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CHAPTER 1
A Framework for Action in
Policy and Politics
Mary W. Chaffee, Diana J. Mason, and Judith K. Leavitt
“The true test of the American ideal is whether we’re
able to recognize our failings and then rise together to
meet the challenges of our time. Whether we allow ourselves to be shaped by events and history, or whether we
act to shape them.”
—Barack Obama
On March 23, 2010, President Barack Obama signed
the Patient Protection and Affordable Care Act
(PPACA)—now known simply as the Affordable
Care Act—into law and ten days later signed a reconciliation bill to fine-tune it. This law is arguably the
most significant piece of social legislation passed in
the U.S. since Medicare was implemented in 1965.
For more than a century, there have been organized
efforts to provide universal health coverage in the
U.S. While PPACA does not guarantee coverage for
all, by 2019 it will cover up to 32 million of the 45
million who were uninsured when the bill was signed
(94% of the population). It ends the ability of insurance companies to deny coverage to people with preexisting conditions, to drop people once they acquire
a costly illness, or to apply annual and lifetime caps
on coverage.
But this landmark legislation promises to do more
than reform the health insurance industry. It includes
provisions for beginning to reform how care is delivered. The nation has realized that it can no longer
afford a health care system centered on providing
technology-intensive, acute care to individuals once
they become sick or injured. Despite spending more
on health care than most developed countries, the
U.S. ranked last or next-to-last in 2004, 2006, and
2007 on five indicators of high-performing health
systems (access, quality, equity, efficiency, and health
lives) compared with five other nations (Australia,
Canada, Germany, New Zealand, and the UK) (Davis
et al., 2007). To improve the health of the public and
reduce health care costs, the foundation of the health
system must be remade into one that focuses on
health promotion and wellness, disease prevention,
and chronic care management (Katz, 2009; Woolf,
2009; Wagner, 1998). Acute care must use fewer
resources, be safer, and produce better outcomes
(Conway & Clancy, 2009).
Nurses know how to do all of this and, in fact, do
so every day. After decades marked by nurses’ fighting
to make their perspectives on health care count, the
nation is realizing that they are key to making this
shift a reality. The PPACA contains a number of measures that reflect this (PPACA, 2010). These include
the following:
• The PPACA is replete with opportunities to test
models of care that already hold promise
for improving health outcomes and lowering
health care costs. A new Center for Medicare and
Medicaid Innovations and other pilot programs
and demonstration projects will test and develop
ideas ranging from transitional care to nurse
managed centers, both of which have been innovations led by and using nurses (www.aannet.org/
raisethevoice).
• One area identified in the law for testing is the
patient-centered “medical” or “health homes”1.
Medical homes are single provider or health teams
1
The PPACA refers to refers to both “medical” and “health”
homes; approval of such homes by the National Commission
on Quality Assurance refers to a “medical home” designation,
so this book will use that language, while recognizing that
“health home” is more consistent with a health promotion
model.
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UNIT 1 Introduction to Policy & Politics in Nursing & Health Care
that take responsibility for coordinating all of the
care for the patients it serves, whether this entails
educating and coaching patients to better manage
their chronic illnesses or ensuring that specialty
care is provided and consistent with the patients’
needs or providing transitional care from hospital
to home. Nurses and social workers are the people
who are and will be doing most of this care
coordination.
Community-based health centers will be expanded
in areas where there are health care provider shortages. Expansion of the National Health Service
Corps is expected to ensure that providers, including registered nurses (RNs) and advanced practice
registered nurses (APRNs) will be available to staff
these centers. An emphasis on primary care will
increase the demand for nurse practitioners, and
the law authorizes additional support for pri­
mary care workforce development (loans, scholarships, new educational program development, and
expansion of existing programs).
Payment reforms include piloting bundled payments and care coordination through “accountable care organizations” (ACO). ACOs are similar
to integrated delivery systems that combine services across health care settings and are able to
focus on ways to improve care delivery and health
outcomes under a bundled payment scheme.
Bundled payments will provide financial incentives to providers and health systems to keep
patients healthy, rather than doing unnecessary
tests and procedures that are currently covered on
a fee-for-service basis. Again, nurses are key to
preventing complications in hospitalized patients,
ensuring smooth transitions to home, and coaching the patient and family caregivers in self-care
management and health-promoting behavioral
changes.
The PPACA authorizes demonstrations of “Independence At Home” models of care to keep older
adults healthy and functioning in their own homes.
The models’ aim is improving the quality of life
and health outcomes while reducing costly nursing
home, hospital, and emergency department usage.
Nurses are already leading such programs and are
essential care providers, often as APRNs.
Public health will get a boost from investments in
prevention research, health screenings, health education campaigns, and other programs aimed at
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promoting health. Public health nurses are already
providing such services and will be increasingly
sought after as these programs expand. Nurse
researchers study ways to promote health and
prevent illness; their work will be highly relevant
to the nation’s understanding of how to improve
health.
• A Center for Innovation will support research that
focuses on how to improve the safety and quality
of care. Nurses are key to quality and safety in
health care; they are leading quality departments
in hospitals and health systems. The new Center
provides such nurse leaders and nurse researchers
with opportunities to demonstrate new methods
for improving care in cost-effective ways.
• Various measures authorize funding for nursemanaged centers, improved payment for advanced
practice nurses including nurse midwives, and
workforce development, including the nursing
workforce.
This PPACA demonstrates that nursing’s time has
come, but it doesn’t mean complacency can now be
acceptable. First, the law is only a first step in reforming health care delivery in the U.S. The Social Security
Act, when first passed by Congress in 1935, excluded
most minorities and women through exemption of
specific job categories such as domestic workers. But
over the subsequent years, the law was amended to
extend coverage to all Americans. This perspective
can alert nurses and others to the need to continue to
develop statutes that improve upon PPACA. At the
same time, some people who opposed PPACA will
seek to dismantle it. Others will examine PPACA’s
impact on local and state health systems and policies
and look for ways to use its mandates and provisions
to improve care on a local level. Nurses can and must
identify opportunities to implement and improve the
law and shape local responses to it.
Second, the implementation of the law is dependent upon the regulations developed by the Department of Health and Human Services (HHS) and
state responses including expansion of Medicaid
(www.healthreformgps.org). For example, the PPACA
provides the HHS Secretary with wide authority to
expand pilot programs once tested. The staff of the
Center for Medicare and Medicaid (CMS) will write
regulations that could remove barriers to APRN practice, such as the restriction that a physician must
order hospice and home health services to be eligible
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CHAPTER 1 A Framework for Action in Policy and Politics for Medicare coverage. This requirement initially was
intended to limit federal costs but now is viewed as
1) impeding efficient care delivery, 2) costing more
because of duplication of providers and continuation
of more expensive acute care services, and 3) presenting unnecessary barriers to access to care.
Another example is the law’s call for an expansion
of home visitation programs for high risk mothers
and infants. The Nurse-Family Partnership is the
model for this measure, but the law does not specify
that the services be provided by nurses despite
evidence that nurses produce significantly better
outcomes than non-nurses as home visitors (Karoly,
Killburn, & Cannon, 2005). States will be responsible
for developing health insurance exchanges to provide
options for coverage for those who are not covered by
employers.
Third, while there are some measures in the law
that bypass the Congressional appropriations process,
most of the public health and workforce initiatives
must have funding appropriated by Congress every
year. As the nation’s deficit increases, Congress is
unlikely to appropriate funding for programs that do
not have strong, vocal advocates.
So while nursing is well positioned to contribute
to a reformed health care system, we cannot assume
that those making the decisions about how to reform
it will automatically seek nurses’ input. A 2010 Gallup
poll of over 1500 non-nurse, health-care opinion
leaders revealed that these leaders viewed nurses as
essential for quality and safety in health care, but only
14% believed that nurses would be influential in
reforming health care (Gallup, 2010). Whether developing new models of care, sharing ideas for regulations with policymakers, working with health care
organizations to develop demonstration projects that
the new law seeks to test, or advocating new legislation to amend and improve upon the law (or preventing it from being dismantled), nurses must assume
the mantle of politically savvy leaders who are shaping
health policy at the local, state, and national levels
within government, workplaces, health-related organizations, and communities.
Policy and the
Policy Process
Policy is the deliberate course of action chosen by
an individual or group to deal with a problem
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(Anderson, 2006). Public policies are the choices made
by public or government officials to deal with public
problems (Kraft & Furlong, 2010). Public policies are
authoritative decisions made in the legislative, executive, or judicial branches of government intended to
influence the actions, behaviors, or decisions of others
(Longest, 2005). When the intent of a public policy is
to influence health or health care, it is a health policy.
Social policies identify courses of action to deal with
social problems. All are made within a dynamic environment and a complex policymaking process.
Policies are crafted everywhere from small towns
to Capitol Hill. Federal health policy takes many
forms including bills passed by Congress such as the
Medicare Modernization Act of 2003 and workplace
safety regulations enforced by the Occupational Safety
and Health Administration. President Bill Clinton
banned smoking in federal buildings by executive
order, another type of policy (Cook & Bero, 2009).
States use policies to specify requirements for licensure in the health professions, to set criteria for eligibility for Medicaid, and to mandate immunization
requirements for public university students, for
example. Hospitals use policies to direct when visitors
may visit patients, to manage staffing, and to respond
to disaster. Public schools employ policies to specify
who may administer medications to schoolchildren.
Towns, cities, and other municipalities use policies to
manage public water supplies, to define who may run
for office, and whether or not residents may keep
exotic pets.
In a capitalist economy such as the U.S., private
markets are permitted to control the production and
consumption of goods and services, including health
services. The government “intrudes” with policies
only when the private markets fail to achieve desired
public objectives. When it is necessary for the government to intercede, two types of policy are used:
• Allocative policies are used to provide benefits to a
distinct group of individuals or organizations, at
the expense of others, to achieve a public objective
(this is also referred to as the redistribution of
wealth). The implementation of Medicare in 1966
was an allocative policy that provided health
benefits to older adults and others using federal
funds (largely from middle- and higher-income
taxpayers).
• Regulatory policies are used to influence the actions,
behavior, and decisions of individuals or groups to
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UNIT 1 Introduction to Policy & Politics in Nursing & Health Care
ensure that a public objective is met (Longest,
2005). The Health Insurance Portability and
Accountability Act of 1996 is a regulatory policy. It
regulates how individually identifiable health
information is managed by users as well as other
aspects of health records.
Forces that Shape
Health Policy
Many forces shape health policy. Some of the most
prominent forces appear in Figure 1-1.
Values
Values influence all political and policymaking activities. Public policies reflect a society’s values—and also
conflicts between values. A policy reflects which value
(or values) is given priority in a specific decision
(Kraft & Furlong, 2010). Once framed, a policy reveals
the underlying values that shaped it. This is usually
apparent in health policies; these often affect those
who are unable to protect themselves like the young,
poor, sick, old, and disabled. Different people value
different things, and when resources are finite, policy
choices ultimately bring a disadvantage to some
groups; some will gain something from the policy,
and some will lose (Bankowski, 1996). To support or
oppose a policy requires value judgments (Majone,
1989). Conflicts between values were apparent
throughout the debate on health care reform; for
example, despite a strong contingent of advocates for
a government-run, non-profit insurance option that
would compete with private insurers, it was not
included in the law after opposition from the insurance industry and from people who believed that it
represented an increase in the government’s control
of health care.
Politics
Politics is frequently associated with a negative connotation, yet it is actually a neutral term. Politics is
the process of influencing the allocation of scarce
Values
Policy
Analysis and
Analysts
Interest
Groups
Problem
Identification
Evaluation
The Media
The
Policy
Process
Agenda
Setting
Advocacy
and Activism
Alternatives
Implementation
Policy
Choice
Science
and
Research
Presidential
Power
Politics
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FIGURE 1-1 The forces that shape policy.
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CHAPTER 1 A Framework for Action in Policy and Politics resources. Policymaking involves the distribution of
resources; so politics or political action can be viewed
as the efforts and strategies used to shape a policy
choice. The definition of politics contains several
important concepts. Influencing indicates that there
are opportunities to shape the outcome of a process.
Allocation means that decisions are being made about
how to distribute resources. Scarce implies that there
are limits to the amount of resources available—and
that all parties likely cannot have all they want. Finally,
resources are usually considered to be financial, but
could also include human resources (personnel),
time, or physical space such as offices (Mason, Leavitt,
& Chaffee, 2007). Politics can also be considered to
be how conflicts in a society are expressed and resolved
in favor of one set of values or interests over another
(Kraft & Furlong, 2010).
Political skill has a bad reputation; for some it
conjures up thoughts of manipulation, self-interested
behavior, and favoritism (Ferris, Davidson, &
Perrewe, 2005). “She plays politics” is not generally
considered to be a compliment, but true political skill
is critical in health care leadership, advocating for
others, and shaping policy. Ferris et al. (2005) consider political skill to be the ability to understand
others and to use that knowledge to influence others
to act in a way that supports one’s objectives. They
believe political skill has four components:
1. Social astuteness: Skill at being attuned to others
and social situations; ability to interpret one’s own
behaviors and the behavior of others.
2. Interpersonal influence: Convincing personal style
that influences others featuring the ability to adapt
behavior to situations and be pleasant and productive to work with.
3. Networking ability: The ability to develop and use
diverse networks of people and the ability to
position oneself to create and take advantage of
opportunities.
4. Apparent sincerity: The display of high levels of
integrity, authenticity, sincerity, and genuineness
(p. 11).
Policy Analysis and Policy Analysts
Analysis is the process of examining an object and
breaking it down to understand it better. Policy analysis uses different methods to assess a problem and
determine alternative ways to resolve it. This encourages deliberate critical thinking about the causes of
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problems, identifies the various ways a government
or other group could act, evaluates the alternatives,
and determines the policy choice that is most desirable. Policy analysts are individuals who, with professional training and experience, analyze problems and
weigh potential solutions. Citizens can also use policy
analysis to better understand a problem, alternatives,
and potential implications of policy choices (Kraft &
Furlong, 2010).
Advocacy and Activism
Advocacy for one patient at a time has long been
considered a core nursing role. Advocating for change
through policy and politics permits nurses to advocate on a larger scale and is endorsed in Nursing’s
Social Policy Statement (ANA, 2003), a document that
defines nursing and its social context. Political activism may be associated with protests and “sit-ins” but
has grown to include diverse and effective strategies
such as blogging, using evidence to support policy
choices, and garnering media attention in sophisticated ways.
Interest Groups and Lobbyists
Interest groups advocate for policies that are advantageous to their membership. Groups often employ
lobbyists to advocate on their behalf, and their
power cannot be underestimated. In the U.S. in
2009, about 1,750 businesses and organizations
spent at least $1.2 billion on lobbyists to advocate
for their interests in the health care reform debate
and on many other issues (Center for Public
Integrity, 2010).
The Media
In 2009 and 2010, Pulitzer-prize winning journalist
Charles Ornstein and his colleague Tracy Weber
published a series of investigative reports on the
California Board of Registered Nursing’s excessive
delays in acting on reports of professional misconduct
by RNs for whom evidence of wrongdoing was
well documented (Weber & Ornstein, 2010). The
board took an average of three years to take disciplinary action, including against nurses who were charged
with physically and sexually abusing patients or were
in prison but still getting their licenses renewed,
The journalists’ initial reports resulted in more staff
being hired by the board, but when it was not
clear that they had successfully improved processing
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UNIT 1 Introduction to Policy & Politics in Nursing & Health Care
times and more reports were published by Ornstein
and Weber, the governor dismissed the board’s
members and replaced them with new ones. The
executive director of the board—a nurse—
subsequently resigned. The governor advocated new
legislation to require employers to notify the board
whenever they fire or suspend a nurse for serious
wrongdoing and permit a state official to suspend the
license of any nurse who is deemed to represent a
threat to the public. In 2010, the legislation was
opposed by leading nurses’ unions in the state (Weber
& Ornstein, 2010).
Ornstein and Weber work for ProPublica, one of
a growing number of non-profit investigative news
organizations. They used traditional newspapers
(the Los Angeles Times) to help disseminate their
stories, but also created an interactive web site (www.
propublica.org/series/nurses) that profiled individual
nurses and provided comparative data on disciplinary
actions by other state boards for nursing. They also
used new media, or social media, to further push their
work out to other audiences. But new media have also
introduced easily accessible tools for activists and
advocates to use to become citizen journalists and
influence policy.
Science and Research
Scientific findings can play a powerful role in the first
step of the policy process—getting attention for particular problems and moving them to the policy
agenda. Research can also be valuable in defining the
size and scope of a problem (Diers & Price, 2007).
This can help to obtain support for a particular policy
option and in lobbying for support for it. Evidence
should be used to inform policy debates and shape
policy choices to help ensure that the solution will be
effective.
Presidential Power
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The president embodies the power of the executive
branch of government and is the only person elected
to represent the entire nation. As the most visible
government official, the president is able to propel
issues to the top of the nation’s policy agenda. Though
the president cannot introduce legislation, he can
provide draft legislation and legislative guidance
(Weissert & Weissert, 2006).
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The Framework for Action
The first edition of this book, Political Action Handbook for Nurses: Changing the Workplace, Government,
Organizations and Community, introduced readers to
a model of political action for nurses (Mason &
Talbott, 1985) named the Framework for Action. The
model used “spheres of influence” to conceptualize
the places where nurses use politics to shape policy
and to work for change in the health system. The
original Framework for Action’s four spheres of influence were labeled: (1) the workplace, (2) the government, (3) organizations, and (4) the community. The
original “workplace” sphere has been broadened now
to include the workplace and the workforce. This
addresses the policy work that is done in a variety of
places to influence the size, educational preparation,
and competence of the nursing workforce. The original “organizations” sphere was defined as professional
nursing associations (Mason & Talbott, 1985, p. 444).
Recognizing that nurses work to influence policy
through other types of associations, such as interdisciplinary groups and unions, this sphere has now been
reconceptualized as “associations and interest groups”
(Figure 1-2).
The Framework for Action has been updated to
reflect current knowledge about health care and the
impact of social determinants on health (Figure 1-3).
It more thoroughly explains nursing’s role in
The
Community
The
Workplace
and
Workforce
The
Community
Interactions
among the
Spheres
Associations
and
Interest
Groups
The
Government
The
Community
FIGURE 1-2 The four spheres of influence where nurses shape
policy. The spheres overlap; activity in one can affect the others.
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CHAPTER 1 A Framework for Action in Policy and Politics Nurses
The
Workplace
and
Workforce
The
Government
Associations
and
Interest
Groups
The
Community
Health and Social Policy
Health System + Social Determinants of Health
Health
FIGURE 1-3 The targets of the spheres of influence. Nurses work
in four spheres of influence to shape health and social policy.
Policies are designed to remedy problems in the health system
and to address social determinants of health to improve health.
improving health through influencing policy. Action
in the spheres of influence can shape policy that can
then influence the health system and social determinants of health.
The spheres of influence are not discrete silos.
Each is a part of a broader, more complex system
where change in one sphere often influences changes
in others. Policy can be shaped in more than one
sphere at one time, and action in one sphere can
influence others. To achieve greater access to care for
the uninsured, for example, nurses may work in their
own organization to alter policy to increase access to
services. They may also use political strategies in the
media, such as blogging or being interviewed on television, to express their support for better access to
care. They may work with their professional association, or an interest group, to communicate their views
to policymakers. Additional context (the who, what,
where, when, and why of nursing’s policy influence)
is provided in Figure 1-4.
Sphere of Influence 1: The Community
While a limited number of nurses will have the
opportunity to influence policy at the highest
levels of government, there are more extensive
Mason_4166_Chapter 1_main.indd 7
opportunities for nurses to influence health and social
policy in communities. Nursing has a rich history of
community activism with remarkable examples provided by leaders such as Lillian Wald, Harriet Tubman,
and Dorothea Dix. This legacy continues today with
the community advocacy efforts of nurses like Cora
Tomalinas, Mary Behrens, Ruth Lubic, Patricia Tobal,
Ellie Lopez-Bowlan, the Nightingales who took on big
tobacco, and the nurses who are a part of the Canary
Coalition for Clean Air (all of their stories appear in
this book).
A community is a group of people who share
something in common and interact with one another,
who may exhibit a commitment with one another,
and may share a geographic boundary (Lundy &
Janes, 2001). A community may be a neighborhood,
a city, an online group with a common interest, or a
faith-based network. Nurses can be influential in
communities by identifying problems, strategizing
with others, mobilizing support, and advocating for
change. In residential communities (such as towns,
villages, and urban districts), there are opportunities
to serve in elected and volunteer positions that influence policy. Many groups, such as planning boards,
civic organizations, and parent-teacher associations,
offer opportunities for involvement.
Sphere of Influence 2: The Workforce
and Workplace
Nurses work in a variety of settings: hospitals, clinics,
schools, private sector firms, government agencies,
military services, research centers, nursing homes,
and home health agencies. All of these environments
are political ones—resources are finite, and nurses
must work in each to influence the allocation of organizational resources. Policies guide many activities in
the health care workplaces where nurses are employed.
Many that affect nursing and patient care are internal
organizational policies such as staffing policies, clinical procedures, and patient care guidelines. External
policies are operative in the health care workplace
also, for example, state laws regulating nursing licensure and immunization requirements of clinical practitioners. Federal laws and regulations are evident in
the nursing workplace such as Occupational Health
and Safety Administration regulations regarding
worker protection from bloodborne pathogens.
Outside of the workplace, policy is made that
influences the size and composition of the nursing
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UNIT 1 Introduction to Policy & Politics in Nursing & Health Care
WHO?
WHERE?
Who acts to
influence health
and social
policy?
In what
environments, or
spheres of influence,
do nurses act to
influence policy?
1. The Workplace
and Workforce
2. The
Government
Nurses
3. Associations
and Interest
Groups
4. The Community
WHAT?
WHEN?
WHY?
What are examples of
strategies nurses use to
influence policy?
When do nurses
act to influence
policy?
Why do nurses act
to influence
policy?
• Conduct political analysis
• Become knowledgeable
about issues
• Provide testimony
• Write letters to the editor
• Make campaign donations
• Participate in community
activism
• Build coalitions
• Contact policymakers
• Obtain media coverage
• Conduct research to create
evidence
• Shape policy with evidence
• Obtain appointments to
influential positions
• Lobby key individuals
• Join influential groups
• Run for office
• Identify policy problems and
analyze solutions
• Publish articles
• Serve on boards
• Identify focusing events
• Identify goals
• Assess political feasibility
• Identify supporters and nonsupporters
• Volunteer on campaigns
• Prepare issue briefs
• Assess who will benefit and
who will lose
• When a social or
health problem
needs a remedy
• When a focusing
event occurs
• When the
political
environment is
ripe
• When the
national (or local)
mood supports
change
• When
opportunity is
identified
• To improve
human health
• To improve
access to care
• To improve the
safety of care
• To improve the
quality of care
• To remove
disparities in care
• To reduce the
cost of care
• When a policy
has unintended
consequences
FIGURE 1-4 The who, what, where, when, and why of nursing’s policy influence.
workforce. The new PPACA authorizes increased
funding for scholarships and loans for nursing
education—potentially augmenting existing workforce programs funded under Title VII and VIII of the
Public Health Act. The non-governmental Commission on Graduates of Foreign Nursing Schools is
authorized by the federal government to protect the
public by ensuring that nurses and other health care
professionals educated in countries other than the
U.S. are eligible and qualified to meet licensure, immigration, and other practice requirements in the U.S.
(Commission on Graduates of Foreign Nursing
Schools, 2009). The National Council of State Boards
of Nursing is a not-for-profit organization that brings
together state boards of nursing to act on matters of
common interest affecting the public’s health, safety,
and welfare, including the development of licensing
examinations in nursing (National Council of State
Boards of Nursing, 2009).
Sphere of Influence 3: The Government
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Government action and policy affects lives from birth
until death. It funds prenatal care, inspects food, bans
unsafe toys and cars, operates schools, builds highways, and regulates what is transmitted on airwaves.
Mason_4166_Chapter 1_main.indd 8
It provides for the common defense; supplies fire and
police protection; and gives financial assistance to
the poor, aged, and others who cannot maintain a
minimal standard of living. The government responds
to disaster, subsidizes agriculture, and licenses funeral
homes (Heineman, Peterson, & Rasmussen, 1995).
Though most health care in the U.S. is provided in
the private sector, much is paid for and regulated by
the government. So, how the government crafts
health policy is extremely important (Weissert &
Weissert, 2006). Government plays a significant role
in influencing nursing and nursing practice. States
determine the scope of professional activities considered to be nursing, with notable exceptions of the
military, veterans’ administration, and Indian health
service. Federal and state governments determine
who is eligible for care under specific benefit programs and who can be reimbursed for providing care.
Sometimes government provides leadership in defining problems for both the public and private sectors
to address (Mason et al., 2007). At least eight House
and Senate committees and subcommittees shape
policy on health, and many more committees address
social problems that affect health. In the House of
Representatives, the House Nursing Caucus, an
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CHAPTER 1 A Framework for Action in Policy and Politics 9
informal, bipartisan group of legislators who have
declared their interest in helping nurses, lobbies for
federal funding for nursing education (Walker, 2009).
Abraham Lincoln’s description of a “government
of the people, by the people and for the people”
(1863) captures the intricate nature of the relationship of government and its people. There are many
ways nurses can influence policymaking in the government sphere—at all levels of government (local,
state, and federal). Examples include the following:
• Obtaining appointment or assignment to influential government positions
• Serving in federal, state, and local agencies
• Serving as elected officials
• Working as paid lobbyists
• Communicating to policymakers their support or
opposition to a policy
• Providing testimony at government hearings or
open meetings
• Participating in grassroots efforts, such as rallies,
to draw attention to problems.
a member of the Safer Chemicals, Healthy Families
coalition, a coalition whose members are united by a
common concern about toxic chemicals in homes,
workplaces, and products used every day. The Coalition for Patients’ Rights is a group of 35 national
organizations representing health care professionals
who are working to fight the American Medical
Association’s attempts to limit patients’ access to
non-physician providers (www.patientsrightscoalition.
org). Twenty-six of the members are nursing
organizations.
Nurses can be influential, not just in nursing associations, but through working with other interest
groups such as the American Public Health Association and the Sierra Club. Some interest groups have
a broad portfolio of policy interests, while others
focus on one disease (e.g., breast cancer) or one issue
(e.g., driving while intoxicated). Interest groups have
become powerful players in policy debates; those with
large funding streams are able to shape public opinion
with television and radio advertisements.
Sphere of Influence 4: Associations
and Interest Groups
Health
Professional nursing associations have played a significant role in influencing the practice of nursing.
Many professional nursing associations have legislative or policy committees that advocate for policies
that support their members’ practice. For example,
the American Nephrology Nurses Association identifies advocacy as a core value in their strategic plan.
One of their goals is to be the leading advocate for
nephrology nursing and to advocate for individuals,
families, and communities affected by real or potential kidney disease (American Nephrology Nurses
Association, 2009). Many nursing specialty groups
provide training and workshops for nurses interested
in learning the ropes of political involvement as well
as online resources to assist members in their advocacy efforts. Working with a group increases the
chances for advocacy to be effective, provides an environment where resources can be shared, and enhances
networking and learning. Nurses can be effective in
association policy activities by serving on public
policy or legislative work groups, providing testimony, and preparing position statements.
When nursing organizations join forces through
coalitions, their influence can be multiplied. For
example, the American Nurses Association (ANA) is
Mason_4166_Chapter 1_main.indd 9
The Framework for Action now includes health as an
element of the model to represent that optimal health
is viewed as the goal of nursing’s policy efforts.
Optimal health (either the individual patient’s or a
population’s) is the central focus of the political and
policy activity described in this book. This focus
makes it clear that the ultimate goal for advancing
nursing’s interests must be to promote the public’s
health.
Health and Social Policy
Health and social policy now appear as elements in
the Framework for Action. Many factors that affect
health status are social factors such as income, education, and housing. Thus it was important to identify
the important role that social policies play in influencing health.
Social Determinants of Health
An important update to the framework is the inclusion of the concept of social determinants of health.
Even in the most affluent nations, people who are
poor have substantially shorter life expectancies and
experience more illness than the rich (Wilkinson &
Marmot, 2003). While health can be improved with
changes to the health system, an agenda for health
10/15/2010 5:29:17 PM
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10
UNIT 1 Introduction to Policy & Politics in Nursing & Health Care
TABLE 1-1 Political Aspects of the Social
Determinants of Health
• The health of individuals and populations is determined
significantly by social factors.
• The social determinants of health produce great inequities in
health within and between societies.
• The poor and disadvantaged experience worse health than
the rich, have less access to care, and die younger in all
societies.
• The social determinants of health can be measured and
described.
• The measurement of the social determinants provides
evidence that can serve as the basis for political action.
• Evidence is generated and used in a continuous cycle of
evidence production, policy development, implementation,
and evaluation.
• Evidence of the effects of policies and programs on inequities
can be measured and can provide data on the effectiveness
of interventions.
• Evidence about the social determinants of health is
insufficient to bring about change on its own; political will
combined with evidence offers the most powerful strategy to
address the negative effects of the social determinants.
Adapted from: National Institute for Health and Clinical Excellence. (2007).
The Social Determinants of Health: Developing an Evidence Base for
Political Action. Final report to the World Health Organization Commission
on the Social Determinants of Health. Lead authors: J. Mackenbach, M. Exworthy, J. Popay, P. Tugwell, V. Robinson, S. Simpson, T. Narayan,
L. Myer, T. Houweling, L. Jadue, and F. Florenza.
improvement should be based on understanding the
social determinants (Wilensky & Satcher, 2009). Policies are needed to address the social and economic
conditions that make people ill. Universal access to
care is one social determinant of health (Wilkinson &
Marmot, 2003). Political aspects of the social determinants of health appear in Table 1-1.
Conclusion
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Nurses are well-positioned for reforming health care
in ways that promote a healthier public and reduce
health care costs. But we must be strategic in our
leadership, whether in clinical settings to improve the
safety and quality of care or advocating for nursemanaged health centers that provide comprehensive
primary care and community services to vulnerable
and underserved populations. The health care opinion
leaders in the 2010 Gallup poll discussed in the
Mason_4166_Chapter 1_main.indd 10
opening of this chapter identified two reasons why
nurses would fall short of influencing health care
reform: too many nurses didn’t want to lead, and the
myriad nursing organizations rarely presented a
united front. We must not fall short. This book can
help nurses to overcome barriers. It is time.
For a list of related websites, please refer to your Evolve
Resources at http://evolve.elsevier.com/Mason/policypolitics/
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