“We are drowning in information but starved for knowledge.”
That research has any nexus to politics or policy may strike one as curious, if not an outright oxymoron. Research, using any methodology, is carefully considered, designed, implemented, and interpreted. Politics is, well, messy. Policy is birthed from political process—and is therefore often complex and messy in its own right. Yet, research is a powerful lever in the world of politics and policymaking. In the last few decades, research has come to play an increasingly influential role in the crafting of both political messages and policy declarations, in nursing and health generally.
So what is Policy?
Policy is usually thought of as formal “rules,” set by Congress, state legislatures, or various agencies at city, county, state, or federal levels. But it is also made by private entities. Clinics and long-term and acute-care settings have infection-control policies, visitation policies, and other rules pertaining to the work. Nursing schools craft policies about student dress codes for clinical settings and academic progression. Insurance companies create policies about how much of the physician’s rate for services will be paid to advanced practice registered nurses (APRNs). The private policy sources often look to evidence in the same manner as do public policymakers.
In both venues, research alone is not responsible for producing policy. The rules for the use of data are the same, but as policy and political actors change, so do considerations about research, and how best to utilize findings, or even what research question to ask. One can think of this as the “political ecology” of policymaking—that is, the many subtle and sometimes overt influences that surround the making of any policy.
What is Research when it Comes to Policy?
Research in policymaking venues involves a roundup of all the usual suspects in quantitative methodology, including the randomized controlled trial, though the opportunities for using this “gold standard” are fewer than in bench science. Meta-analysis has tremendous potential in the world of policy. A meta-analysis is a “study of the studies,” sifting, distilling, and analyzing quantitative data gathered from multiple studies on the same topic. It produces a solid summary of evidence in one package—efficient for both advocates and policymakers. Meta-analyses can also “refocus attention” on key policy points (Aiken, 2008, p. 75). Qualitative methods are increasingly invoked for use within the policy realm (Brazier, Cooke, & Moravan, 2008).
Data-mining, the use of data collected through large health care entities and government agencies, offers a strong nexus between problems and policy solutions as well (Cheung, Moody, & Cockram, 2002). Diers has been a proponent of data-mining of clinical databases for nursing’s benefit, such as how patient acuity influences nursing’s work (Diers & Potter, 1997; Heslop, Gardner, Diers, & Poh, 2004; Diers, 2007; Duffield, Diers, Aisbett, & Roche, 2009). Using “secondary data” is challenging, but rewarding given its immense scope in time and data points, compared to what most researchers can accomplish in traditional data collection (Garmon Bibb, 2007).
And then there are a few surprises when it comes to what qualifies as research in policymaking. Policymakers are interested in data, “hungry … for new solutions and new ideas for addressing old and new health care challenges” (Fitzpatrick, 2004, p. 71). Reports from expert panels, foundations, and government research agencies can all carry great weight, if introduced in the context of moving an issue forward (Goldstein, 2009; Aiken, 2008; Winkelstein, 2009). Op-ed pieces by experts, and position papers generated by legislative staff or others can also be powerful. The point is that one must be wide open to sources when looking for evidence to support or oppose a policy position.
In presenting data to policymakers, it behooves the advocate to be short and to the point. Legislators and other policy-generators deal with a tremendous number of issues across economic, health, and social terrains. Keeping the focus on one’s issue requires policy briefs that are short and specific to the problem and the policy solution (McDonough, 2001; Jennings, C. P., 2002; Jennings, B. M., 2003; Goldstein, 2009).
Narrative—that is, the telling of a pertinent story to bring the issue to life—also has its place in the process (McDonough, 2001). Deborah Stone, a prominent observer of policymaking, refers to what she calls “causal stories” as necessary to the very genesis of a policy initiative. She notes that “[S]ocial problems do not exist ‘out there,’ waiting to be discovered by careful empirical observation and analysis.” Rather, people have to view any particular trend, experience, or event as problematic and capable of solution; stories are the mechanism for crafting this view (Stone, 2006, p. 127). Narrative data must meet the standards of rigor expected of other data: truthful, verifiable, and representative of the problem or solution it is put forward to illustrate (Steiner, 2007).
The Chemistry between Research and Policymaking
Research can be extremely useful in casting light on a problem and nudging policymakers to action, which is easier when the problem is non-controversial, such as violence against women (Moodie, 2009). Nursing has a distinguished lineage of nurses affecting policy through the use of data, from Nightingale’s Crimean data to American midwives who accomplished great things for their practice by persistent and consistent collection of ordinary practice data (Diers & Burst, 1983). Today, health care research examines how intricately intertwined in practice are the pieces of the health care puzzle: delivery, providers, procedures, patients, families, cultures, reimbursement, and so on. One consequence of this examination is a growing acknowledgement by non-nurse researchers of nursing’s contributions (Ginsburg, 2008; Needleman, 2008).
Breaking through professional and disciplinary silos is critical for research and policymaking, particularly as care has become both interdisciplinary in nature and under intense financial scrutiny (Talsma, Grady, Feetham, Heinrich, & Steinwachs, 2008). Pay-for performance policies recently implemented by Medicare and several large private payers highlight the need for nursing to work across party lines to ensure a voice in the ongoing discussion about this financing approach (Kurtzman & Buerhaus, 2008). It is equally important that decision-makers be aware that nursing is absolutely essential to meaningful health care, from cradle to grave; for rich or poor; during prevention, secondary, or tertiary care alike. But neither our constancy nor our work is universally acknowledged when it comes to implementing policies in these systems.
Using Research to Create, Inform, and Shape Policy
An example of how research can vitalize policy decisions (and of the benefit of outside advocacy for nursing services) comes from Australia. Early in this decade, a body of Australian research found that the risk for death in some rural communities was over 300 times that in a city. Armed with this initial research, the Clinical Oncological Society of Australia (a physician specialty association) issued a report in early 2006, mapping available services across the continent (and documenting the paucity of services by doing so); nursing services were fortunately part of the mapping and were clearly in short supply (Clinical Oncology Society of Australia, 2006). By August 2006, the Australian Government Department of Health and Ageing had funded and directed implementation of a national effort to “direct the long-term workforce development of nurses specialized in cancer care” based on this report (Piggott, 2006, p. 33).
We have a powerful mapping project in our own country, undertaken by an advanced practice nurse, which illustrates the utility of casting a wide net in nursing research. Each year over the past several decades, Linda Pearson has provided an updated snapshot of nurse practitioner (NP) practice across the United States by state. She has never endeavored to describe the clinical practice itself—a practice that remains consistent across state boundaries as it is driven by the patient populations for whom the NP provides care, and by current standards of care. Pearson is instead describing the political state of practice—what NPs can and cannot do according to state law and regulation. Despite curricula adhering to national standards, and national certifying exams for each recognized NP specialty, advanced nursing practice is contradictory from state to state in legally-allowed scope. Pearson’s annual update catalogs which states sanction fully autonomous practice without mandatory physician presence, require physician supervision or have a compromise position between the two.
Pearson cleverly added two other descriptors recently. She now presents data from the National Practitioner Data Bank illustrating the rates of malpractice actions against NPs compared to the rate against physicians. She also includes data from the Healthcare Integrity and Protection Data Bank, capturing the rates of “accumulated adverse action reports, civil judgments, and criminal conviction reports” for physicians and NPs (Pearson, 2009). Nurses score quite well in these rankings. Advocates are using the data to lobby for removal of unnecessary restrictions on APRN practice.
Equally important to breaking through professional silos in creating research is the need for nurses to present its research in non-nursing forums. It may be that those looking for research on a particular topic (including policy researchers and policymakers) overlook or discount nursing’s role, or vice versa. The public’s health will be best served when the two communities of health policy research and nursing better understand their common interests. The expertise residing in each will produce a stronger base of evidence from which to launch policies on which the two communities, and the public, agree.
Although nurses continue to score high in public opinion, many in the policy world and elsewhere do not understand what it is we really do—a fact of which we have been aware for some time (Fagin & Diers, 1983) and which continues. A 2009 article in a leading health policy journal lumped NPs together with physician assistants and concluded that only 42% of visits to this combined group involve primary care, even though 66% of NPs practice in primary care settings (Bodenheimer, Chen, & Bennett, 2009; American Academy of Nurse Practitioners, 2009). Lack of accurate understanding about the contributions of advanced practice nursing to patient access and health outcomes makes it extremely difficult to advocate for moving that practice forward.
Research and Political Will
The key to moving any issue into the public or institutional eye is transforming it into a political issue—that is, casting the issue as problematic enough to make public or private policymakers want to fix it. Effective research casts the problems it exposes as bad, even immoral, situations that must be addressed (Stone, 2006). But how will any particular issue be perceived, among the numerous issues competing for attention? Sometimes political leaders themselves offer the issue as important, as has been the case with health care reform under the Obama administration. Other times, the issue comes to the fore because of the general social environment, as with the financial regulation efforts in the wake of a major recession. An issue can also be presented via a compelling summary of the research on the problem; the Institute of Medicine’s reports on patient safety and health disparities come to mind. Framing the policy question at hand is also important, because it is fundamental to setting up the argument. So, the strategic use of research will anticipate the viewpoints of other stakeholders.
Highlighting a problem and getting it on the agenda is not enough to advance policy in most instances. There must be enough “political will” to devote attention, time, and effort to solve the problem, particularly when the problem is pervasive or long-standing. Complex problems are challenging because it is difficult to capture a single framing perspective, leading to many differing opinions about what the real problem is and a subsequent dilution of political will about the issue. Health disparities have been extremely well-documented, for example, and embraced by several presidential administrations as an issue that needs fixing. The ultimate measure of eliminating these disparities is improved health status, but it is enormously complex figuring out exactly what leads to good health. Thus it is difficult to propose a straightforward solution to ending disparities and hard to capture sustained political will to undertake the work of eliminating this form of discrimination (Stone, 2006).
This interplay of research, political will, and policymaking frequently frustrates action-oriented people such as nurses, who want to see change happen more directly and in a timely manner. Forty years of outcomes research documenting that advanced practice nurses are safe, competent providers is now coupled with a current policy environment that is trying to solve the primary care provider shortage. It seems pretty straightforward, right? Several factors intervene that make the progress to full autonomous practice nationwide slow, sometimes agonizingly so. Nursing and, in particular, advanced practice nursing is not well understood outside of the outdated (and questionable) paradigm of “working under physician orders.” It is surprising how many legislators, even those whose personal provider is a nurse practitioner, have no idea that we are diagnosing and prescribing on our own, and quite safely.
The Strategic Researcher
Changing the worldview of policymakers and others is not a quick or linear process. But it is crucial—it means that a researcher must first examine his or her own assumptions. Frederick Grinnell, a cell biologist, notes that “[r]eal-life scientists begin their work situated within particular interests and commitments” (2009, p. ix). He later describes how his own discoveries in cell function were impeded by his dogged fidelity to his original assumptions, which took him many years to question. Long before Grinnell, Butterfield (1957) noted that scientific knowledge is due not so much to new or additional evidence, as much as it has to do with “the art of handling the same bundle of data as before, but placing them in a new system of relations … by giving them a new framework” (p. 13). Policymakers are no different, nor are any of us really. We all come to the table with predefined assumptions about health care, nursing, outcomes, and so on. So ascertaining what assumptions already exist is fundamental to making a case for a new policy in any setting. Research that offers new perspectives or that assuages doubts about abandoning preconceived notions is equally vital to the policy process. In fact, sometimes the very act of researching can lift the veil from one’s eyes, and from there others can be educated (Smith, 2002).
But back to advanced practice nursing. There is a second reason policymakers often do not jump readily toward removing barriers to practice. Often a very powerful stakeholder (e.g., organized medicine in one form or another) sits at the table, opposing any further entry into its “world” by nursing or other professionals. And like it or not, this is a potent disincentive for policymakers to move off the dime on an issue.
So there must be a compelling story to engage legislators in advancing full autonomous nursing practice. In the past, the theme has been access to health care in rural areas. A quick look at the states who first achieved APRN practice independent of physician involvement (e.g., Alaska, Maine, and New Mexico) reveals that they have large rural populations in need of competent providers. Lately, the theme is turning to the decreased number of physicians entering or staying in primary care practice—something we know from research into health care workforce distribution. Organized medicine often has a hand in causing this research to exist as part of a strategy to increase medical education dollars and resources. Nursing could turn this research into a successful foray for independent practice by offering competent APRN providers right here and now, without the need for additional resources or expenditure. And these providers cannot fill primary care needs unless barriers such as collaborative agreements or inadequate insurance reimbursement schemes are removed (Hansen-Turton, Ritter, Rothman, & Valdez, 2006).
Further research is needed, however. In 1994, in the context of an earlier perceived crisis in primary care, Sekscenski and colleagues (1994) published a study examining whether or not state practice environments had any impact on the number of NPs and physician assistants available. Strong correlations were found between environments that sanctioned APRN autonomy and higher numbers of practicing NPs. An update to this research in the current climate would be quite useful. Policy researchers investigating the state of practice for the Arkansas legislature found some intriguing possible associations between states with independent practice and lower rates of teen births, infant mortality, and other state health indicators (Bureau of Legislative Research, 2008); additional research on these questions would also be handy to have in one’s pocket while advocating to remove barriers to nursing practice.
So in addition to setting the scene for policy intervention by illuminating a problem, research has a vital role in creating an atmosphere conducive for policymakers to step up to the plate, especially when the issue is likely to be controversial. Ginsburg (2008) offers some valuable insights about nursing in the hospital setting and the research necessary to capture policymakers’ interest in nursing intensity and hospital payment, for instance. Moodie (2009) suggests that researchers interested in moving policy forward pay attention to what policymakers need answered, as well as the constituencies to which they have to answer, a theme also echoed by the September 2009 Briefing Paper from the Overseas Development Institute (ODI).
Moodie and the ODI are looking at research from a “marketing” viewpoint: the researcher is using data to persuade a policymaker that a certain policy answer is the one called for, based on the evidence. Moodie (2009) describes the various “ecologic” factors that a researcher should assess before designing any particular research with an eye toward influencing policy. The ODI paper (2009) also emphasizes Moodie’s point that research needs to be mindfully performed and presented. “Simply presenting information to policymakers and expecting them to act upon it is very unlikely to work” (ODI, p. 1). ODI sets forth five other lessons for “policy entrepreneurs” who want to involve policymakers in evidence-based decisions. This advice from non-nurse policy researchers recognizes that in addition to highlighting a problem, research can enhance, perhaps even shape the political climate in which change can occur; this is valuable advice to nursing as it continues its political and policy evolution. And along these lines, there is one other way research is influencing the policy context—through artful dissemination in documentaries seen on television and in movie theaters.
Research—not just for Journals
In 2005, David Satcher (former Surgeon General in the Clinton Administration), with a host of esteemed public health and academic colleagues, published a study entitled “What If We Were Equal? A Comparison of the Black-White Mortality Gap in 1960 and 2000.” One of those esteemed colleagues was Dr. Adewale Troutman, whose most recent appointment in a distinguished career is Director of the Louisville, Kentucky, Metro Health Department. The study concluded that annually we could prevent more than 83,000 “excess deaths” in the African-American community if we addressed health disparities, and their consequent gulag effect on access to care for minority populations.
This research, and other health disparity documentation, was picked up and studied again, journalistically, by Larry Adelman in 2008. He produced a 7-hour series called “Unnatural Causes,” which aired on PBS later that year. During the segment entitled “In Sickness and in Wealth,” Dr. Troutman offers a compelling visual tour of both the physical and sociological realities of his city, vividly illustrating the interplay of poverty, social class, and health outcomes in what could be a new frontier of compelling qualitative research, which seeks to engage the public (and policymakers) directly through visual and narrative data. It is worth noting how effective such documentaries can be at getting an issue out into public discourse while bypassing special interests.
Nursing’s future rests on the clear and convincing record of research on nursing work. Moving our future forward requires that we and others understand our role in the complex and dynamic world of health and health care (Kurtzman, 2009). As nursing is increasingly recognized as a vital pillar in the temple of health care, we must continue to document and broadcast who we are, what we do, and why it matters to patients, to policymakers, to budgets, and to the delivery of meaningful health care to all.
For a list of related websites, please refer to your Evolve Resources at evolve.elsevier.com/Mason/policypolitics/