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Assessing the Policy Environment

Ruth E. Malone, RN, PhD, FAAN

t has been observed that nurses, with some stellar exceptions, have not seized on opportunities to provide policy leadership (Boswell, Cannon, & Miller, 2005; Mason,

999). Too few nurses, it is said, recognize the olitical and policy dimensions of clinical ractice issues and thus may not act to effect olicy change (Mason, Leavitt, & Chaffee, 2002). olicy creates and sustains biomedically ominated institutional and economic structures at impede articulation, recognition, and

evelopment of nursing’s contributions; split ursing managers and administrators from edside practitioners; and contribute to ppressed group behavior (Farrell, 2001; Roberts, 983, 1997, 2000). Yet although several recent itiatives are encouraging, policy is not

onsistently emphasized as part of nursing ducation, and how policy awareness can be tegrated into clinical practice is not always clear

nurses (Boswell et al., 2005). Until fairly ecently, much nursing education about policy cused on identifying and using the policy anual in the institutions where nurses practice, aving many nurses with a procedural, overly

This article proposes a basic framework for assessing the policy environment. Environment is a key concept in nursing’s much-discussed “metaparadigm,” but the policy environment is rarely considered. Too often, bedside nurses do not recognize the policy dimensions of clinical practice issues. Yet nursing assessment involves identifying and appraising aspects of patients’ situations that are salient to their responses to actual or potential health problems. Policy may be such a salient factor, as it shapes the physical aspects of patients’ surroundings; the relationships possible between practitioners and patients; the institutions in which health care is offered; and, on a broader scale, the prospects for global survival. This article proposes a question- based framework for clinical practice nurses to use in assessing the policy environment.

Keywords: policy; environment; assessment; theory; nursing; advocacy

cal view of how policy shapes what they do. Environment has long been identified as one of e key concepts of nursing’s contentious meta-

aradigm (Fawcett, 1978; Fawcett, Cody, alinski, & Rawnsley, 1996), but its conceptual- ation remains underdeveloped (Kleffel, 1991). nvironment, in the nursing literature, is often nked to physical aspects of the patient’s home

uthor’s Note: Work on this article was partially supported by a sidential fellowship at University of California’s Humanities esearch Institute.

olicy, Politics, & Nursing Practice ol. 6 No. 2, May 2005, 135-143

DOI: 10.1177/1527154405276141

2005 Sage Publications

surroundings (such as pollution) or of the imme- diate care setting (such as institutional noise lev- els). McFarlane (1985) was perhaps the first to integrate political and policy aspects into an eco- logical model for assessing child health risks: “To focus on selected child health needs . . . without simultaneously attending to the environment from which the needs arise could be an inappro- priate use of time, personnel, and money” (p. 2). More than a decade ago, Stevens (1989) called for a critical reconceptualization of the environment that would include the social, political, and eco- nomic environments. Helms, Anderson, and Hanson (1996) characterized the policy environ- ment as a dynamic process shaped by several fac- tors: space, timing, size, scope and form of solu- tions and displacement of policy objectives as implementation occurs.

However, to date nursing education, practice, and research remain primarily focused on the individual and local level. Policy may not be men- tioned at all, despite the fact that it shapes impor- tant physical and social aspects of patients’ sur- roundings (Crum, Lillie-Blanton, & Anthony, 1996; Lindheim & Syme, 1983; Pederson, Bull, & Ashley, 1996); the relationships possible between practitioners and patients; the institutions in which health care is offered (Scott, Aiken, Mechanic, & Moravcsik, 1995; Wright, Avirappattu, & Lafuze, 1999); and, on a broader scale, the prospects for global survival (Listorti, 1999).

Nursing assessment involves identifying and appraising aspects of patients’ situations that are salient to their responses to actual or potential health problems. Such an appraisal, in turn, evokes professional and moral obligations to make efforts to address on behalf of patients or to help them address factors that contribute to ill health or impair good health. However, nursing assessment is commonly limited to physiological, pharmacological, psychosocial-behavioral, or physical environmental factors, leaving out policy factors that may have preventive, etiological, or therapeutic significance.

For example, nurses caring for patients with asthma are likely to include assessment of lung sounds; medications taken; coping strategies; tobacco-use status; and, possibly, assessment of the home environment for molds, dust, and other

potential triggers for asthmatic episodes. Less likely to be considered, but possibly equally important to the patient’s status, are such factors as clean indoor air policies that prohibit smoking in workplaces, including restaurants and bars (Dimich-Ward, Gee, Brauer, & Leung, 1997; Eisner, Smith, & Blanc, 1998); policies related to advertising and promotion of tobacco use (Hastings & MacFadyen, 2000; Wakefield & Chaloupka, 2000); policies affecting access to timely medical and nursing care (Landrigan et al., 1998); and policies that locate polluting freeways and industries primarily in poor neighborhoods (Bansal & Davis, 1998).

It is unrealistic to propose that all nurses become policy experts and, in addition to provid- ing direct patient care, take on roles as policy activists across the multiple policy arenas impor- tant to health. However, all nurses can assess, identify, and articulate for (or on behalf of) patients some of these broader factors; provide information to patients on options for impacting policy; and work to effect policy change through professional and advocacy organizations. In addi- tion, nursing educators can work to develop pol- icy skills and new policy roles for nurses that com- plement and support the work of nurses providing direct patient care, and nurse research- ers can conduct policy studies and explicate the policy implications of their work. Assessing the policy environment is essential to all of these activities.

This article proposes a working framework for assessing the policy environment. Because policy encompasses multiple layers and aspects of pub- lic life, this framework must be regarded as a broad lens rather than a comprehensive analysis of all possible policy-relevant elements or con- cepts. Such a comprehensive analysis (if it were really possible to do, which is doubtful; see Lindblom, 1959) would be rapidly outdated and practically unworkable, because the making and remaking of policy is a fluid process characterized by advancement and retrenchment, compromise, and contestation (Helms et al., 1996; Kingdon, 1984). Rather, this framework is aimed at help- ing practicing nurses consider how the policy environment may be contributing to their patients’ health problems and what they might do about it.

136 POLICY, POLITICS, & NURSING PRACTICE / May 2005

WHAT IS POLICY?

According to Mason et al. (2002), policy “encompasses the choices that a society, segment of society, or organization makes regarding its goals and priorities and the ways it will allocate its resources” (p. 8). Regarding policy as a choice or decision suggests that it might be something fixed, a product of deliberation or compromise. Indeed, local ordinances and state and national laws often are the products of such activities. Most cities, for example, have ordinances against littering, which are the product of deliberations on how to address public health, safety, and quality of life concerns.

However, policy is also a process in which views of the problem and possible solutions to it, ethical arguments, and political ideologies are continually being contested (Malone, 1999). The policy process has been characterized as includ- ing problem definition, policy advocacy, agenda setting, policy analysis (including selection among alternative proposed solutions), policy implementation, and policy evaluation. Passing a law or making a regulation does not by itself cause policy change; policy requires ongoing implementation activities, monitoring, and evalu- ation. The mayor of San Francisco recently pro- posed new initiatives to reduce littering in the city, including deputizing many city workers to be authorized to issue littering citations. How- ever, the success or failure of these initiatives will hinge on many process-related factors, including what penalties a citation will carry and how they will be enforced; resources to provide protection to deputies when issuing citations; arguments regarding which areas deserve more resources on this issue, and the relative importance of littering compared to other issues, especially for key constituencies.

Policy has several distinctive aspects that are worth brief mention. First, policy always has gen- erality; that is, it is intended to address more than one person and more than one individual set of circumstances. Second, it has normativity: Poli- cies formalize implicit or explicit normative judg- ments about what course of action is good or better than alternatives and the rules under which those alternatives will be weighed.

Policy also has scale: Policies are intended to apply at different levels of social organization, and policies at one level can supersede or preempt those at “lower” levels. Another aspect of scale pertinent to policy is the level of specificity or scope involved; for example, some policies pro- vide abstract principles on the basis of which indi- viduals, groups, or governments are to take actions, whereas others proscribe or require spe- cific actions to be taken. Helms et al. (1996) point out that “the larger the proposed policy shift, the more policies affected. The more policies affected, the greater the number of constituencies . . . involved” (p. 35). This creates more difficulties in crafting compromises and creates a bias toward incremental changes rather than broad reforms (Helms et al., 1996).

Finally, policy is always decided by someone. Although this may seem obvious, the actual peo- ple who make policy decisions are often relatively invisible, obscured by institutional structures and processes. We may read that “the decision was made” as though it just happened in the absence of an agent. But someone (or a group of people) actually made those choices. Knowing who is in a position to make policy decisions is part of assess- ing the policy environment.

THE POLICY ANTECEDENTS OF CLINICAL PROBLEMS

Nurses’ educational preparation emphasizes that biomedical diagnoses alone are not constitu- tive of the patient’s health care concerns. Nursing embraces a holistic conception of the patient in which individuals are seen as embedded within a web of family and social relations. Yet those webs of relations are themselves shaped by institu- tional, local, state, and federal policies.

For example, state regulatory policies on the scope of duties that may legally be delegated to unlicensed assistive personnel have an impact on whether nurses are viewed as supervisors, whose relationships with patients are more peripheral, or as direct caregivers, whose relationships with patients are grounded in moment-to-moment interactions with patients and families (Barter, McLaughlin, & Thomas, 1997). Much of the dis- tress voiced by clinicians during the restructuring of the past decade has been related to their

Malone / ASSESSING THE POLICY ENVIRONMENT 137

attempts to continue traditions of practice that are obstructed by new staffing patterns (Weiss, Malone, Merighi, & Benner, 2002). Those patterns, in turn, are related to other policies on hospital reimbursement and staffing levels and the ideolo- gies and power relations underlying those policy decisions (Malone, 2003).

The public health emphasis on considering upstream factors (McKinlay & Marceau, 2000) is useful because it urges that rather than merely treating the presenting symptoms or diseases, we consider less proximal causes. This effort can seem overwhelming, as policy is multilayered and covers such a broad range of interrelated issues. But basic health policy literacy means hav- ing some understanding of the ways policy issues have been shaped by larger social forces, and how they have been addressed in the past.

A FRAMEWORK FOR ASSESSING THE POLICY ENVIRONMENT

Ten questions can be helpful in assessing the policy environment:

What is the problem? Where is the process? How many are affected? What possible solutions could be proposed? What are the ethical arguments involved? At what level is the problem most effectively

addressed? Who is in a position to make policy decisions? What are the obstacles to policy intervention? What resources are available? How can I get involved?

What is the Problem? Defining policy problems is not easy or

straightforward. The social constructionist per- spective suggests that the definition of a problem is constitutive of that problem (Kitsuse & Spector, 1973; Schneider, 1985). Seen from different disci- plinary, theoretical, or practical perspectives, the same set of policy-relevant conditions can be defined very differently as a problem (Linder, 1987; Malone, 1995). This means that different social actors are constantly struggling over trying to establish their definitions of the problem as the “true” one (Stone, 1997).

For example, emergency nurses are often frus- trated by the “frequent flyer” patients who come to the emergency department regularly (Malone, 1996). Is this a policy problem, and if so, what kind? The answer depends on the perspective from which the issue is viewed, because the prob- lem may be seen as undesirable patient behavior; failure of the larger health care system to provide adequate access or services, an improperly func- tioning health care market; or as not a problem at all, unless patient rights are violated. These defini- tions, in turn, each call for different policy solu- tions, respectively: patient reeducation and refer- ral, development of additional access points and services, “gatekeeping” policies to decrease ineffi- cient or “inappropriate” utilization, or monitoring of patient dispositions (Malone, 1995). It can be helpful to consider what, if anything, has changed or shifted to make these conditions appear prob- lematic at this time (Malone, 1998), because policy problems are continually evolving. It is also help- ful to consider how different definitions may serve to advance the other interests of individuals or groups (Stone, 1989).

An important barometer of problem definition is media accounts and how the issue is being “framed” in the media. For example, is obesity typically presented as an individual problem and therefore not a policy issue (e.g., people being too fat because they eat too much junk food) or as a social or community problem, potentially amena- ble to policy intervention (e.g., lack of full-service groceries in poor areas, aggressive advertising of inexpensive junk food, lack of transportation options that encourage walking or bicycling)? Public opinion is influenced by media accounts (Jordan, 1993; McCombs & Shaw, 1973; Page & Shapiro, 1992). Media advocacy has been identi- fied as an effective strategy for changing the focus of coverage from individual behavior to social policy issues (Dorfman, Woodruff, Chavez, & Wallack, 1997; Wallack, 1994).

Where is the Process? The process of getting attention for policy

issues is complex, and the historical progression of public opinion and legislative activity on any issue must be considered. Kingdon (1984, p. 207) suggests that policy agenda setting involves prob- lems, politics, and visible participants. As noted

138 POLICY, POLITICS, & NURSING PRACTICE / May 2005

above, problem definitions are critical, because not all conditions are defined as problems. Politics affect policy in numerous ways: Those in power have the ability to shape laws or regulations, appoint those who will enact policies favorable to their points of view, allocate resources for enforcement or monitoring, and use their posi- tions to advocate for policies. Visible participants are those who get media coverage and public attention, such as elected and appointed officials or, increasingly, celebrities of various sorts. How- ever, there are also many less-visible but impor- tant participants, including key legislative staff, regulators, and academics. Kingdon notes that policy consensus tends to result from bargaining and trading rather than persuasion. This means that effective participation in the politics of policy tends to mean building organizations or coali- tions that have the ability to trade their support on one issue for efforts on others that they espouse, or that have enough public support to give them bargaining power on their issue. Having political allies and using political capital are essential (Dodd, 1997).

Depending on the issue, the current process may be a struggle to get anyone to notice the prob- lem (as, for example, with advocates who are seeking increased funding for various diseases that affect very few people), an ongoing battle between two or more ideologically opposed fac- tions (as in the abortion policy debate), a coalition- building effort to push policy change over the top (as happened in 2004 with Medicare drug legisla- tion, which garnered support from groups previ- ously on opposing sides), or a regrouping follow- ing a failed effort to push policy forward (as after the failure of the Clinton plan for health system reform). It is important to understand something about the recent history of any policy issue to better understand the obstacles and resources in play.

If a policy is already on the public agenda, there may be opportunities to influence its develop- ment by providing written or oral comment during a public comment period or by testifying on the issue at a public hearing. Contacting gov- ernmental representatives or agencies with jurisdiction over the issue (often there is more than one) can get nurses on mailing lists for such opportunities. Policies are shaped by legislation,

regulation, and institutional actions. Pending and passed legislation may be available on the Inter- net through state-operated Web sites or through the federal government’s Government Printing Office access Web site (http://www.gpoaccess. gov/multidb. html), which will allow for complex searches by subject matter. Regulatory policies are often available on state government Web sites or through contacting the agencies directly. Institu- tional policies already in place are typically avail- able through contacting administrators; it may require some sleuthing to learn about new poli- cies under consideration.

How Many Are Affected? Problems that affect only a small number of

people are difficult to get addressed through poli- cies, because (as noted above) the politics of policy making tends to rely on building coalitions and leveraging power. Issues that affect a small num- ber may have a better chance of success if those affected or concerned are powerful individuals or groups, or if the issues can be reframed in such a way as to build ongoing public or media concern. A problem that appears small when viewed on the institutional or local scale may actually be quite considerable if its effects are similarly felt across the entire nation. It can be important to pull together whatever facts and figures are available, or even to point out the gaps in knowledge that preclude knowing how widespread the problem may be. For example, gay and lesbian health advocates struggled for years to obtain research and health program resources because sexual ori- entation was not included as a variable in most national datasets. This rendered it impossible to determine how many lesbian and gay people there were and whether disease or substance-use rates were higher among these populations than among the general population; advocates there- fore began by highlighting small-scale studies that helped make the case for more policy atten- tion to the issue.

What Possible Solutions Could be Proposed?

Before committing to any single solution to a policy problem, it is important to examine other options and evaluate whether your preferred solu- tion may prove politically unpalatable, practically

Malone / ASSESSING THE POLICY ENVIRONMENT 139

unworkable, or otherwise difficult to achieve. For example, there could be several policy solutions to the problem of injuries from automobile acci- dents: increased driver education, better enforce- ment of seat belt laws or speed limits, improved road conditions, or regulation of auto manufac- turers to require air bags. Which of these solutions, if any, is pursued depends on how the problem appears on the policy agenda. If a congressperson’s son is killed in an auto accident attributed to poor road conditions, it may spur media and policy-maker interest in a “new funds for road repairs” solution over others. Kingdon (1984) notes that policy entre- preneurs may wait years for a focusing opportunity to argue for their favorite policy solution.

If a problem would be worsened by new poli- cies under consideration, nurses can provide highly credible, on-the-ground information about how the policy would play out in practice, mar- shalling data and evidence to enhance their case. Likewise, nurses can provide similar feedback on the results of policy implementation. “Backward mapping”—working backwards from the last step in the policy implementation process to the top level of decision making—has been proposed as a way to identify policy obstacles that will pre- vent effective implementation or create new prob- lems (Elmore, 1982). For example, an agency head wanting to change a behavior at the service deliv- ery level would consider what the ultimate desired change would look like, then ask those at the level closest to that change to recommend how to achieve the goal, rather than instituting top- down implementation procedures that might con- flict with existing ways in which practitioners manage the complexity that characterizes most service organizations.

What Are the Ethical Arguments Involved?

Policy decisions are, at bottom, always ethical decisions, insofar as they involve making choices that will affect the lives of others whom we do not know. They often also involve allocation of resources and decisions about prioritizing these. There can be ethical arguments in favor of or against several different policy alternatives; these may or may not be explicitly stated. Under- standing the ethical concerns at stake for key actors in the process can be helpful in seeing how

another solution might address these most effec- tively, thus potentially removing an obstacle to compromise. For example, environmental activ- ists may argue that it is unethical to destroy the habitat of endangered species for development purposes. Proponents of development, however, argue that as populations continue to grow, it is unethical not to develop new housing and jobs. To address this concern, some environmental advo- cates have worked with developers to support higher density housing and urban infill, which provides both jobs and housing while preserving more natural habitat for other species.

At What Level is the Problem Most Effectively Addressed?

It is sometimes possible to address a problem at several different levels. For example, tobacco- control policies have been very effectively devel- oped at the local level, where officials typically do not receive large tobacco industry contributions as they do at the state level (Glantz & Balbach, 2000). The tobacco industry, recognizing this fact, has worked aggressively to try to get state and national governments to enact preemption poli- cies that would invalidate the stronger local ordi- nances in favor of weaker ones at higher levels of government (Siegel et al., 1997). Public health advocates have worked hard to defeat such indus- try efforts.

Deciding what level may be appropriate is dependent on numerous factors, including the scope of the problem, the relevance to the policy agendas at different levels, where the problem is in the policy process, whether any particular reg- ulatory agency has jurisdiction, and what kind of mobilization is possible.

Who is in a Position to Make Policy Decisions?

As noted above, some person or group of per- sons always makes policy decisions. Determining who does make decisions can sometimes be an elusive quest, as institutional and bureaucratic complexity and informal divisions of labor may obscure the process. For example, tobacco regula- tion at the federal level is addressed by federal law and the regulations of many different agen- cies, including the Federal Trade Commission,

140 POLICY, POLITICS, & NURSING PRACTICE / May 2005

Federal Communications Commission, Depart- ment of Agriculture, and others. However, at least for public entities, persistence usually pays off. Contacting one’s governmental representative can be a quick way of learning the identity and contact information of decision makers on specific issues. Advocacy groups working on an issue are also good sources for this kind of information.

What Are the Obstacles to Policy Intervention? Nurses are experts in working around obsta-

cles, but often tend not to confront them directly, which itself can be an obstacle. Obstacles to policy intervention include lack of media attention, ideo- logical opposition from those in decision-making positions, lack of sufficient monetary resources, advocacy leadership struggles, and efforts by those actively opposed to the policy. It is not always easy to identify one’s real opponent in pol- icy debates. For example, the tobacco industry has spent millions of dollars on lobbying and forma- tion of “front” groups to oppose tobacco-control policies. However, tobacco-control advocates have learned through experience that publicly confronting politicians and exposing their finan- cial ties to the tobacco industry is more effective than trying to use insider strategies to achieve pol- icy goals, because there is strong public support for tobacco-control policies (Glantz & Balbach, 2000). A useful resource for nurses interested in policy issues and campaign finance is a Web site maintained by the Center for Responsive Politics (http://www.opensecrets.org/) that provides information on campaign contributions by indi- viduals, political action committees, and other groups to candidates for federal and some state offices.

What Resources Are Available? Resources include information resources,

advocacy resources, and economic resources. Information on a policy issue or set of concerns may be obtained from governmental agencies (most now have Web sites for easy access to infor- mation), advocacy groups, professional organiza- tions, policy researchers, media reports, and libraries. Having the most up-to-date data at hand is helpful in mustering support for one’s position on a policy issue and is essential for developing

policy proposals. For example, nurses arguing in favor of a recently proposed “lift team” bill in Cal- ifornia came to the hearings armed with recent statistics on hospital worker back injuries and related workers’ compensation costs.

Another information resource is the variety of media that may help draw attention to an issue. The currency of newspapers, for example, is news. If advocates can successfully frame an issue for newsworthiness, an investigative reporter may decide it is worth learning more about and reporting on the issue (Chaffee, 2000). Typically, sustained media attention is necessary for an issue to move forward on the policy agenda.

Advocacy resources include grassroots volun- teer groups, advocacy organizations (such as the American Lung Association or American Cancer Society), professional organizations (such as the American Nurses Association, state associations, collective bargaining groups, and specialty orga- nizations), political allies, and others. Getting a feel for the policy environment on an issue means doing some detective work to find out who is working on an issue or a related cause, conduct- ing outreach, or even starting an advocacy organization.

Economic resources are always helpful in pur- suing policy objectives. Money can allow for advertising to promote policy aims. However, coalition building may be even more important because political power lies in numbers.

How Can I Get Involved? Nurses are educated to be patient advocates.

Extending this skill at advocacy to the policy arena can increase the impact of such efforts (Wil- liamson & Drummond, 2000). Nurses have the advantage of frontline experience in how health policy decisions play out at the level of patients and families. This information, if effectively docu- mented and presented, can be hard to ignore.

Policy literacy begins through becoming an informed citizen. Reading a daily newspaper, preferably one that includes critical analyses of policy in various areas, is a first step. Increasingly, health policy-related articles are found in the business pages, rather than in the main section, reflecting the reframing of health care during the last two decades from a service activity to a

Malone / ASSESSING THE POLICY ENVIRONMENT 141

business activity. Policy information and analyses are also available in nursing and health policy journals and in lay journals that cover a broad range of policy issues. Nurses can initiate policy activity through letters to the editor and submis- sion of opinion pieces, linking their issue to other currently active issues.

Through their professional organizations, or through other health-related organizations, nurses can become involved in lobbying efforts and direct action supporting or opposing policy positions. Volunteer effort is always welcome, and some nurses move from volunteer positions into paid policy-related positions.

However, nurses can also affect policy in less direct ways. For example, tobacco-control advo- cates have effectively used shareholder resolu- tions and shareholder activism to draw public attention to the activities of the tobacco industry and its allies and push for policy changes (Crosby, 2000; Hilton, 2004). Nurses might explore forming groups, buying sufficient shares of the corporate entities controlling their hospitals and engaging in similar activities, thus drawing public and media attention to care issues and the hospital industry. Assessing the policy environment can help nurses identify many innovative ways to be part of the ongoing policy discourse in areas in which they have expertise.

CONCLUSION

The framework proposed in this article is a broad guide, a starting point. Assessment of the policy environment means becoming aware of factors beyond the institutional level and under- standing the dynamic nature of policy arenas. This is an ongoing process: increasing one’s skills as a citizen also enhances one’s skills as a nurse. By increasing awareness of the policy dimensions of clinical problems and working to integrate pol- icy intervention skills with clinical intervention skills, nurses can better educate and empower their patients and themselves to more effectively address health problems.

142 POLICY, POLITICS, & NURSING PRACTICE / May 2005

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Ruth E. Malone, RN, PhD, FAAN, is an associate professor of nursing and health policy in the Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco (UCSF). Her current research focuses primarily on tobacco control policy and the public relations aspects of public health, especially as these pertain to marginalized populations and business practices associated with globalization of the tobacco disease epidemic. She is a core faculty member at the Institute for Health Policy Studies and is nationally and internationally known for her work on the tobacco industry. She serves as director of the master’s health policy specialty program in the UCSF School of Nursing and is also the founder of the Nightingales, a nursing advocacy group focusing on tobacco control and the role of the tobacco industry (www.nightingalesnurses.org).