Nurses’ policy influence: A concept analysis
Abstract
Background:
Nurses’ influence on health policy protects the quality of care by access to required recourses and opportunities. This is a new and important concept for nursing; however, research studies on policy influence of nurses in health care sector are lacking a basic conceptual understanding of what this concept represents. The aim of this paper is to clarify the concept of nurses’ policy influence and to propose the definition of this concept, considering the context of Iran.
Materials and Methods:
The eight stages of Walker and Avant approach was used to guide this concept analysis. Various databases and internet engines were searched to find all related information about the concept. Textbooks were also searched manually. English language literature reports published between 1990 and 2012 were reviewed.
Results:
Based on the analysis undertaken, nurses’ policy influence is nurses’ ability in influencing decisions and affairs related to health through political knowledge, effective communication, and collaboration with other members of the health team, which results in the improvement of nurses’ job environment and increases patient outcomes. This is a dynamic process situated on a spectrum and is accompanied with nurses’ knowledge, competency, power, and advocacy, and also their ability to change.
Conclusions:
Nurses have individual views on health care issues and influence health care policies in different ways. With a common understanding of nurses’ policy influence as a concept, nurses will recognize the importance of policy making in the health sector and their influence on this process and also on patients’ outcomes.
Introduction
Health systems are rapidly developing and changing. Nurses, as a part of this system, should move forward along with these changes.[1] For this purpose, nurses need to influence the formulation of health policies rather than just implementation of them. Then, they need to be active in the development of health policies to be better able to control their practice.[2] In this process, nurse leaders have a very important role. They need to acquire policy-making skills in order to address professional challenges.[3] Because of their values, professional ethics, advocacy skills, and experiences, nurse leaders have unique and valuable views toward health policies.[2] There has been increasing growth toward nurses’ presence, role, and influence in health policies during recent decades. Nurses are expected to identify the issues deliberately and work with other decision makers to advance health care policies. They should understand the levels of power, and know who controls the resources of health services in their organizations.[4] Therefore, we can go ahead and say that nurses have to be involved in policies which affect patients, families, themselves, and the whole health care system.[5]
Nurses’ influence in health polices protects patient safety, increases quality of care, and facilitates their access to the required resources and promotes quality health care.[4,6] Accordingly, the concept of policy influence in nursing is a new and important concept, but there is lack of conceptual clarity with regard to what this concept really represents. Dowswell et al. (2002) in their study showed that most primary care groups in primary care centers consulted with local nurses about the key fields in care services and they believed that consultation with nurses had been effective.[2] On the other hand, results of a survey about the health managers’ and authorities’ perceptions of the effect of various health professions on revision of health affairs reveal that nurses are in the sixth (the last) grade with a dominant point interval in comparison to other health professionals.[7]
There is an ambiguous point here whether or not what Dowswell et al. (2002) reported as consultation with nurses in local fields really represents nurses’ policy influence. It seems that the extent of applying this concept is wide and not clearly addressed in literatures. On the other hand, we should state that health systems’ policies settle within three levels: Micro, macro, and meso. In the micro level, policies are just for especial parts, fields, or groups, and have not been made essentially by the government, whereas in the macro level, policies are for the whole country and have been made essentially by the government.[8] The meso level policies settle between micro and macro levels and have usually been made by official organizations.[9] Now can we call what happens in all these three levels as policy influence? So, clarifying and defining this concept in order to develop it, especially in different levels of nursing management is essential. By clarifying this concept, we can reach a common language and help to increase the credibility of future studies.
Materials and Methods
This study was carried out using concept analysis approach, by which an abstract concept is defined and clarified and differentiated from similar concepts.[10] We used the eight-stage Walker and Avant approach, which is a clear and systematic method of concept analysis and also the most common one. Table 1 shows Walker and Avants's eight stages method for concept analysis. This method is especially useful for novice concept analysts,[11] and had been successfully applied in previous analysis of the concepts.
Table 1
Walker and Avants’ eight stages method for concept analysis
One probable concern about using Walker and Avant approach is insufficient conceptual clarification[12] due to the context-free nature of this approach.[11] Concepts may have different meanings in different theoretical contexts. While conceptual clarification should be achieved through referring to different existing theoretical contexts, some analysts have commitment that the concepts’ own theoretical context should be highlighted. Thus, they suggest that if there is no theory or theoretical framework for the concept in literatures, this should be stated explicitly by the analysts.[12] In the present concept analysis, we have considered this concern. While there is not any direct theory that represents the concept of nurses’ policy influence, we have referred to relevant theories with both nursing and management context. In the “Discussion” section, we have addressed the concept's relevance with existing theories.
In the process suggested by Walker and Avant, the first and second stages are identifying a suitable concept for analysis and then determining its purpose.[10] As mentioned earlier, the extent of using nurses’ policy influence as a concept has not been determined clearly. This means it is not clear whether we can address consultation with nurses from operational levels of nursing care about health and nursing issues as influencing the policies or this is a concept that just addresses high levels of nursing management and leadership. It is not clear which one of activities carried out in these extended levels can be introduced as policy influence. Thus, this is a new and valuable concept for nurses. The principal purpose of this concept analysis is to clarify and develop the concept and to propose a definition for it, through which nurses can better understand the importance of policies in health care system and the necessity for their involvement in policies and to have their influence on them.
The third stage is review of literature. According to Walker and Avant, review of literature should not be limited to nursing literatures to prevent bias in understanding the concept.[12] In the search strategy, we searched various databases including PubMed, Science Direct, Elsevier, CINAHL, and also Google Scholar as an internet search engine, using relevant key terms, “nursing AND policy involvement,” “nursing AND policy influence,” “nursing AND policy making,” and “nursing AND decisional involvement.” Only English articles published between 1999 and 2013 were reviewed. Finally, 24 articles related to nurses’ policy influence were selected. We also searched English dictionaries, the textbooks about nursing management, and nurses’ guide to health policies manually. Here is a summary of this review:
Looking back at the nursing background in the 19th century, we find nurse leaders such as Florence Nightingale, Sojourner Truth, Lillian Wald, and Margaret Sanger who have had extraordinary roles in the development of policies, especially in women's, newborns’, school children's, and environmental health.[4] In 1991, the American Association of College of Nursing (AACN) announced that it is necessary to add health policy education to the field of nursing at Master's level.[5] We also found nursing courses with the content of policies in baccalaureate degree programs after the year 2000.
Therefore, it seems that nurses should be knowledgeable about all issues related to health system, and not just caring issues. Certainly, days of just carrying out the prescribed orders are over for nurses globally. Now it is time for nurses to be health legislators and develop practical policies.[13] Kowalik and Yoder point to health care organizations which have identified the importance of nurse leaders’ participation in decisional affairs. They believe that the outcomes of having strong voice in the fields of decision making will enhance the quality of patients’ care.[14]
However, the managerial roles of nurse leaders, such as decision making, analyzing, control, and budgeting, are still considered as less valuable from the viewpoint of health system managers.[15] Nurses should know that the political ideology of health care system and policy-making process will shape nursing leadership, whether it is a political, clinical, academic, or management leadership.[16]
There are two words in the lexicon (2006) including “policy” and “politics,” which need to be defined. Although these two words are different, because of their similar tone, they infer same concepts and are usually used interchangeably. In order to wildly define these two words, both as a general and as a management and health concept, analysts have referred to dictionaries, articles, and books with the approach of nursing policy and nursing management.
The word “policy” comes from “politia” which is a Latin word. Policies are decisions which are made by people who have power and authority. On the other hand, policy sometimes means regulations for how to behave.[17] Thus, we can define policy as, “practical ways or principles accepted or suggested by a government, group, profession, or an individual.”[18] Meanwhile, Mason, Leavitt, and Chaffee are nurses who define policy as, “choices of society or a part of society or organization, with consideration of purposes, health priorities, and ways of resource supply in order to reach purposes.”[19] In management books, policies are guidelines for procedures and helping people for decision making. What is important for management's authorities is to understand how policies can support effective leadership.[20]
The word “politics” is derived from “politica,” a Greek word which means “related to citizens.” In fact, this word has been driven from Aristotle's book named “Citizen Affairs” which is about government and how to govern. For the first time in 1430, this word with the title of “politiqu” was imported to English, and in 1520, was changed to “politics”. Politics is the art and science of governing. Politics refers to people's affairs and authority of government. As we see, polities is always related to organizational process and government function, while policies sometimes are principles and acts for how to behave. Finally, politics refers to the ways and techniques for regulation and using policies.[17] Mason et al. define politics as the art of influence to supply rare resources such as money, time, personnel, and materials.[19] From management point of view, “politics” is the art of influencing others; it is a means to get ends.[20]
To better clarify the concept of policy influence, we also need to define the concept of “influence.” In Webster's dictionary (1977), influence is defined as affecting others without any force or pressure.[21] As previously mentioned, some authorities of management define politics as the art of influence. Thus, the words “influence” and “politics” or “influence” and “policy” are very much related to each other. In fact, without influence, many wise policies are operationally unusable. For example, imagine a person who has a lot of important and consistent views and opinions about one of the patient care issues, but the people working with him/her think contrary. Here, we should ask the questions of how we can influence others to make them come in our direction and what kind of power we can use.[20] Also, the concept of influence has a very near association with the concept of power. We will discuss about it more in this article.
Results
Attributes
The fourth stage is clarifying attributes. According to Walker and Avant (2005), attributes are characteristics which are with the concept or related to it.[10] Review of literature helps us to find these attributes. Instead of using many attributes which are less related to the concept, it is better to use less attributes with more relations.[12] Policy influence is accompanied with the following attributes: the spectrum of policy influence, power, and advocacy. Before explaining these attributes, let us first discuss the concepts with a close meaning to policy influence. These are concepts which have some, but not all of the attributes of the concept. These are decisional involvement, policy making, political influence, and policy involvement. The concept of decisional involvement was analyzed by Kowalik and Yoder. They stated that decisional involvement is affecting a judgment or a result.[14] Thus, decisional involvement is a means for policy making and achieves policy influence. Policy making is one of the activities which are done during the process of policy influence. Political influence refers to governmental persons who have points of authority and power. Most of the times, for individuals to be influential in polices, they require to be politically influenced. Policy involvement may have very close meaning to the concept of policy influence.
Like policy influence which can be considered on a spectrum, policy involvement has three levels. According to Boswell et al., policy or political involvement entails the use of activities and behaviors to have an effect on governmental and legislative strategies. In the first level, the individual will just be a voter. At the second level, the individual goes beyond just voting and will take a hard look at personal values, beliefs, and world views. These stimulators will make them as being an adherent for a group of individuals. In the final level, the individual reaches a level of commitment that involves the development of health policies.[22]
The attributes to policy influence have been described below.
Policy influence is moving on a spectrum which begins from policy literacy, moves forward to policy acumen, and then continues to policy competence and finally to policy influence. Policy literacy was first introduced by Malon (2005). For nurse beginners, there are two ways to practice policy literacy. One way is referring to policy documents and asking these questions: What is the problem? When was the process begun? How many are affected? And who are the stakeholders?[23] Another way is to participate in especial political courses.[16,24]
When the abilities of beginners are developed, they can involve in policy acumen. Policy acumen is the ability to analyze policies, and when nurses acquire policy acumen, they can actively analyze organizational process and health care services. Policy competence is related to management in health care. Managers who have acquired policy competence can direct their organizations in response to the challenges and opportunities related to political situations and also make policies which have desirable effects on their organizations. Finally, we have reached policy influence which refers to the nurses who are able to give especial consultation to governments about nursing issues and have important roles in development, implementation, and evaluation of government policies about health care.[23]
The second attribute of policy influence is power. Power is the ability to achieve goals. On the other hand, power is the inherent ability to influence others. Potential factors for maximum influence will be achieved by strengthening the basis of power. Power is an essential aspect for leadership. Thus, nurses should acquire enough information about the presence and place of power fields. What nurses need and should know about power is “power with others” instead of “power on others.” Indeed nurses need power as one attribute of policy influence to protect the quality of care and to change organizations.[20]
The third attribute of policy influence is advocacy. Nurses have long been known as patient advocates. An advocate should be active in political process of his/her country (i.e. by voting). Without involvement in policies, advocating role of nurses will be ineffective.[22] Nurses as advocates should know that when they want to influence decision makers, they need to understand that they are working in an “open system,” so they are affected by many factors. An advocate should ensure that everything influencing decision makers for developing a plan has been understood and considered.[24] They need to recognize conflicts as important components to success and manage them effectively.[25]
Model case
The fifth stage is presenting a model case. Model cases are valuable for better clarification of abstract concepts in nursing and should have all the attributes of a concept.[10] A model case of Iranian nurses policy influence is presented here. Iranian Nursing Organization (INO) was established in December 2001 after years of work for counseling, mentoring, and lobbying. INO is the most active nursing organization and the largest one in Iran which has been established by Iranian nurse activists. This is a non-governmental organization (NGO) according to Iran's constitution. The main mission of this organization is to improve nursing profession in Iran by protecting and supporting nurses’ rights, improving their knowledge, skills, and on-the-job education, and introducing nursing to society.[26]
If we look at the pathway that Iranian nurse activists paved to establish this organization, we can find the attributes of policy influence. First of all, Iranian nurse activists searched and investigated for similar constructions in the world, such as American Nursing Association (ANA), and in this way, they increased their policy literacy. Then, they started to analyze the findings and reached a consensus on the establishment of this organization as their policy acumen developed. Iranian nurse leaders who were well educated, together with other nurse activists facilitated the process as policy competent people. They put the primary plan in writing and sent it as a statement to Islamic consultative parliament. The statement was assessed during numerous agendas and the needed amendments were proposed. Finally, when all amendatory acts were accomplished, the establishment of INO was approved and the statement changed to a law. In this way, policy influence occurred.
Although the legislation system of Iran is centralized and all the health policies are made in the Ministry of Health, INO has the authority and power to act for the improvement of Iranian nurses’ welfare and patients’ rights.
According to the World Health Organization (WHO), there are some domains in which NGOs like INO are required to advocate and, therefore, be involved in political actions such as influencing on workplace policy procedures, funding allocation decisions, practice models, setting of standards, and also special licensure and credentialing.[25]
Antecedents
In the sixth stage, antecedents of the concept should be identified. According to Walker and Avant, antecedents are events or factors which come before the occurrence of the concept.[10] Antecedents are related to the social context in which the concept has been used.
Antecedents of policy influence in nursing which were identified in this analysis are listed and discussed as follows.
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1)Strengthening political knowledge through especial educational programs in nursing[23]: There are a number of formal programs to increase the political knowledge of nurse leaders in Iran. These are Leadership for Change (LFC) and Leadership for Development (LFD), which are conducted similar to International Council of Nursing (ICN) and Eastern Mediterranean Region Office (EMRO) Nursing Advisor.[27] Meanwhile, there are a number of such programs in the United States with emphasis on this issue. One wonderful program is New York State Nurses Association's Lobby Day (NYSNA’S Lobby Day), which is an exciting dynamic course for baccalaureate nursing degree programs.[28] The well-known program in the UK is Royal College of Nursing Political Leadership Program (2005). This program corresponds to the needs of leaders, students, and other related groups, and is presented as workshops and active learning sessions.[29]
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2)Communications: Policy and politics have a very close relationship with communication skills. Nurses’ communication skills increase their influence on policies. Nurses are well experienced on how to communicate with people and how to attract their interest in order to meet different institutional needs and achieve their goals.[5]
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3)Teamwork: Policy making is teamwork and needs support and hard work, which is only possible through effective decision making by groups.[22] Teamwork in policy affairs is very creative and active because many people are involved who support each other. There are two important aspects for teamwork in policy influence: One of them is nursing coalitions in the framework of associations and organizations and the second one is inter-disciplinary participation.[5] INO, Iranian Scientific Nursing Association (ISNA), Iranian Nursing Association (INA), and Iranian Cardiac Nursing Association (ICNA) are four nursing coalitions in Iran that provide the required framework for policy influence in nursing.
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4)Strengthening public mental image: Policy is related to perceptions and images. For policy influence, nurses need to strengthen mental images. Nurses’ ability to influence policies depends on others’ images of nursing and also their own images of themselves.[18] In this regard, media plays an important role. Increasing visibility of nurses in media would enhance their participation in public health discussions.[30]
Consequences
The seventh stage of this concept analysis is identification of consequences of the concept. Consequences are events or outcomes which occur as a result of the concept. As for antecedents, consequences depend on the social context in which the concept has been used.[10] According to the findings of this analysis, the consequences of nurses’ policy influence are as follows.
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1)Adequacy of nurse workforce size: Nursing workforce is an important problem in the health care system of Iran. Maintaining nursing workforce by recruitment of more new nurses will have significant effects on health system outcomes.[31] Some of these effects are: Increased presence of nurses in the bedside, listening to patients more, and better maintenance of patients’ munificence.[32] Although during recent years, some policies have been applied for compensating nurse workforce shortages in Iran, such as training nurse assistants through short-term courses, recruitment of undergraduate nursing students as part-time staff, and receiving agreement to recruit 23,000 nurses in governmental health centers,[26] nursing shortage is still the most important problem which needs policy making.
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2)Modification of nursing duties and organizing nursing care systems: Evidence indicates that most part of the nurses’ time is spent for official works and not for direct care of the patients.[33] In Iran, traditional functional system of nursing and weak relationship patterns still are destroying nursing work environments and need to be handled by effective policies.
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3)Improving nursing education congruent with social needs: Along with the changes in lifestyle and health care systems, there is a serious need to improve nursing education and expand nurses’ roles.[34] In Iran, constructive changes have been made in nursing education, especially in Master's degrees, during recent years. For example, because of population aging, rise in survival rate of neonates, and also high levels of road accidents, new educational programs such as geriatric nursing, intensive care nursing, and neonate intensive care nursing have been recently developed. But we still need effective policies to expand nurses’ roles in some fields like cancer and diabetes in the community.
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4)
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5)Improvement of patient outcome: The final product of nurses’ policy influence is improvement of patient outcome, and in this way, health systems can claim that they have achieved their mission.[33] Table 2 shows antecedences, defining attributes, and consequence of nurses’ policy influence.
Table 2
Antecedents, defining attributes, and consequences of nurses’ policy influence
Finally, all of the above consequences can be summarized as making change in health care strategies.
Empirical referents
In the eighth and the last stage of this kind of concept analysis, the empirical referents of the concept should be presented. Because of high abstraction level of concepts, their existence in real situations and also the way they have been measured should be determined.[10]
Although no instrument has been developed to directly measure nursing policy influence and its attributes, “Political Astuteness Inventory” (PAI) can measure some aspects of this concept indirectly. PAI measures the level of political astuteness and identify conceptual factors contributing to organizations, awareness of health policy issues, knowledge of the officials, and involvement in the political process. It is a 40-item tool, and it takes about 70 min to be completed. Each item answered with yes is worth one point. Based on the total score, four levels of political astuteness are categorized: 0-9 points, totally unaware; 10-19 points, slightly aware; 20-29 points, beginning political astuteness; and 30-40 points, politically astute. Although PAI just measures political astuteness and not direct policy influence of a person, it defines awareness, understanding, and evaluation of policy influence.[24] There are also a number of qualitative studies which have focused on nursing influence and its wide effects on patients and nurses. For example, Gebbie et al. described the ways nurses can be influential in the development of health policy and its barriers.[36] In the United States, Byrd et al. introduced a series of learning experiences which have been designed to make students engage in policy involvement process.[24] Finally, Fyffe (2009) introduced strategies for nurses to be influential in policies.[30]
Definition
Based on this analysis, the concept of nurses’ policy influence would be defined as “nurses’ ability to have an effect on decisions and affairs related to health care using power, advocacy, and policy competence, which is acquired by policy awareness, effective communication, teamwork, and strengthening images and will result in improvement of nurses’ and patients’ outcomes.” Accordingly, policy influence is the highest level of involvement in policies which are just carried out by high level of nursing management. Therefore, activities such as consultation with nurses about health issues will not adequately address this concept.
Discussion
Explaining precise and specific meaning of a concept through various theoretical contexts with emphasis on the favorite context is sufficient.[12] The concept of policy influence at all and nurses’ policy influence, in particular, has not been adequately addressed in various theoretical contexts. But there are many theories with relevant to these concepts. In this section, our analysis has been compared with theses theories.
Kingdon's theory (1995) of policy streams proposes presence of some streams in the process of policy making before agenda setting and policy formulation take place. Kingdom believed that in spite of the dominant effect of governmental agents in progression of an agenda setting, some interest groups also may have a key role in acceptance or obstruction of an agenda setting through formation of a coalition. Kingdom, according to Dohler (1991), states that a united and constant coalition increases the chance for victory in policy streams.[37] The results of current concept analysis of policy influence also forebode the significance of communication and teamwork as two important antecedents for policy influence. As mentioned before, policy activists need to work together as a team and have an acceptable level of communication.
Margaret Newman's theory of “health as expanding consciousness” can be seen as related to raising political awareness. Her theory emphasizes that all people, of any health status and from any circumstance, are a part of the process of expanding consciousness.[28] Her theory defines consciousness as the capacity of the system to interact with the environment. Some of the dimensions of this interaction are exchanging, communicating, relating, choosing, moving, perceiving, and knowing.[38] In summary, expanding consciousness is a metaphor for the changing health systems. Nurses’ awareness of policies will assist expanding consciousness and change health systems.[28] In the present study, we have achieved attributes such as policy literacy, policy acumen, policy competence, and also strengthening political knowledge as antecedents, all of which build policy awareness. These are concepts which can be abstracted from some of Newman's dimensions of interaction with environment, i.e. knowing and perceiving. Meanwhile, other dimensions of Newman, i.e. exchanging, communicating, and relating, can be accommodated to other antecedents of policy influence, i.e. communication and teamwork, in this study. Finally, choosing and moving are Newman's dimensions which are related to making change in health care strategies as overall consequence of policy influence in the present study.
The other theories which the results of current concept analysis are related to are philosophical theories of nursing advocacy. Advocacy as a concept had been considered by nurse theorists, and each of them has a unique definition of nursing advocacy. For example, Gadow (1983) propounded the concept of existential advocacy. She has a moral view of advocacy and believes that the ultimate goal of advocacy is to increase patient outcomes.[39] Kohnke (1980) propounded a model of functional advocacy, in which nurses are agents who inform patients and support patients’ decisions.[19] The results of the current concept analysis are pertinent for Gadow's and Kohnke's theories, since we postulated advocacy as an attribute of policy influence and an inseparable part of the role of nurses as health care providers.
It is notable that the role of advocacy is not limited to patient advocacy, but rather it is allocated to professional advocacy too. Nurses as professional advocators are concerned about nursing workforce, nurse — patient ratio, prevention of malpractice, and the expansion role of nurses.[39] In the present study, we have also introduced pertinent activities such as adequacy of nurse workforce size and improving nursing education, congruent with social needs, as the consequences of policy influence, all of which address professional advocacy.
The aim of this article was to clarify the concept of policy influence associated with nursing management, leadership, and practice in the context of Iran. In this unique analysis, attributes of the concept, such as advocacy, power, and policy competence, were identified. Nurses have the ability to affect health policies. This effect is impossible without the required knowledge of health care system as a whole. Nurses need to be aware of policy agendas, policy makers, and political backgrounds. They are advocates for improvement of the quality of care, but many of them do not have adequate organizational and personal power for advocating patients’ rights. In fact, for nurses to be in a state of empowering patients, it is first essential for them to be empowered.[40] Their expertise, judgment, and policy influence, all together help them to achieve their goals and to facilitate the professional process and the efficacy of health care system. We hope this concept analysis addresses a clear definition of nurses’ policy influence for all nurses and encourage political influence, especially for nurse leaders. In summary, results of this concept analysis indicate that although there are some theories about policy-making process and its facilitators and barriers, there is still lack of nurses’ theories in which the main concepts are involving them or their influence in health policies. However, these are stepping stones in nursing discipline, as we can see them in Newman's model and advocacy models which have been developed by nurses’ theorists.
Conclusion
Considering the state of nurses’ policy involvement in reports and research papers identified that this involvement has various levels but not all levels indicates influencing in policies. Our definition of this concept may represent a broad theoretical understanding of this concept and may discriminate between similar or related concepts. This analysis will potentially inform nurses about how they could be really influence in policies and what they need to achieve for this purpose. Moreover nurse researchers may use this definition to increase clarity in their research. The identified antecedents, attributes and consequences of policy influence may also give guidance to nurse administrators and managers to achieve high level of leadership step by step to be influence in policies. Finally this paper may offer a theoretical framework to guide future work on this concept.
Acknowledgments
The authors would like to thank the INO for its sincere cooperation in providing some documents for this study. This article was written based on the first investigator's PhD dissertation at the Faculty of Nursing and Midwifery, Tehran University of Medical Sciences (TUMS); therefore, the financial support from the TUMS is also acknowledged.
Footnotes
Source of Support: Tehran University of Medical Sciences.
Conflict of Interest: None declared.
