“When spider webs unite, they can tie up a lion.”
Federal health care reform catalyzed the formation of coalitions whose aims were in support of or in opposition to all or some of the proposals. Because of the complexities of health care reform, virtually no patient, provider, financing, medical device, pharmaceutical company, or other health industry group was left untouched by reform. Many formed coalitions as a strategy to influence their positions. The power of coalitions lies in their ability to bring people together from diverse perspectives around clearly defined purposes to achieve common goals. Strength lies in numbers—in working together and in strategizing for success.
In this chapter, we will compare two coalitions for health reform—one at the national level and one at the state level. The National Coalition on Health Care (National Coalition) formed in 1990. It includes over 70 national organizations ranging from the AARP through the U.S. Conference of Catholic Bishops (one nursing organization belongs—the American College of Nurse Midwives) (National Coalition on Health Care, 2010). Its purpose is to advocate for health reform that ensures access to health care for all, cost management, and quality and safety.
In 2009, the state-level coalition formed but disbanded within weeks. It was created to represent the interests of stakeholders opposing a legislative initiative aimed at insuring more Virginians through stripped-down, low-cost insurance policies. If passed, the plans would have eliminated such benefits as well-baby examinations, immunizations, diabetic test strips, hospice care, and mental health coverage. Within a day, lobbyists representing the imperiled mandated benefit groups, for individual and group plans, galvanized into a coalition (Mandate-Lite Coalition) to oppose the bill.
What factors contribute to success or failure of coalitions? How do we go about forming and maintaining coalitions? What are the ingredients? How do we know when or whether coalitions achieve their goals? This chapter details the ingredients for successful coalition building, maintenance, and success. The ingredients work in small sizes for local and regional coalitions and are equally effective in creating and sustaining larger coalitions at the local, state, national, and international levels.
Birth and Life Cycle of Coalitions
In simplest terms, a coalition is a group of individuals and/or organizations with a common interest that agree to work together toward a mutually defined goal (Berkowitz & Wolff, 2000). Spangler (2003) defines coalitions as temporary alliances of groups in order to achieve a common purpose or to engage in joint activity. Coalitions are means to achieving goals that individual members cannot easily achieve by themselves. Because of the numbers of members or groups involved, the formation of a coalition can shift the balance of power in a challenging situation. Even people who are less powerful and resourced can form coalitions that can be successful against opponents with more resources and status (Spangler, 2003).
Coalitions arise out of challenges or opportunities, and the key for all coalitions is to maintain their effectiveness until they achieve their goals. For some coalitions, the work may be completed within a matter of weeks, such as with the Mandate-Lite Coalition; others, like the National Coalition, persist for years to address a continuing problem.
Building and Maintaining a Coalition: the Primer
To build and maintain an effective coalition requires four ingredients: leadership, membership, resources, and serendipity. First and foremost is leadership. Coalitions cannot exist without outstanding leadership. Leaders may exist a priori or may emerge early from the membership of the coalition, but without leaders, coalitions will falter and fade away.
Two types of leaders are critical to coalition work: inspirational and organizational. An inspiring leader uses personal strengths and power to constructively and ethically influence others to an endpoint or goal. She or he motivates others to participate and meet their obligations. The leader balances a personal inner drive to move forward while assisting coalition members to solve problems and make decisions, knowing when to steer forward, when to idle, and when to back up, if necessary (Bleich, 2007; Siek & Hague, 1992). An organized leader possesses the skills to keep members on track between meetings, ensures that communication methods are in place, and follows through on coalition assignments. Inspiration and organization may coexist in one person; but frequently two leaders are needed to serve the coalition.
As important as leaders are, they are no more important than the coalition members, without whom the coalition would not exist. Members increase the productivity of the coalition. But they also increase the potential for conflict. Members increase the visibility of the coalition, because they represent diverse constituencies and networks. Members must commit to the goals of the coalition. The extent to which members value belonging to the coalition will help, in part, to gauge their commitment and willingness to work for the groups goals. Membership should be beneficial for the coalition and the individual (Berkowitz & Wolff, 2000; Rabinowitz, 2010).
Coalitions need adequate resources to accomplish their work. Resources are the tools for the leaders and members to accomplish the coalitions’ goals. They include money and in-kind donations from members and others, such as support for developing marketing materials, purchasing supplies, putting on educational sessions, and developing and maintaining websites and social media.
Finally, an essential ingredient for coalition success is serendipity—the happy occurrence of an opportunity not specifically sought—so long as coalition members take advantage of the serendipitous event or opportunity. Successful coalitions use resources at hand, devise innovative ways to sustain their work, seize opportunities that come along unexpectedly, and are willing to take risks. In order to effectively use serendipity, leaders and members must obligate themselves to conduct continual environmental scans, such as tracking current events, connecting with many different kinds of people, and spending time thinking creatively.
The National Coalition and the Mandate-Lite Coalition illustrate these ingredients. The leadership of each is strikingly different yet successful. A staff of 14 leads and manages the work of the National Coalition. The Board of Directors is led by a president with years of experience in working in non-profit organizations devoted to civil and human rights. The staff consists of lawyers, public relations specialists, and policy consultants. This coalition’s leadership, therefore, consists of both inspiring and organizational leaders. The Mandate-Lite Coalition, on the other hand, congealed quickly with two lobbyists assuming informal leadership positions. Both shared roles in organization and inspiration, but in this case, organization was more critical than inspiration, because members were inspired to oppose the insurance bill. Most important in this case was to define the work, assign members to complete it, report frequently on progress, and find legislators to support them. The two informal leaders consulted with one another frequently and kept the coalition’s work on track.
Membership in the two coalitions is very different. As indicated, the National Coalition has over 70 organizational members, and the Mandate-Lite Coalition consisted of lobbyists representing many of the insurance mandates and the people potentially affected by the loss of mandates (e.g., children’s health, poverty law, social justice economists, hospice, hemophilia, cancer, and mental health). In the latter case, members joined out of the desire to assure that their particular mandates would not be stripped in the bill; all realized that their effectiveness would be better served by working together than separately.
The third ingredient, resources, highlights the differences in the funding for the two coalitions. In addition to the National Coalition’s 501(c)(3) tax-exempt status, it has an action fund with a 501(c)(4) tax-exempt status, which enables that arm to lobby for the coalition’s aims. Anyone can donate to the action fund, and the National Coalition encourages donations. These funds are not tax deductible, since they are used for lobbying purposes. The Mandate-Lite Coalition, on the other hand, had no fiscal resources. Volunteers provided the work, including a position statement (from the social justice economists), amendment language for the bill to create a requirement for an annual report of effectiveness (from the poverty law center member), and the strategy for getting the amendment introduced (from a former state senator who lobbied for one of the member groups).
Finally, the ingredient of serendipity can best be illustrated by the Mandate-Lite Coalition, which formed and achieved its work around a number of serendipitous happenings. One member tagged the bill and brought it to the attention of other stakeholders. The social justice advocates were asked to participate, and they found evidence of similar bills’ ineffectiveness in other states. In addition, they performed an economic analysis and distributed it to each member of the legislative committee hearing the bill. All coalition members agreed to texting each other when they found out new information. While many of these occurrences were unplanned from the beginning of the coalition’s work, all members took advantage of their potential and utilized each in conducting the work of the coalition. No chance happening was allowed to pass without someone analyzing its usefulness to achieve the coalition’s goals.
Structure refers to the organization of the coalition, and it defines the procedures by which the coalition operates. The structure serves the members, not the other way around. It also includes how members are accepted, how leadership is chosen, how decisions are made, and how differences are mediated. Effective coalitions operate using group process, meaning that they go through a life cycle that involves “norming and storming” (creating group behavioral norms and settling disagreements) before establishing group processes. Having a structure helps provide a framework for the processing that must take place in order for the coalition to be active and successful.
Coalition structure, while necessary, is dynamic, depending upon the resources and the cause. Some coalitions are highly structured, with formal committees, task forces, or work groups, and communication mechanisms; others are more loosely structured, with shared leadership and work done by ad hoc groups. Moreover, the structure may change over time, depending on the lifespan and work of the coalition. Highly structured coalitions may be necessary if the coalition work is complex and multifaceted, involving more than one goal. Committees and/or task forces may be established around the goals.
Coalition structure should make provisions for governance. This is especially true if the size exceeds 15 people. Beyond this number, the group becomes too large for effective, efficient decision-making. The governance committee should, at the very least, include all committee and work group chairs to facilitate communication. The committee should represent the diversity of the members (Smith & Bell, 1992).
No matter what coalitions call themselves or how they structure themselves, an important factor to achieving goals is to engage appropriate support systems. Someone must agree to do a task, and that someone should have the means to get the task done. The work may be done by volunteers, as it is in many coalitions. However, there may be consequences to all-volunteer efforts. Often, paid staff can deliver on the tasks and move the coalition along more effectively, especially when the work is complex and multifaceted.
Decision-making is a source of great concern, usually at the beginning of a coalition’s life. Because members represent different constituencies and perspectives, they will often not trust one another. Everyone wants to protect his or her own interests. As the coalition decides on its mission and goals, it also has to figure out how it will make its decisions. Most often, decisions are made without voting by consensus; members simply agree or disagree. However, when decisions are close, coalition members should step back and discuss the situation again. When one is operating on consensus, the coalition members must come to a decision with which all are comfortable. What frequently happens is that alternative solutions are offered until one is made to which all can agree. Consensus building is by nature time-consuming, but it fosters involvement and buy-in from all the coalition members, and coming to consensus requires leadership skill and finesse (Berkowitz & Wolff, 2000).
Coalitions must meet; otherwise, the work doesn’t get done. People come to coalition meetings for at least two reasons—to get work done and to make social connections. The meetings must combine both, in just the right combination, to keep people coming back.
The interval between meetings and the time of meetings is very important. The time interval should be long enough for members to accomplish their assignments. Meetings should consist ideally of presenting alternatives for action and making decisions. If the interval between meetings is too long, little interim work will get done, as the human response is to wait until right before a meeting to complete an assignment. The leader should confirm with members the amount of time each will need to get the work accomplished in the interim and then schedule the next meeting accordingly.
The content of the meeting should be focused on problem solving and decision-making. There should be a sense among members that work is being done and decisions made; otherwise, results-oriented members will soon stop attending meetings. A good meeting has energy. If the meeting is primarily conducted to exchange information, some members will see this as a waste of their time, and they may drop out. Alternatives such as e-mail and electronic bulletin boards exist for disseminating information. Consequently, coalition leaders and members should regularly assess the content of the meetings to see what works and what doesn’t and to make necessary adjustments.
Promoting the Coalition
What good is a coalition if no one knows it exists? Coalitions are formed to advance a common agenda, and communication is the vehicle with which that agenda is advanced. Early on in the coalition’s life, members must develop and implement a communications plan aimed at getting the coalition’s message out to the broader community of interest. The plan should include branding (i.e., logo and tag line), ways to reach intended audiences (i.e., website and social marketing venues, such as Facebook and Twitter), and assigning individuals to keep the communication up-to-date and vibrant.
Coalition work takes money. Some coalitions, like the Mandate-Lite Coalition, run on little or no money, using the time and talent of their members. These coalitions may be unable to sustain their work over the long haul because of lack of resources. Generally speaking, coalitions will need to look for additional funds to stay solvent and accomplish their work. How much money is needed depends on several factors. First are the mission and aims of the coalition. Second, the strategic plan will define the resources needed; then members can decide how to best obtain the funds. Third, members should develop a fund-raising plan that includes tailoring the message to prospective funding sources, assigning people to make the contacts, communicating the mission and aims of the coalition, and seeking funding.
Pitfalls and Challenges
Coalitions usually start out with a flurry of excitement and activity. Leadership plays a critical role in sustaining the excitement and guiding the activity. Nevertheless, coalition work is difficult and complex, with lots of challenges. Following are some common pitfalls and challenges, with suggestions for overcoming them.
Failure to Get the Right People to Participate
Coalitions should attract those who are most interested in seeing that the work gets done, and these members will commit to participating in the coalition. At regular intervals, coalitions should assess who is “at the table” and who is not. The following two common membership errors exist: First is the error of exclusion of an entire group of stakeholders. In examining the purpose of the coalition, members should ask themselves these questions: “Who have we excluded?” “Whose expertise do we need?” “Who may work to derail the coalition’s work if not invited to become a member?”
The second error in coalition membership is not achieving buy-in from major players, like the “800-pound gorillas.” Coalition members should identify these individuals/organizations and seek their buy-in. For example, a nursing coalition that does not include the major leaders or associations may have difficulty advancing its agenda.
Cultural and Language Differences among Coalition Members
Because coalition members represent different perspectives on the goals and mission of the coalition, all must learn the meaning of significant words used by coalition members. Sometimes simple words carry completely different connotations, such as the word time for nurse administrators (who operate day-to-day) and nurse educators (who operate by semesters). Coalition leaders and members must continually be attuned to words that have different connotations, and they should agree on a common definition (if possible) or agree to understand the differences in the meaning of words.
Persistent Distrust among Coalition Members
Distrust is perhaps one of the thorniest challenges that coalition leaders face, because much of the success of coalitions comes from the ongoing interaction among members that allays misperceptions and builds trust. When members become disengaged from coalition work, their absence can derail progress, especially if they fail to keep their own constituencies informed. Another source of distrust emanates from long-standing perceived inequalities among members, such as active membership of licensed practical nurses or certified nursing assistants in a nursing coalition. To overcome distrust, leaders and members must work diligently on including these potentially disenfranchised members. In the end, people must feel valued and treasured for all their participation and contributions to the enterprise.
Control Freaks and Protecting Turf
The tendency to control and protect turf can happen at the individual member level and at the coalition level. At the individual level, there are those in whom coalition success breeds a new brand of person—one who knows “the truth” and is always willing to share it. These individuals need to be gathered back into the fold and made to feel that their ideas are worthy, but at the same time, they must understand that they do not possess all the answers to the work at hand. At the coalition level, successful coalitions may easily rest on past achievement and ignore the need for retooling for ongoing challenges. Hence, competing coalitions may form, leading to turf protection and dysfunctional competing coalitions.
Poor Handling of Different Perspectives
By their very nature, coalitions consist of individuals representing constituencies with differing perspectives on issues. For example, hospital associations are concerned with adequate reimbursement from insurers; quality, safety, and risk management; surpassing their current market edge; and maintaining an adequate nursing workforce to preserve patient safety and quality of care. Nurses associations’ primary advocacy concerns are about the practice of registered nurses, including staffing and standards and ethics of nursing practice. Consequently, the perspectives of hospitals and nursing associations frequently differ over practice issues such as mandatory overtime and staffing ratios. Both types of organizations are concerned with quality and safety of care, thus working together can be most effective in creating solutions. Coalition leaders and members have an obligation to recognize points of contention and determine how they will be handled—by consensus, compromise, or agreeing to avoid the conflict if it is not essential to the work of the coalition (Siek & Hague, 1992).
Failure to Act
Coalitions begin with fire in their bellies. Unfortunately, going from words to action is sometimes more difficult than members had originally thought. Some coalitions formulate and reformulate action plans ad infinitum without getting to the action piece. However, action is the coalition’s currency. Without action, there will be no resources to support the work. At least two factors contribute to failure to act. One is lack of leadership, and the other is the inability for the coalition to coalesce around solutions. To resolve the leadership issue, new leaders will have to emerge. Resolving the consensus issue requires a regrouping and reexamination of the purposes of the coalition and an analysis of whether or not any consensus can be achieved.
Coalition leaders and members wear out. Managing, leading, and working in coalitions drain energy. All members are entitled to personal lives and must know that they do not have to keep their coalition jobs for life. Each person must assess his or her readiness to step aside and support the leadership and membership activities of new recruits. Therefore, coalitions should set in place a means for leadership succession planning at regular intervals.
Political Work of Coalitions
Should coalitions speak out on issues that matter to them? Should nursing coalitions speak out for nursing? Of course they should. But advocacy work has its downsides and upsides.
Reasons Not to Advocate
When coalitions advocate for certain positions, they run into opposition from stakeholders who diverge from those positions. The further coalitions go out on the limb, the more people line up to saw off the limb. In fact, coalitions stand to lose their financial support if they go too far. In addition, there are legal restrictions on advocacy by tax-exempt groups in lobbying, so coalitions may be forced to pull back if they become too forcefully active. Therefore, coalitions should choose their battles carefully, making certain that they are willing to accept the consequences of winning or losing (Bowers-Lanier, 2010).
Reasons to Advocate
Nursing and other health care coalitions that are established to advocate for particular legislative or policy initiatives will be successful if the initiatives are enacted into law or become established policies. When that happens, the coalition will have met its goal, and it may disband. Alternatively, it may envision another goal and begin work toward accomplishing that.
How to Advocate with Grace
The solution, of course, is to proceed with care. By its very nature, advocacy involves risk. Coalition members should work out their differences and carefully select the words they will use when advocating for positions. Coalition members should agree in advance on the advocacy approaches they will take that will not jeopardize their legal status as well as disenfranchise funders and members.
Evaluating Coalition Effectiveness
Coalitions should evaluate their effectiveness on a regular basis. Evaluation helps to keep members on track, determine strengths and areas for improvement, and in the final analysis, determine whether the coalitions’ goals are met or if further work is needed. Evaluation should be both formative (assessing the progress of the coalition on a continual and regular basis such as after each meeting) and summative (assessing the status of coalition deliverables after a defined period of time such as annually) and should occur at regular intervals. Stakeholders create coalitions to bring diverse groups of people together around a common cause. Table 86-1 lists the questions governing formative and summative coalition evaluation.
|Evaluation Type||Questions to Be Answered|
|Formative||Questions to be asked at a regular basis (by meeting, monthly, quarterly at maximum)|
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