, they will likely fail unless nurses can garner the support of other powerful stakeholders such as members of the state board of nursing, the state nurses association, physicians, and consumer advocacy groups. Such stakeholders often hold the power to either support or oppose the policy change. (See Chapter 75 for a discussion of building coalitions.)
Effective political strategy requires an analysis of the power of proponents and opponents of a particular solution. Power is one of the most complex political and sociological concepts to define and measure. It is critical to be aware of the sources of power, regardless of setting or issue, to understand how influence happens and to build your own sources of power for leadership in the political process.
Power can be a means to an end, or an end in itself. Power also can be actual or potential. Many in political circles depict the nursing profession as a potential political force considering the millions of nurses in this country and the power they could wield if more nurses participated in politics and policy formation. Any discussion of power and nursing must acknowledge the inherent issues of hierarchy and power imbalance that arise from the long-standing relationships between nurses and physicians. Some of nurses' discomfort with the concept of power may also arise from the inherent nature of “gender politics” within the profession. Male or female, gender affects every political scenario that involves nurses. Working in a predominantly female profession means that nurses are accustomed to certain norms of social interactions (Tanner, 2001). In contrast to nursing, the power and politics of public policymaking typically are male dominated, although women are steadily increasing their ranks as elected and appointed government officials. Moreover, many male and female public officials have stereotypic images of nurses as women who lack political savvy. This may limit officials' ability to view nurses as potential political partners. Therefore nurses need to be sensitive to gender issues that may affect, but certainly not prevent, their political success.
Any power analysis must include reflection on one's own power base. Power can be obtained through a variety of sources such as those listed in Box 9-1(French & Raven, 1959; Benner, 1984). An analysis of the extent of one's power using these sources can provide direction on how to enhance that power. Although the individual may hold expert power, it will be limited if one attempts to go it alone. An individual nurse may not have sufficient power to champion an issue through the legislative or regulatory process, but a network, coalition, or alliance of nurses or nursing organizations can wield significant power to move 85an issue to the public agenda and to successfully solve it. Nurse’s Role in Influencing the Legislative Process Essay Paper.
Box 9-1
Sources of Power
1. Legitimate (or positional) power is derived from a belief that one has the right to power, to make decisions and to expect others to follow them. It is power obtained by virtue of an organizational position rather than personal qualities, whether from a person's role as the chief nurse officer or the state's governor.
2. Reward power is based on the ability to compensate another and is the perception of the potential for rewards or favors as a result of honoring the wishes of a powerful person. A clear example is the supervisor who has the power to determine promotions and pay increases.
3. Expert power is based on knowledge, skills, or special abilities, in contrast to positional power. Benner (1984) argues that nurses can tap this power source as they move from novice to expert practitioner. It is a power source that nurses must recognize is available to them. Policymakers are seldom experts in health care; nurses are.
4. Referent power is based in identification or association with a leader or someone in a position of power who is able to influence others and commands a high level of respect and admiration. Referent power is used when a nurse selects a mentor who is a powerful person, such as the chief nurse officer of the organization or the head of the state's dominant political party. It can also emerge when a nursing organization enlists a highly regarded public personality as an advocate for an issue it is championing.
5. Coercive power is based on the ability to punish others and is rooted in real or perceived fear of one person by another. For example, the supervisor who threatens to fire those nurses who speak out is relying on coercive power, as is a state commissioner of health who threatens to develop regulations requiring physician supervision of nurse practitioners.
6. Information power results when one individual has (or is perceived to have) special information that another individual needs or desires. For example, this source of power can come from having access to data or other information that would be necessary to push a political agenda forward. This power source underscores the need for nurses to stay abreast of information on a variety of levels: in one's personal and professional networks, immediate work situation, community, and the public sector, as well as in society. Use of information power requires strategic consideration of how and with whom to share the information.
7. Connection power is granted to those perceived to have important and sometimes extensive connections with individuals or organizations that can be mobilized. For example, the nurse who attends the same church or synagogue as the president of the home health care agency, knows the appointments secretary for the mayor, or is a member of the hospital credentialing committee will be accorded power by those who want access to these individuals or groups.
8. Persuasion power is based in the ability to influence or convince others to agree with your opinion or agenda. It involves leading others to your viewpoint with data, facts, and presentation skills. For example, a nurse is able to persuade the nursing organization to sponsor legislation or regulation that would benefit the health care needs of her specialty population. It may be the right thing to do, but the nurse uses her skills of persuasion for her own personal or professional agenda.
9. Empowerment arises from any or all of these types of power, shared among the group. Nurses need to share power and recognize that they can build the power of colleagues or others by sharing authority and decision making. Empowerment can happen when the nurse manager on a unit uses consensus building when possible instead of issuing authoritative directives to staff, or when a coalition is formed and adopts consensus building and shared decision making to guide its process.
Consider the nursing organization that is seeking to secure legislative support for a key piece of legislation. It can develop a strategy to enhance its power by finding a highly regarded, high-profile individual to be its spokesperson with the media (referent power), by making it known to legislators that their vote on this issue will be a major consideration in the next election's endorsement decisions (reward or coercive power), or by having nurses tell the media stories that highlight the problem the legislation addresses (expert power). A longer-range power-building strategy would be for the nursing organizations to extend their connections with other organizations by signing onto coalitions 86that address broader health care issues and expanding connections with policymakers by attending fundraisers for key legislators (connection power); getting nurses into policymaking positions (legitimate power); hiring a government affairs director to help inform the group about the nuances of the legislature (information power); using consensus building within the organization to enhance nurses' participation and activities (empowerment), or, finally, by identifying a legislative champion for the issue who could garner the use of several power bases at once.
Goals and Proposed Solutions
Typically, there is more than one solution to an issue and each option differs with regard to cost, practicality, and duration. These are the policy options. The political analysis of the issue involves the context of the issue, stakeholders, values, power, and what is politically feasible. By identifying the goal, and developing and analyzing possible solutions, nurses will acquire further understanding of the issue and what is possible for an organization, workplace, government agency, or professional organization to undertake. There needs to be a full understanding of the big picture and where the issue fits into that vision. For example, if nurses want the federal government to provide substantial support for nursing education, they need to understand the constraints of federal budgets and the demands to invest in other programs, including programs that benefit nurses and other health care professionals. Moreover, support for nursing education can take the form of scholarships, loans, tax credits, aid to nursing schools, or incentives for building partnerships between nursing schools and health care delivery systems. Each option presents different types of support, and nurses would need to understand the implications of the alternatives before asking for federal intervention. Nurse’s Role in Influencing the Legislative Process Essay Paper.
The amount of money and time needed to address a particular issue also needs to be taken into account. Are there short-term and long-term alternatives that nurses want to pursue simultaneously? Is there a way to start off with a pilot or demonstration program with clear paths to expansion? How might one prioritize various solutions? What are the tradeoffs that nurses are willing to make to obtain the stated political goals?
Such questions need to be considered in developing a political strategy.
Political Strategies
Once a political analysis is completed, it is necessary to develop a plan that identifies activities and strategies to achieve the policy goals. The development and implementation of a political strategy to solve an issue requires that there is a tightly framed message, an aligned common purpose or goal, and a well-defined target audience. Messaging is critical to the development of a political strategy. Nurses need to be able to communicate with policymakers, other health care leaders, and the public, and may sometimes use social media for messaging to advise on institutional and public policy.
Look at the Big Picture
It is human nature to view the world from a personal standpoint, focusing on the people and events that influence one's daily life. However, developing a political strategy requires looking at the larger environment. This can provide a more objective perspective and increase nurses' credibility as broad-minded visionaries, looking beyond personal needs.
In the heat of legislative battles and negotiations, it is easy to get distracted. However, the successful advocate is the one who does not lose sight of the big picture and is willing to compromise for the larger goal. It is critical for nurses to frame their policy work in terms of improving the health of patients and the broader health delivery system, rather than a singular focus on the profession. Nurse’s Role in Influencing the Legislative Process Essay Paper.
Do Your Homework
We can never have all the information about an issue, but we need to be sufficiently prepared before we advocate. Usually it is unlikely to know beforehand when a particular policy will be acted on; nonetheless, it is not sufficient to claim ignorance when confronted with questions that should be answered. However, if one has done everything possible to prepare and is asked to supply information 87that is not anticipated, it is reasonable and preferable to indicate that one does not know the answer. The information should then be obtained as soon as possible and distributed to the policymaker who requested it. Remember not to let perfection be the enemy of good; gather the requested information, and present it as clearly and simply as possible.
Some of the ways to be adequately prepared are provided in Box 9-2.
Box 9-2
Being Prepared for Political Advocacy
Here are some ways to ensure that you're prepared for advocacy around a specific issue. Conducting a full political analysis will inform your preparation strategy.
• Clarify your position on the problem, your goal in pursuing the issue, and possible solutions.
• Gather information and data, and search the clinical and policy literature.
• Prepare documents to describe and support the issue.
• Assess the power dynamics of the stakeholders.
• Assess your own power base and ability to maneuver in the political arena.
• Plan a strategy, and assess its strengths and weaknesses.
• Prepare for the opposition. Nurse’s Role in Influencing the Legislative Process Essay Paper.
• Line up support.
Read between the Lines
It is as important to be aware of the way one conveys information as it is to provide the facts. When legislators say they think your issue is important, it does not necessarily mean that they will vote to support it. A direct question such as, Will you vote in support of our bill? needs to be asked of policymakers to know their position. Communication theory notes that the overt message is not always the real message (Gerston, 2010). Some people say a lot by what they choose not to disclose. What is not being said? Are there hidden agendas that the stakeholders are concerned about? When framing the issue, know the hidden agendas and covert messages. Be careful to make the issue as clear as possible and test it on others to be certain that reading between the lines conveys the same message as the overt rhetoric. Nurse’s Role in Influencing the Legislative Process Essay Paper.
In God We Trust, All Others Bring Data
This quote is attributed to W. Edwards Deming (Hastie, Tibshirani, & Friedman, 2011) who developed principles for managers to transform business effectiveness through the application of statistical methods. He suggested that by presenting data to workers, they can see the outcomes or intended results of their work and make improvements to meet goals. This quote resonates in today's current heath care environment in that it requires measurement and data reporting by most health care organizations, by many health care professionals, and at all levels of practice, including the institutional, local, state and national. Data are important to the political analysis process and again during strategy development to move an issue through the policy process. Decision makers are often dissatisfied with their ability to get or understand the data needed to make good policy decisions. They need an interpretation of the data in a form that is understandable and useable for their purposes. Nurses are skilled are interpreting and reporting data in the clinical setting and as researchers and consumers of clinical research. A nurse can make himself or herself valuable to a policymaker by preparing a report of the important points on an issue under consideration that translates data into concise information.
Money Talks
Follow the money and understand the flow of funds within a private health care organization/system or the public sector. Money is important in both the public and private sectors, and the more money you have, the more powerful you appear to others, whether the money is revenue, profits, or donations. In the political arena, special interest groups, such as professional organizations (for example, the American Nurses Association), solicit money from their members and spend it to maintain a presence in Washington, DC, and 50 state capitals through political action committees (PACs). Other organizations, such as labor unions, trade associations, and some large corporations, also make donations to influence the agenda in Washington and the state capitals. One other type of influential group is the 88“527 committees” that get their name from the IRS code section that governs their existence. These 527 committees are advocacy issue groups that are outside the mainstream of special interest groups and corporate America. They may have ties to some of the other groups, but they have less stringent rules to follow on the use of money and how it influences the political process.
These advocacy groups hire professional advocates or lobbyists to monitor the policy and political environments and influence elected and appointed officials on issues of importance to their special interest group. Even though money is important to have and can be very influential, the problem with money in politics is who is spending the money, what they are asking for in return, and how that affects the allocation of public resources. Nurse’s Role in Influencing the Legislative Process Essay Paper.
Communication is 20% What You Say and 80% How You Say It and to Whom
Using the power that results from personal connections can be an important strategy in moving a critical issue forward. In the example of APRN reimbursement, the original legislation that gave some APRNs Medicare reimbursement was greatly facilitated by the fact that the chief of staff for the Senate Majority Leader was a nurse. Or consider the nurse who is the neighbor and friend of the secretary to the chief executive officer (CEO) in the medical center. This nurse is more likely to gain access to the CEO than will someone who is unknown to either the secretary or the CEO. Building relationships and partnerships and networking are important long-term strategies for increasing influence but can also be short-term strategies.
Equally important is the way the message is framed and conveyed to stakeholders. We have often been told, it's not what you say but how you say it. When delivering the message, learn to use strong, affirmative language to describe nursing practice. Use the rhetoric that incorporates lawmakers' lingo and the buzz words of key proponents. This requires having a sense of the values of the target audiences, whether they are legislators, regulators, hospital administrators, community leaders, or the consumer public. Stakeholders appreciate a succinct and framed message that is responsive to the values and concerns of your supporters or opponents. For example, during health reform discussions, APRNs framed their issue in terms of quality of care and cost savings. Since the nation continues to be concerned about the amount of money spent on health care, the message of reducing costs without compromising quality resonated with the Administration, Members of Congress, insurers, employers, and the public alike. How you convey your message involves developing rhetoric or catchy phrases that the media might pick up on and perpetuate. Nurses need to develop their effectiveness in accessing and using the media, an essential component of getting the issue on the public's agenda.
Learn and use good communication techniques; in particular, the use of a persuasive and assertive communication style that focuses on the facts and the data, and limits any emotional appeals to stories that illustrate the human impact of the problem. As discussed above, it is important to develop a message that is important to your target audience. Nurse’s Role in Influencing the Legislative Process Essay Paper.
And finally, don't be afraid to toot your own horn. Don't assume that your good work will be recognized or valued by others. If nursing is leading an initiative or has generated the research evidence to support the issue, present the evidence to the policymakers and let them know what has been studied or found to be effective and inform them that nurses led the work. Nurse’s Role in Influencing the Legislative Process Essay Paper.
You Scratch My Back and I'll Scratch Yours
Developing networks involves keeping track of what you have done for others and not being afraid to ask a favor in return. Often known as quid pro quo (literally, something for something), it is the way political arenas work in both public and private sectors. Leaders expect to be asked for help and know the favor will be returned. Because nurses interface with the public all the time, they are in excellent positions to assist, facilitate, or otherwise do favors for people. Too often, nurses forget to ask for help from those whom they have helped and who would be more than willing to return a favor. 89Consider the lobbyist for a state nurses' association who knew that the chair of the Senate public health and welfare committee had a grandson who was critically injured in a car accident. She visited the child several times in the hospital, spoke with the nurses on the unit, and kept the legislator informed about his grandson's progress and assured him that the boy was well cared for. When the boy recovered, the legislator was grateful and asked the lobbyist what he could do to move her issue. Interchanges like this occur every day and create the basis for quid pro quo.
Strike While the Iron is Hot
The timing of an issue will often make a difference in terms of a successful outcome. A well-planned strategy may fail because the timing is not good. An issue may languish for some period because of a mismatch in values, concerns, or resources but then something may change to make an issue ripe for consideration. The passage of the ACA is a good example. President Obama knew from studying the history of legislation in this country that the best chance of passing sweeping legislation was in the early years of a presidential term. Once elected, with both the U.S. House of Representatives and the U.S. Senate under the control of the Democratic Party, the President knew that the only hope of passing comprehensive health care reform would be if it became his priority within his first year.
United We Stand, Divided We Fall
The achievement of policy goals can be accomplished only if supporters demonstrate a united front. Collective action is almost always more effective than individual action. Collaboration through networking, alliances, and coalition building can demonstrate broad support for an issue.
A 2010 Gallup poll of health care leaders found that the lack of a united front by national nursing organizations was viewed as a major reason why nursing's influence on health care reform would not be significant. To maximize nursing's political potential, we must look for opportunities to reach consensus or remain silent in the public arena on an issue that is not of paramount concern.
Sometimes diverse groups can work together on an issue of mutual interest, even though they are opponents on other issues. Public and private interest groups that identify with nursing's issues can be invaluable resources for nurses. They often have influential supporters or may have research information that can help nurses move an issue forward.
The Best Defense is a Good Offense
A successful political strategy is one that tries to accommodate the concerns of the opposition. It requires disassociating from the emotional context of working with opponents and is the first step in principled negotiating. A person who is skillful at managing conflict will be successful in politics. The saying that politics makes strange bedfellows arose out of the recognition that long-standing opponents can sometimes come together around issues of mutual concern, but it often requires creative thinking and a commitment to fairness to develop an acceptable approach to resolving an issue. Nurse’s Role in Influencing the Legislative Process Essay Paper.
It is also important to anticipate problems and areas for disagreement and be prepared to counter them. When the opposition is gaining momentum and support, it can be helpful to develop a strategy that can distract attention from the opposition's issue or that can delay action. For example, one state nurses' association continually battles the state medical society's efforts to amend the Nurse Practice Act in ways that would restrict nurses' practice and provide for physician supervision. Nurses have become concerned about the possibility of passage during a year when the medical society's influence with the legislature was high. A key strategy to deal with this specific example is to develop coalitions and alliances to work with other health provider organizations engaged in similar battles with the physicians (e.g., optometrists, pharmacists) to monitor the current environment and be vigilant if changes arise. With this type of strategy in place, the physician groups will know that there would be a large coalition to deal with if any changes are proposed.
In developing a good defense, arm yourself with data and information about the issue. Be sure to understand how the issue fits in to either the 90organization's current priorities or other important public agenda items. Know the supporters and opponents of the issue. Many groups maintain voting records of legislators on their key legislative agenda priorities. Finally, learning as much as you can about current public agenda items and organizational priorities is critical to being an informed health care professional. Visit your professional organization websites, including, the online home of the American Nurses Association. Also, the websites of specialty nursing organizations can provide valuable up-to-date information on the key issues facing the profession and health care in general.
Don't Make Enemies and Don't Burn Bridges
To burn one's bridges is to cut off any potential future support or collaboration with a person or organization. Because nursing or even health care is such a small world, it is critically important not to burn bridges, no matter how tempted you might be! Building bridges rather than burning them is a much smarter option for the future. It is critical to handle tricky political maneuvers with care and finesse. Everyone has experienced a sound defeat at some stage and the person who can congratulate the winner and move on to learn from the experience will thrive.
Rome Was Not Built in a Day
It is important to remember that it takes a long time to do important work, to create something long lasting and sustainable. This is very true when referring to influence in the political process, whether it is governmental or organizational. It is often reported that it feels like the arguments have been going on for years, but policy successes will not happen immediately. It will take the involvement of many workers or volunteers and countless meetings, going through the political analysis of an issue and pursuing a political strategy to find a policy solution. It is critical not to overestimate the importance of that building process nor underestimate the importance of adding another brick.
Discussion Questions
1. When you are attempting to undertake a political analysis of an issue, one of the key questions to continually ask during the process is: “In this political [or social or economic] climate, can we get this done?” How would you evaluate the barriers that arise from climate or context or timing on a specific issue of interest?
2. For the same issue, who are the stakeholders and how could they be used in a political analysis that might be different from their use in political advocacy? Nurse’s Role in Influencing the Legislative Process Essay Paper.
3. What are the political strategies that could leverage facilitators and constraints into political momentum to move the issue forward?
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Benner P. From novice to expert. Addison-Wesley: Menlo Park, CA; 1984.
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French J, Raven B. The basis of social power. Cartwright D. Studies in social power. University of Michigan Press: Ann Arbor, MI; 1959:150–167.
Gallup. Nursing leadership from bedside to boardroom: Opinion leaders’ perception. [Retrieved from]; 2010.
Gerston LN. Public policy making: Process and principles. M.E. Sharpe: Armonk, NY; 2010. Nurse’s Role in Influencing the Legislative Process Essay Paper.
Hastie T, Tibshirani R, Friedman J. The elements of statistical learning. 2nd ed. Springer: New York; 2011.
Kingdon J. Agendas, alternatives and public policies. 2nd ed. Pearson: New York; 2010 [(Longman Classics in Political Science)].
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Tanner D. Talking from 9 to 5: Women and men at work. [(reprint ed.)] William Morrow Paperbacks: New York; 2001. Nurse’s Role in Influencing the Legislative Process Essay Paper.
Online Resources
American Nurses Association's Take Action.
American Association of Colleges of Nursing.
National League for Nursing. Nurse’s Role in Influencing the Legislative Process Essay Paper.
American Organization of Nurse Executives.
Nurse’s Role in Influencing the Legislative Process Essay Paper.