Political Analysis and Strategies

Judith K. Leavitt, Diana J. Mason and Ellen-Marie Whelan

“You campaign in poetry and you govern in prose.”

—Mario Cuomo

Nursing and politics are a good match. First, nurses understand people. Success in any political situation depends on one’s ability to establish and sustain strong interpersonal relationships. Second, nurses appreciate the importance of systematic assessments. Nurses engaged in the politics of the policy process will find that their efforts are most effective when they systematically analyze their issues and develop strategies for advancing their agendas. Finally, nurses bring to the deliberations of any health policy issue an appreciation of how such policies affect clinical care and patient well-being and can foresee possible unintended consequences. Few policymakers have such an ability. Thus nurses have much to offer public and private sector discussions and actions around health policy issues.

Components of Political Analysis

The best approach to accomplish change must include a thoughtful analysis of the politics of the problem and proposed solutions. This must be done simultaneously with policy analysis, as explored in Chapter 7 (Box 8-1).

BOX 8-1

Steps of a Political Analysis

1. Identifying and analyzing the problem

2. Outlining and analyzing proposed solutions

3. Understanding the background of the issue: its history and previous attempts to address the problem

4. Locating the political setting and structures involved

5. Evaluating the stakeholders

6. Conducting a values assessment

7. Recognizing the resources (both financial and human) needed to reach the intended goals

8. Analyzing power bases

The Problem

The first step in conducting a political analysis is to identify the problem. Answering several questions is useful for framing the problem:

• What are the scope, duration, and history, and whom does it affect?

• What data are available to describe the issue and its ramifications?

• What are the gaps in existing data?

• What types of additional research might be useful?

Not all serious conditions are problems that warrant government attention. The challenge for those seeking to get public policymakers to address particular problems (e.g., poverty, the underinsured, or unacceptable working conditions) is to define the problem in ways that will prompt lawmakers to take action. This requires careful crafting of messages so that calls for public, as opposed to private sector, solutions are clearly justified. This is known as “framing” the issue. In the workplace, framing may entail linking the problem to one of the institution’s priorities or to a potential threat to its reputation, public safety and wellbeing, or financial standing. For example, inadequate nurse staffing could be linked to increases in rates of infection, morbidity, and morality—outcomes that can increase institutional costs and jeopardize an institution’s reputation and future business.

Sometimes what appears to be a problem is not. For example, proposed mandatory continuing education for nurses is not a problem. Rather, it is a possible solution to the challenge of ensuring competency of nurses. After an analysis of the issue of clinician competence, one might review the policy outcomes and establish a goal that includes legislating mandatory continuing education. The danger of framing solutions as problems is the possibility that it can limit creative thinking about the underlying issue and leave the best solutions uncovered.

Proposed Solutions.

Typically, there is more than one solution to an identified problem, and each option differs with regard to cost, practicality, and duration. These are the policy options. The political analysis revolves around what is politically feasible. By identifying and analyzing possible solutions, nurses will acquire further understanding of the issue and what is possible for an organization, workplace, government agency, or professional organization to undertake. There needs to be a full understanding of the big picture and where the issue fits into that vision. For example, if nurses want the federal government to provide substantial support for nursing education, they need to understand the constraints of federal budgets and the demands to invest in other programs, including those that benefit nurses. Moreover, support for nursing education can take the form of scholarships, loans, tax credits, aid to nursing schools, or incentives for building partnerships between nursing schools and health care delivery systems. Each option presents different types of support, and nurses would need to understand the implications of the alternatives before asking for federal intervention.

The amount of money and time needed to address a particular problem also needs to be taken into account. Are there short-term and long-term alternatives that nurses want to pursue simultaneously? Is there a way to start off with a pilot or demonstration program with clear paths to expansion? How might one prioritize various solutions? What are the tradeoffs that nurses are willing to make to obtain stated political goals? Such questions need to be considered in developing the political strategy.

Background

When striving to affect policy formation, one must know about previous attempts to move an issue. This will provide insight into the feasibility of a particular approach and provide lessons on what worked and what did not. Knowledge of past history will also provide insight into the position of key public officials so that communications with those individuals and strategies for advancing an issue can be developed accordingly. For example, if one knows that a particular legislator has always questioned the ability of advanced practice nurses (APNs) to practice independently, then that individual would need special coaxing and perhaps a stronger emphasis on the evidence about the quality and value of APNs to support legislation allowing direct billing of APNs under Medicare.

Historical precedent for one issue can affect the politics of another. For example, in the United States today, one would not expect to be successful in moving social welfare legislation that was associated with high taxes because of the predominant value of “get government out of our lives”—as was evident during the debate preceding the passage of health care reform. This was not always the case. Social Security, Medicare, and Medicaid were all passed because at that time the public understood the need for government support to help those lacking adequate resources. In a classic work, Fox-Piven and Cloward (1993) documented that societies go through cycles of expanding and contracting social policies and programs aimed at supporting vulnerable citizens. As the size and need of the vulnerable population increases, social policies for safety nets are more likely to be put into place as a response to escalating social unrest and upheaval. This work reminds us that historical precedent does not mean that what happened in the past will remain the same. In fact, it suggests that we should be cognizant of cycles of change, seek to support a shift in political climate that will support our agendas, and be prepared to act when the time is right. The Affordable Care Act (ACA) is a good example of how lessons learned from the health care reform debate under President Clinton was instrumental in final passage under President Obama (Table 8-1).

TABLE 8-1

Historical Precedent: Lessons That Helped Pass the Patient Protection and Affordable Care Act

	President Clinton	President Obama
Strike while the iron is hot	Clinton hoped to send legislation to Congress within the first 100 days of his new Administration, but it took nearly a year. By that time, fear had escalated and momentum had waned.	Like Clinton, Obama made health care reform a top priority. Although it took longer than expected, Obama worked on health care after his election and kept working until he signed the bill into law.
It’s not what you say, it’s how you say it	Clinton spoke about health care reform more as a moral imperative: “It’s the right thing to do for the nation.”	Obama learned that the message didn’t resonate with the public. Instead he reiterated that under his plan: “If you like what you have (health insurance) you can keep it.”
Proposed solutions	Clinton worked out all the details of a plan within the administration and presented the completed plan to Congress. The members of Congress were unhappy about not having input.	Obama learned that Congress needed to be involved—from the very beginning. Instead of working out the details, he presented Congress with a set of seven principles for health reform and instructed them to write the legislation.
Stakeholders	Clinton did not negotiate with key stakeholders in the development of the plan. As a result, the insurance industry launched the now infamous “Harry and Louise” commercials that some credit with successfully killing the legislation.	From the beginning, Obama met with key stakeholders including health professional groups, hospitals, insurance companies, and drug companies. He told them he was moving forward and wanted them at the table from the very beginning to help map out a health reform plan. In the end, most of the major stakeholders supported the final product.
United we stand, divided we fall	Clinton was forceful in telling Congress that if they sent him a health care proposal that “did not guarantee every American private health insurance that can never be taken away,” he would veto the legislation.	Obama’s team declared early on they would try to get bipartisan agreement on the legislation and be willing to negotiate to accomplish this. The Senate Finance Committee deliberated for months trying to get bipartisan support in their committee and succeeded, though with only one Republican vote. In the end, despite a bipartisan summit held by Obama and the inclusion of many GOP ideas, the bills were passed with only Democratic support.

Political Setting

Once the problems and solutions have been clearly identified and described, the appropriate political arenas for influencing the issue need to be analyzed. Usually this begins by identifying the entities with jurisdiction over the problem. Is the issue primarily within the public domain, or does it also entail the private sector? Many issues require a mix of public and private sector players, but responsibility for decision-making will ultimately rest with one sector more than the other. For example, nurses interested in improving workplace conditions would first turn to their employers and other local stakeholders. It is seldom prudent to turn to public officials until other efforts in the private sector have failed. Additionally, making a change in one arena, such as Medicare in the public arena, affects other sectors such as private payers.

With regard to public policy, nurses need to clarify which level of government (federal, state, or local) is responsible for a particular issue. When one communicates with legislators and develops strategies, it is critical to understand the level of government responsible for a particular issue and how the levels interrelate. Scope of practice is a good example. Although typically defined by the states, there are examples where the federal government has superseded the state’s authority—such as in the Veteran’s Administration and the Indian Health Service. (See Chapter 64 for a full discussion of how government works.)

In addition to the level of government, nurses need to know which branch of government (legislative, executive, or judicial) has primary jurisdiction over the issue at a given time. Although there is often overlap among these branches, nurses will find that a particular issue falls predominantly within one branch (see Chapter 65 on the legislative and regulatory processes).

If the issue is in the problem definition and policy formation stage, then nurses will focus on the legislative branch. If an issue entails the implementation of a program, including promulgating regulations, then nurses will focus on the executive branch while maintaining an eye toward the legislative role in oversight. Issues that are within the courts call for knowledge of the judicial system.

Nurses can also apply a political analysis to the workplace or community organization. Regardless of the setting, nurses will want to identify who has responsibility for decision-making for a particular issue; which committees, boards, or panels have addressed the issue in the past; the organizational structure; and the chain of command.

At an institutional level, once the relevant political arenas are identified, the formal and informal structures and functioning of that arena need to be analyzed. The formal dimensions of the entity can often be assessed through documents related to the organization’s mission, goals, objectives, organizational structure, constitution and bylaws, annual report (including financial statement), long-range plans, governing body, committees, departments, and individuals with jurisdiction.

Does the entity use parliamentary procedure? Parliamentary procedure provides a democratic process that carefully balances the rights of individuals, subgroups within an organization, and the membership of an assembly. The basic rules are outlined in Robert’s Rules of Order (www.rulesonline.com). Whether in a legislative session or the policymaking body of large organizations, such as the American Nurses Association (ANA) House of Delegates, one must know parliamentary procedure as a political strategy to get an issue passed or rejected. Countless issues have failed or passed because of insufficient knowledge of rule making.

It is also vital to know the informal processes and methods of communication. A well-known example of the power of informal processes and communication is the case of the business lunch or the golf game that in the past excluded women.

Stakeholders

Stakeholders are those parties who have influence over the issue, who are directly influenced by it, or who could be mobilized to care. In some cases, stakeholders are obvious. For example, nurses are stakeholders in issues such as staffing ratios. In other situations, one can develop potential stakeholders by helping them to see the connections between the issue and their interests. Many individuals and organizations can be considered stakeholders when it comes to staffing ratios. Among them are employers (i.e., hospitals, nursing homes) payers (i.e., insurance companies), legislators, other professionals, and, of course, consumers. The role of consumers cannot be underestimated. In the political arena, these are the constituents and therefore the voters.

In many cases, nurses are working on behalf of stakeholders, the patients, who are affected by the care they receive. Nursing has increasingly realized the potential of consumer power in moving nursing and health care issues. For example, nurses have worked with the National Alliance for Mental Illness on mental health parity and with the American Cancer Society on tobacco and breast cancer issues. A consumer advocacy organization such as AARP represents significant lobbying power. When nursing wanted to advance the idea of a Medicare Graduate Nursing Education benefit, similar to the Medicare Graduate Medical Education funding to hospitals for the clinical training of interns and residents, AARP championed the proposal and it was included in the ACA as a pilot project. AARP advocated this benefit because it views the nursing shortage as a threat to its members’ ability to access health care.

What kind of relationships do you or others have with key stakeholders? Look at your connections with possible stakeholders through your schools, places of worship, or business. Which of these stakeholders are potential supporters or opponents? Can any of the opponents be converted to supporters? What are the values, priorities, and concerns of the stakeholders? How can these be tapped in planning political strategy? Do the supportive stakeholders reflect the constituency that will be affected by the issue? For example, as states expand coverage of health services through each state’s Medicaid, it is vital to have parents of enrolled children let their policymakers know how important the issue is for them. These parents can share their personal stories of how the program has made a difference for their children. Yet stakeholders who are recipients of the services are too often not identified as vital for moving an issue. Nurses as direct caregivers have an important role in ensuring that recipients of services are included as stakeholders—especially when bringing issues to elected officials.

Values Assessment

Every political issue, especially those issues that entail “morality policies,” could prompt discussions about values. Morality policies are those that primarily revolve around ideology and values, rather than costs and distribution of resources. Among well-publicized morality issues are abortion, stem cell research, immigration, and the death penalty. But even issues that are not classified as morality policies require that stakeholders assess their values and those of their opponents.

Values underlie the responsibility of public policymakers to be involved in the regulation of health care. In particular, calls for extending the reach of government in the regulation of health care facilities implies that one accepts this as a proper role for public officials, rather than as a role of market forces and the private sector. Thus, electoral politics affect the policies that may be implemented. An analysis that acknowledges how congruent nurses’ values are with those of individuals in power can affect the success of advancing an issue.

Although nurses may value a range of health and social programs, legislators will hear their calls for increased funding for nursing research and education within the context of demands from other constituencies. Here timing is critical. When a request is made, it is critical to link it to the “problem” it may solve. It is also important to make sure issues are framed to show how they will help the public at large and not just the nursing profession. Any call for government support of health care programs implies a certain prioritization of values: Is health more important than education, or jobs, or the war in Afghanistan? Elected officials must always make choices among competing demands. And their choices reflect their values, the needs and interests of their constituents, and their financial supporters such as large corporations. Similarly, nurses’ choice of issues on the political agenda reflects the profession’s values, political priorities, and ways to improve health care.

Resources

An effective political strategy must take into account the resources that will be needed to move an issue successfully. Resources include money, time, connections, and intangible resources, such as creative ideas. Analyzing resources requires both short-term and long-term needs.

The most obvious resource is money, which must be considered in relation to both the proposed policy solution and the campaign to champion it. The proposed solution needs to include an analysis of the resources needed for the solution to be successful. Thus, before launching a campaign for a particular bill or program, campaign leaders must know how much the proposed solution will cost, who will be bearing those costs, and the source of the money. It is also critical to fully examine—despite the initial financial outlay—the potential for cost savings it may produce. In addition, it is helpful to know how budgets are formulated for a given government agency or institution. What is the budget process? How much money is allocated to a particular cost center or budget line? Who decides how the funds will be used? How is the use of funds evaluated? How might an individual or group influence the budget process?

Money is not the only resource. Sharing available resources, such as space, people, expertise, and in-kind services, may be best accomplished through a coalition (see Chapter 86). It may require a mechanism for each entity to contribute a specific amount or to tally their in-kind contributions such as office space for meetings; use of a photocopier, telephone, or other equipment; or use of staff to assist with production of brochures and other communications. Other cost considerations include accessing the media or other publicity efforts; printing brochures and other educational materials; paying for postage; and establishing access to electronic communications.

Nurses can also provide in-kind contributions. When nurses and other volunteers are recruited for a political issue, project, or campaign, a common response is lack of time for involvement. Nurses need to figure how to get volunteers while simultaneously protecting one of their most precious commodities, time. One must find creative ways to use available resources. For instance, an option for limited volunteer time might be contracting for specific services; such as writing testimony or other communications, or producing white papers or other scholarly activities to help elucidate complicated policy details around an issue.

Creativity is a precious resource that enables nurses and others to develop strategies that will be inspiring and captivating to one’s audience. How much creativity is evident among the stakeholders? How can one stimulate and channel creativity? Allocating enough time for brainstorming and strategic planning, especially among a diversified coalition, will pay off in the end if well-designed and creative approaches result.

Power

In the workplace, government, professional organizations, and community, effective political strategy requires an analysis of the power of proponents and opponents of a particular solution. Power is one of the most complex political and sociologic concepts to define and measure. It is also a term that politicians and policy analysts use freely, without necessarily giving thought to what it means.

Power can be a means to an end, or an end in itself. Power also can be actual or potential. The latter implies power as undeveloped but a “force to be reckoned with” (Joel & Kelly, 2002). Many in political circles depict the nursing profession as a potential political force, given the millions of nurses in this country and the power we could wield if most nurses participated in politics and policy formation—and if nurses could identify issues on which they could speak with a single voice.

Any discussion of power and nursing must acknowledge the inherent issues of hierarchy and power imbalance that arise from the long-standing relationships between nurses and physicians. Some of nurses’ discomfort with the concept of power may arise from the inherent nature of “gender politics” within the profession. Male or female, gender affects every political scenario that involves nurses. Working in a predominantly female profession means that nurses are accustomed to certain norms of social interactions (Tanner, 2001). In contrast to nursing, the power and politics of public policymaking typically are male dominated, although women are steadily increasing their ranks as elected and appointed government officials. Moreover, many male and female public officials have stereotypic images of nurses as women who lack political savvy. This may limit officials’ ability to view nurses as potential political partners. Therefore nurses need to be sensitive to gender issues that may affect, but certainly not prevent, their political success.

Many nurses find political work unsavory because of the inevitability of conflict this power struggle sometimes causes. Conflicts between political parties, between those with different ideologic values, and between nurses and other stakeholders are inherent to the political process. Conflict is unavoidable, and it is also necessary for identifying the different viewpoints that will structure subsequent negotiations. Conflict presents opportunity. Especially when there is disagreement, it is important to find a way to move forward. In this case, nurses as natural problem solvers, can excel. Unlike other situations in which conflict may be unwelcome, in politics it is necessary for establishing the parameters of discourse and the terms of compromise. This holds true for any setting, whether in the workplace, the community, organizations, or governmental arenas (see Chapter 12 for a discussion of conflict management).

Although individuals develop political skill and expertise, it is the influence of large organizations, coalitions, or like-minded groups that wield power most effectively. Too often nurses become concerned about a particular issue and try to change it without help from others. Although the individual may hold expert power, it will be limited if one attempts to “go it alone.” In the public arena particularly, an individual is rarely able to exert adequate influence to create long-term policy change. For instance, many APNs have tried to change state Nurse Practice Acts to expand their authority. As well intentioned and knowledgeable as the policy solutions may be, they will likely fail unless nurses can garner the support of other powerful stakeholders such as members of the state board of nursing, the state nurses association, and physicians, either through the medical association or the state Board of Medicine. Such stakeholders often hold the power to either support or oppose the policy change.

Any power analysis must include reflection on one’s own power base. Power can be obtained through a variety of sources (Ferguson, 1993; French & Raven, 1959; Joel & Kelly, 2002; Mason, Backer, & Georges, 1991):

1. Coercive power is rooted in real or perceived fear of one person by another. For example, the supervisor who threatens to fire those nurses who speak out is relying on coercive power, as is a state commissioner of health who threatens to develop regulations requiring physician supervision of nurse practitioners.

2. Reward power is based on the perception of the potential for rewards or favors as a result of honoring the wishes of a powerful person. A clear example is the supervisor who has the power to determine promotions and pay increases.

3. Legitimate (or positional) power is derived from an organizational position rather than personal qualities, whether from a person’s role as the chief nurse officer or the state’s governor.

4. Expert power is based on knowledge, special talents, or skills, in contrast to positional power. Benner (1984) argues that nurses can tap this power source as they move from novice to expert practitioner. It is a power source that nurses must recognize is available to them and tap. Policymakers are seldom experts in health care; nurses are.