To enhance your understanding of this chapter, try the Student Exercises on the Evolve site at http://evolve. elsevier.com/Black/professional.

Never before has the national policy-making stage seemed so close at hand to the American public. National media networks and 24-hour cable news coverage have brought life “inside the Beltway” of Washington, D.C. into American living rooms and under scrutiny. Interest and involvement of American citizens in governmental processes and accountability are good for democracy. Events on the national and even the world stage seem very close at hand (Figure 15-1).

Chapter opening photo from istockphoto.com.

National politics and policy are of great interest; however, much of the politics and policy that affect our daily lives occurs at the state and local levels. The workings of government in your state legislature and local municipalities are likely to be much less familiar to you than what is occurring nationally. Even less conspicuous are the policy-making and policy-influencing activities that occur within the professional organizations that support and shape nursing practice. Yet our day-to-day lives, both professionally and personally, are shaped to a large degree by what happens at the local and organizational levels. This chapter will focus on politics and policy making in several arenas of importance to nursing. This discussion will start with professional organizations and their roles in setting practice and policy, then will turn to politics and policy in government from both national and local perspectives.

Several chapters of this book cover material that is heavily influenced by government. The content of Chapter 1, the current status of nursing, will be the content of a future edition’s Chapter 2, the history and social contexts of nursing. The content of both of these chapters reflects policy and politics that affect who nurses are and what we do. Chapter 4 is directly concerned with policy that affects practice. Governmental regulation through licensure is an issue, but the influence of professional organizations to set standards and affect nurse practice acts demonstrates the two-way process that is required to keep nursing relevant and up-to-date within the health care arena. The focus on ethics in Chapter 5 describes issues of justice and autonomy, foundational principles in American jurisprudence, which shape how we understand and resolve ethical dilemmas.

Issues of nursing education (Chapter 7) are directly shaped by governmental regulation to ensure that schools of nursing produce graduates that can be entrusted to provide safe care. In Chapter 11, nursing research is shown to be heavily dependent on the financing of the National Institutes of Health’s National Institute for Nursing Research and other centers and institutes funded with federal dollars. Research is key to the development of the knowledge base of nursing, which in turn protects its status as a profession and an academic discipline and its influence in both academic and policy arenas. The previous chapter, Chapter 14, addressed the complex issues surrounding how health care is delivered and financed. This is a heavily regulated endeavor with incredibly intricate implications affecting how and where nurses practice. This completes the circle, in a sense, drawing you back to Chapter 1, the current status of nursing, and where we are going.

Furthermore, you are on the edge of a significant movement for health care reform, through which nurses do not have to be passive recipients of decisions made on their behalf about practice. Nurses are poised to participate in decisions about health care reform in which nurses, the largest single group of health care providers in the country, can have significant influence.

Policy and politics

Policy and politics are more than what is happening in Washington, D.C. They encompass what happens to us in our daily lives, in the workplace, and in our organizations, as well as in government. Politics has two meanings. Concise definitions are as follows:

1. The science of government; that part of ethics which has to do with the regulation and government of a nation or state, the preservation of its safety, peace, and prosperity, the defense of its existence and rights against foreign control or conquest, the augmentation of its strength and resources, and the protection of its citizens in their rights, with the preservation and improvement of their morals.

2. The management of a political party; the conduct and contests of parties with reference to political measures or the administration of public affairs; the advancement of candidates to office; in a bad sense, artful or dishonest management to secure the success of political candidates or parties; political trickery.

http://dictionary.reference.com/browse/politics, 2009

We tend to think of politics in terms of the second definition, the one associated with political parties; campaigns; promises; and wrangling for votes, support, and position. However, the first definition is the one that has the more lasting impact on society. The government is the political body that has to do with the regulation and preservation of the nation. The politics of the second definition is the process by which we determine who will occupy the government in our representative democracy.

Policy, on the other hand refers to the following:

. . . a plan or course of action, as of a government, political party, or business, intended to influence and determine decisions, actions, and other matters: American foreign policy or American health care policy.

http://dictionary.reference.com/browse/policy, 2009

Policy is shaped to a great degree by those who are successful in the political arena (the second definition). These are the elected officials who describe their agenda before the election to receive support, endorsements, and, ultimately, enough votes to be elected into office. For instance, during the 2008 presidential campaign, the pros and cons of health care reform were discussed and debated at length, and as the nominee, Barack Obama took a stand in favor of health care reform. This was debated again in the 2012 campaign. That Obama embarked on a complex and wide-ranging effort to make health care more affordable should have been of no surprise to anyone who was paying attention to the 24-hour cable news outlets that both reported and argued the various merits of his health care campaign agenda throughout these campaigns. In other words, President Obama used politics as a process (the second definition) to achieve a goal of managing the government (first definition) so that he could influence change in health care policy with the expectation and hope of improving affordability. One of the first pieces of legislation signed by President Obama was the State Children’s Health Insurance Program (SCHIP) reauthorization legislation that extended health insurance coverage to 8 million children whose parents cannot afford health insurance coverage (Figure 15-2).

Power, authority, and influence

A review of the concepts power, authority, and influence will help focus the discussion of policy and the remainder of this chapter. Power is strength or force that is exerted or capable of being exerted. Power in and of itself is latent.

A person who has authority has legitimacy to exert power, that is, to enforce laws, demand obedience, make commands and determinations, or judge the acts of others. People who have been vested with this power—for instance, through a fair and democratic process—are known as authorities, especially a government or body of government officials. Influence is a form of power that is not legitimated through official channels, that is, elections or appointments by one in authority, but influence is the action or process of producing effects on the actions, behavior, and opinions of others. For example, the issue of lobbyists got much attention in the past two presidential elections. Lobbyists are people who try to influence government officials to act in a certain way that will benefit the constituency that hired the lobbyist to work on its behalf, that is, to exert influence.

A simple clinical example will clarify the difference among these three concepts.

Jane Wilson, registered nurse (RN), is an experienced labor and delivery nurse, and her patient is Ms. Foster. Ms. Foster has been in labor for several hours but is not making very much progress. Jane believes that augmenting her labor with oxytocin would be a good idea. Jane cannot begin this infusion because she does not have the authority to do so without Dr. Martin’s order. Dr. Martin has both the power and the authority to write orders. Jane, because she is very experienced, understands that she can influence Dr. Martin’s decision by giving Dr. Martin her expert opinion on the situation. Jane calls Dr. Martin, influences Dr. Martin to order the oxytocin, and begins the infusion in a few minutes. Ms. Foster delivers a healthy baby girl 3 hours later. Note that Jane exerted power through influencing Dr. Martin’s behavior; Dr. Martin had latent power, that is, power that had not yet been used to write an order for the oxytocin; and Dr. Martin had the authority as a licensed physician to write the order.

This is a common scenario between nurses who need something for their patients and physicians who hold the authority to write orders. As the patient’s advocate, skilled nurses know how to influence physicians to get what their patient needs. This is not to be confused with manipulation, which is not a good personal or professional behavior. But being able to state your case on behalf of your patient clearly, without manipulation, is an excellent way of influencing the outcome in a way that you and your patient would like.

Policy

Policy involves principles that govern actions directed toward given ends; policy statements set forth a plan, direction, or goal for action. Policies may result in laws, regulations, or guidelines that govern behavior in the public arena or in the private arena. Health policy refers to public or private rules, regulations, laws, or guidelines that relate to the pursuit of health and the delivery of health services. Policy reflects the choices that an entity (government or organization) makes regarding its goals and priorities and how it will allocate its resources.

Policy decisions (e.g., laws or regulations) reflect the values and beliefs of those making the decisions. As values and beliefs change, so do policy decisions. For instance, laws limiting smoking in public buildings or private restaurants were nonexistent 50 years ago because the harmful effects of smoking and secondhand smoke were not yet well known. As the public became more aware of the dangers of smoking, values about smoking changed. Changes in laws followed the change in values. Laws limiting smoking and the sale and use of tobacco products have now become commonplace. Elected officials responded to the changing values of the public and recognized that the public supported the passage of laws limiting smoking. In a representative democracy, this is how policy is changed. Officials are elected to represent and then act on the interests of their constituents, that is, the people of their state, congressional district, or municipality.

In professional organizations, policy focuses on the rules and guidelines established by the governing body of the organization, usually a board of directors. Those guidelines or policies also reflect the values of the organization. For instance, one would expect a nursing organization such as the American Nurses Association (ANA) to focus on issues of health promotion, illness prevention, and nursing practice issues. That would be quite different from an organization such as the National Collegiate Athletic Association, in which the values of its members would be reflected in policies and recommendations that support and regulate athletics at the college level across the country.

Politics

Politics is a process that requires influencing the allocation of scarce resources. Allocation assumes that there are not enough resources for all who may want them. Those resources might be money, people, time, supplies, or equipment. Who gets what, or how those resources are allocated, is determined through the political process. Policies are the decisions; politics is influencing those decisions. There are always stakeholders, individuals with a vested interest, who try to influence those with the power to make the final decisions.

In organizations, stakeholders are the members, the larger community served by the work of the organization, and other groups or individuals affected by those decisions. For example, Patients Out of Time, an organization started by a nurse, has worked for years to educate the public and health care professionals about the therapeutic use of cannabis and to advocate for the medicinal use of marijuana (www.medicalcannabis.com). Stakeholders for this organization are affected patients and families, health care providers, and those who make decisions about the laws and regulations about cannabis use. These include state and federal legislators, as well as the U.S. Food and Drug Administration (FDA), the Secretary of Health and Human Services (who oversees the policies of the FDA), and organizations such as the ANA and the American Public Health Association, both of which support the therapeutic use of cannabis/marijuana (ANA, 2008; American Public Health Association, 1995).

Politics works similarly in the public arena. For example, to garner support from state legislators to increase funding for nursing scholarships, an organization or coalition of organizations must have a plan to mobilize stakeholders to lobby legislators. Such stakeholders would include administrators of nursing organizations, colleges of nursing, hospitals, nursing homes, and other health care organizations, as well as physician groups and others who know the necessity of having a competent and adequate nursing workforce. The more stakeholder support that can be mustered, the more likely it is that policymakers will appreciate the broad constituent support for the issue and the more likely they will be to vote for increased funding for nursing education and scholarships.

Linking practice, policy, and politics

Leaders in nursing, from Florence Nightingale to Lavinia Dock, saw and understood the connection between their work and the larger world in which policy decisions affected what they were able to do. Nightingale could not have been successful in the Crimea without the support of Sir Sidney Herbert, Secretary of War. Lavinia Dock joined with other nurses to found the ANA, pressure hospital administrators to improve working conditions for nurses, and galvanize support for nursing registration (Lewenson, 2007, p. 23). A recent example is Karen Daley, a modern nurse who went public with her needlestick injury from which she contracted human immunodeficiency virus (HIV) and hepatitis C infections (Daley, 2007). She went public to influence legislation requiring protective devices. In each instance, these leaders knew that nursing practice could be improved only through legislation, regulation, or unification to create a formidable national organization. Daley recognized the power in her story and the extent to which her experience could influence those with authority to make nursing practice safer. Her testimony before the House Committee on Education and the Workforce’s Subcommittee on Workforce Protection can be found at http://archives.republicans.edlabor.house.gov/archive/hearings/106th/wp/needlestick62200/daley.htm.

The larger world of public policy and the work of organizations become the arena in which someone with a vision for improved health or working conditions can change the way health is delivered and improve the health of populations. With these examples in mind, we now turn our attention to professional organizations as a means of activism.

Professional organizations

Professionals create organizations to work collectively on issues that enhance their work and their involvement in communities, to ensure continued learning and competence, and to use political action to influence policy makers to support the mission of the organization. Professional organizations offer a supportive way to learn leadership skills, to test ideas, and to follow these ideas to completion. Nursing has a national organization open to all RNs, the ANA (www.nursingworld.org); a national student nurses organization, the National Student Nurses Association (NSNA, www.nsna.org); and many other specialty organizations developed around particular practice areas. Nursing organizations influence public policy in a variety of ways. The following section examines the role and function of organizations, explores why nurses do or do not join organizations, and discusses examples of collective action. Because organizations are often the catalyst for involvement in political action, we will also explore the broader area of political action in the public arena.

Joining a professional organization

Nurses join organizations to network with colleagues, to pursue continuing education and certification opportunities, to stay informed on professional issues, to develop leadership skills, to influence health policy, and to work collectively for job security. Yet less than 10% of the nation’s RNs are members of the ANA and only about 20% of nurses belong to one of the 100 or more specialty nursing organizations. Nurses cite issues of high cost of dues, lack of time, and lack of interest as reasons they do not join. In some states, complex relationships between the state nurses association, the ANA, and collective bargaining units restrict ANA membership. There are also different expectations and interests among generations of nurses. Although Baby Boomers and older members may accept traditional organizational structures and volunteer tasks, younger colleagues prefer short-term projects, using technology such as blogs and chat rooms rather than face-to-face meetings. As older members retire, organizations become more responsive to incorporating processes and products that reflect preferences of younger members.

Types of associations

There are more than 100 national nursing organizations and many more state and local groups. Nurses often express confusion about which group to join. In general, associations can be classified as one of three main types:

1. Broad-purpose professional associations

2. Specialty practice associations

3. Special interest associations

The ANA is an example of a broad-purpose association. Individual nurses who belong to the ANA typically become members of their state’s constituent member association.

As the nursing profession’s body of knowledge and research grows and diversifies, many nurses limit their practices to specialty practice areas such as maternal/infant care, school or community health, critical care, or perioperative or emergency/trauma nursing. They often join the specialty organization for their area of clinical interest. Members of specialty practice nursing associations also may choose to belong to the ANA or one of its constituent member associations (at the state level) to support the entire profession because specialty associations focus only on standards of practice or professional needs of the particular specialty. Sixty-six specialty organizations are represented in the Nursing Organizations Alliance.

Examples of special interest organizations include Sigma Theta Tau International (the Honor Society of Nursing), which one must be invited to join, and the American Association for the History of Nursing, which focuses on a particular area of study in nursing. Comprehensive and frequently updated lists of nursing organizations are available online at www.nurse.org/orgs.shtml.

Nurses are connected internationally through the International Council of Nurses (ICN). The ICN is a federation of national nurse associations representing nurses in 118 countries. The ANA represents U.S. RNs in the ICN, and the NSNA represents U.S. nursing students in the ICN.

Founded in 1899, the ICN is the world’s first and widest-reaching international organization for health professionals. Operated by nurses for nurses, the ICN works to ensure quality nursing care for all, sound health policies globally, the advancement of nursing knowledge, the presence worldwide of a respected nursing profession, and a competent and satisfied nursing workforce. For additional details about the ICN’s activities in professional nursing practice, nursing regulation, and the socioeconomic welfare of nurses, visit the ICN home page (www.icn.ch).

Purpose and activities of organizations

An organization’s activities reflect its mission statement. The mission statement is generated by the membership and defines the organization’s purpose and who is served by the organization. For instance, the ANA’s goals are “fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the public” (www.nursingworld.org, 2012). These goals are reflected in their concise mission statement: Nurses advancing our profession to improve health for all (www.nursingworld.org, 2012). These goals and mission define the association’s areas of focus as practice standards, a code of ethical conduct, continuing education and conferences, and collective action around workplace issues.

Nurses and unions

Unionization of nurses is a controversial topic. Nurses may choose to join unions to work collectively, to have control over their practice and workplace, and to work to equalize power between management and staff. This can be an effective approach if the health care organization is willing to work collaboratively with unions. Union affiliation is a highly complex process, one that is defined by rules and regulations under the National Labor Act and overseen by the National Labor Relations Board. There are limits on what issues unions can bargain; for instance, hours, pay, and benefits are included in all contracts for all unionized workers.

For nurses, additional issues are increasingly part of contract negotiations. These include issues such as staffing, work assignments, and shared governance responsibilities. The recent nursing shortage created an environment in which both management and nurses themselves aspired to develop work environments that decreased turnover and ensured a competent workforce.

National Nurses United (NNU) is an affiliation of collective bargaining organizations that work to improve working conditions for nurses because this in turn results in better care for patients. The NNU was formed in 2009 when United American Nurses (UAN), which represented only nurses, merged with the California Nurses Association (CNA), National Nurses Organizing Committee, and the Massachusetts Nurses Association. Some nonnursing unions have nursing units: the Service Employees International Union (SEIU); the American Federation of Teachers (AFT); the Association of Federal, State, County, and Municipal Employees (AFSCME); and the United Mine Workers (UMW). These organizations all have nursing units but also represent larger, nonnursing constituencies.

Nurses wonder whether they should join unions. Much of that depends on where they work. If seeking a staff position in an institution in which a nursing union already exists, a nurse may be required to join the union as a condition of employment. This is called a “closed shop,” meaning that management is required to bargain with the union, and union membership is required as a condition of employment. An “open shop” is one in which employees are not required to join but in which an individual’s contract will be dependent on what union and management have negotiated. Most nurses work in nonunion facilities. Some states are more “union friendly” than others. States in which labor unions flourish, such as in the Northeast, Northwest, and Midwest, have the vast majority of nursing unions. Smaller states, particularly in the Southeast (other than Florida) and Southwest, have few or no nurse unions. These are known as “right to work states.” Although unions have made numerous attempts to organize nurses in these states, the value system of the work culture is less supportive of union affiliation by nursing professionals. Figure 15-3 shows nurses protesting during a 1-day strike in California in September, 2011.

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