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Schober Global Healthcare Consulting, Indianapolis, IN, USA
Keywords
Critical factorsStrategic approachPolicy processFrameworksConceptual Policy FrameworkParticipationDespite extensive literature supporting the value of the concept of advanced nursing practice (ANP), the most favorable processes for development and implementation of advanced practice nursing (APN) roles remain unclear (Delamaire and Lafortune 2010; DiCenso et al. 2010; Horrocks et al. 2002; Sastre-Fullana et al. 2014; Schober 2016). Mounting evidence suggests that effective integration of APNs into the healthcare workforce must be tailored to meet a country’s healthcare and population needs based in the respective healthcare environment. Frequently this is part of wider healthcare systems reform (Buchan et al. 2013; Fukuda et al. 2014; Gagan et al. 2014; Schober 2016; Vatankhan et al. 2013). Variability between countries and even within the same country appears to be dependent on national and local contexts including government, healthcare, nursing, and consumer cultures.
This chapter begins by proposing key factors to consider in exploring the possibilities of introducing an advanced nursing practice scheme. This is followed by an introduction to various aspects of the policy process along with recommendations of how nurses can participate in the policy process. Descriptions of theoretical frameworks and a country-specific illustration based on a theoretical conceptual policy framework are offered as guidance for planning, strategic thinking, and decision-making.
2.1 Key Factors to Consider in Exploring the Possibilities for an Advanced Nursing Practice Initiative
Based on a comprehensive review of the ANP and APN international literature for a study conducted in Singapore (Schober 2013) and development of Volume 1 of the Springer advanced practice in nursing monograph series, Introduction to Advanced Nursing Practice: An International Focus (Schober 2016), a number of key factors were found to be essential when considering the possibility of an ANP initiative. These factors include:
The need to establish mechanisms and policy to support the full authority and scope of practice for APN roles
A mandate to clearly differentiate APN roles from other healthcare professionals including other nurses
The criterion to develop strategies for policy development and to increase awareness of the expected function of APNs
The necessity for strong managerial leadership to facilitate effective implementation
Repeatedly, whether looking at a successful ANP initiative retrospectively or anticipating creation of a new scheme for the introduction of APNs, the topics of policy development, legislation, regulation, and standards relevant to this new nursing role emerge as necessary for supportive development and implementation (Schober 2016). Policy emerges as a product of the political environment that involves a course of action or procedure by government entities that supports a principle or idea. Legislation is the act of making or enacting laws. Regulation is an authoritative rule or order issued by an executive authority or regulatory agency. Standards refer to a universally agreed upon level of quality or achievement that is considered to be desirable in behavior or practice for a basis of comparison or as a model to emulate.
In a survey of 39 countries with varied levels of task shifting in primary care from physicians to nurses, Maier and Aiken (2016) concluded that a supportive policy context includes up-to-date regulation and education reform. In addition, this survey found, however, that even countries with more advanced experience with APN roles demonstrated variance in regulatory environments that were thought to impact practice patterns. For example, in the United States due to the decentralized, state-specific jurisdictional authority over scope of practice laws, changes have been ongoing for decades and vary from state to state. Decentralized regulation appears to result in uneven role implementation generating barriers to the effective integration of APNs into the healthcare workforce. The concept of advanced nursing practice is facing an era of attention and enthusiasm in noting evidence of positive outcomes for nurses functioning at an advanced level. However, the implication is that this increased awareness should move policy dialogue forward to effectively support and guide effective implementation of APN roles.
2.2 Defining the Policy Process
Policymaking is a complex, multidimensional, dynamic process influenced by the values of the individuals who establish the policy agenda, determine the policy alternatives, and define the goals to be achieved by the policy, the implementation methods, and ultimately the manner in which the policy is evaluated (Porche 2012). Theories about policymaking are usually concerned with processes. Walt (2006) suggests that macro theories of consensus and conflict and the micro theories of policymaking come together in describing who and what influences policy development. Kingdon (2003) proposes that policymaking is a set of processes including at least:
The setting of the agenda
Specification of alternatives from which a choice is to be made
An authoritative choice among specified alternatives such as in a legislative vote or governmental decision
The implementation of the decision
Kingdon (2003) further emphasizes that success in one process does not necessarily imply success in others. An additional explanation is provided by Hogwood and Gunn (1984) who identify the following set of processes:
Deciding to decide (issue search and agenda setting)
Deciding how to decide (issue filtration)
Issue definition
Forecasting
Setting objectives and priorities
Option analysis
Policy implementation, monitoring, and control
Evaluation and review
Policy maintenance, succession, or termination
While there is little disagreement that the policy process consists of various stages, there is a great deal of disagreement as to how far policy follows a rational or logical process from problem identification to policymaking. A point that is discussed throughout this chapter (see also Chap. 8) questions if it is possible to develop a rational strategic approach or to formulate rational policies. A contrasting viewpoint is that rationality does not fully describe the erratic nature that represents the real world of developing policy. There is an argument that theoretical frameworks give a false impression by implying that policymaking follows a linear process going through sequential phases. This variance in perspective will be discussed in further detail in later sections of this chapter and in Chap. 3 – Theories of Social and Healthcare Policy. Refer also to Chap. 8 – Rational Policy Decision Making: Idealism versus Realism.
2.2.1 Agenda Setting
Agenda setting is often considered to be part of the policymaking process when determining what topics or issues are likely to catch the attention of policymakers and are deserving of policy solutions and resolution. The agenda is a list of topics, issues, or concerns to which government officials, and people outside of government but closely associated with these officials, are paying some serious attention to at any given time. Theoretically, out of a set of identifiable issues to which policymakers could be paying attention, more consideration is paid to some topics rather than others.
In theory, the agenda setting process narrows the set of possible topics to a set of issues that actually become the focus of decision-makers’ attention (Hall et al. 1975; Kingdon 2003). Within the domain of healthcare, for example, the ministry of health or health department will be considering a range of issues at any one time. Out of an array of issues or problems, some obtain serious attention in preference to others. The ministry of health may have a more specialized agenda such as health sector reform and cost of healthcare services, whereas decision-makers on the ground may be looking at effective access to care, preventative healthcare, or specific population needs (Walt 2006). As a result, before a policy can be formulated and adopted, the issue must compete for space on the agenda or list of items being actively taken into consideration. Agenda setting can be viewed as an early phase of the policymaking process following identification of the issue needing attention.
From this perspective, a topic or issue must make it on to the policy agenda in order to progress through the policy process to ultimately progress to formal legislation, regulation, and subsequent implementation. For policy change to occur, policymakers must be convinced that a problem or issue is serious and deserves their consideration. Reaching agreement among policymakers as to what constitutes a topic worthy of discussion toward a solution can be challenging and often requires strategic planning. In addition, developing strategies includes knowing the various decision-makers and their spheres of influence in order to identify possible ways to influence the policy process (refer to Chap. 3, Sects. 3.1 and 3.2 for further in-depth discussion of agenda setting).
2.2.2 Policymakers and Their Networks
Interpersonal social and political networks influence agenda setting (Porche 2012). Policymakers do not start with a blank sheet of possibilities. Previous decisions affect present policymaking (Walt 2006). Many individuals may have a say over discussion of policy, but in most situations, the government and government entities have ultimate control over legislation and the policy process. Within governmental structure, such as with the ministry of health, there may be some tension on the topic of ANP that may occur between key stakeholders representing medicine and nursing and the politicians (Walt 2006). However, in policy formulation, ministries of health and governmental agencies will have established structural and infrastructure mechanisms to facilitate consultation with a variety of professional bodies and/or interest groups.
The effectiveness of various consultants, advisors, and representatives of lobbying groups is likely to be dependent on the extent of decentralization or centralization in the political system (Maier and Aiken 2016; Walt 2006). In countries where power is tightly controlled at the top level or center, a small number of key decision-makers may have the power to resist, block, or delay either policy formulation or implementation (see Chap. 3 for further in-depth discussion of Walt’sapproach to policy development).
In attempting to identify what issues might be considered for a policy agenda, Walt (2006) proposes asking the following questions in order to focus attention on an issue:
Who identifies a particular issue as a problem or concern?
Is it a “real” problem and legitimate for policymakers to intervene?
Is there likely to be agreement and support for the issue/concern?
Is the time for policymaking premature?
Is the policy context/environment acceptable?
Is the issue being considered at the appropriate level of agency, unit, or decision-making body?
Is the causal structure predisposing to the problem/concern understood?
Can implications of the issue be specified and quantified?
Even though it would be preferred, policymaking seldom proceeds as a rational linear process. Identifying pointed questions may be a simplification of a very complex process but is intended to pique the interest of the reader to move toward creative thinking and strategic planning. Many different reforms or changes compete for policymakers’ attention. As healthcare professionals, knowledgeable of healthcare cultures in the country, APNs have the opportunity to participate in and guide discussions to clearly identify topics that will catch the attention of policymakers.
2.2.3 Influencing Policy Decisions
There are multiple ways to influence the policy process and promote desired policies. However, it can be argued that power and the authority to set policy is decided by a small group of influential leaders within and/or outside of government. Alternatively, another view is that domestic policies on such topics as health are likely to be developed with some participation from different groups or individuals at different points in the policy process. The potential for participation such as lobbying on behalf of interest groups often exists; however, it is not always clear in what way and at what level participation can be influential and most effective.
Insightful discussion and analysis of the policymaking processes are useful in that it increases awareness of the gaps between what is considered to be rational procedures and what actually happens in real practice. Efforts from the rational to the erratic identification of the components of policy decision-making can lead to beneficial outcomes. The author suggests that knowledge of how policy processes function and identifying ways to influence it strengthens the position APNs will have in engaging in that process (see Chap. 5 for further discussion on nurses’ stages of political engagement and acquiring the necessary skills).
2.2.4 Nurses’ Participation in the Policy Process
The emergence of the concept of ANP has contributed to increased visibility for nurses and their various levels of practice. This increased visibility suggests that nurses must actively participate in policymaking, the policy process, and strategic planning dialogues. It is increasingly important that nurses, specifically APNs, take on advocacy roles and strengthen their leadership skills to become policy leaders and influence the decision-making processes. In addition, APNs must recognize that policy and the impact of supportive policies are an integral part of everyday professional nursing practice (Stewart 2014).
Lack of advocacy and lack of efforts by the nursing community to educate others regarding the value and importance of APN roles are viewed by Shamian and Ellen (2014) as a major barrier to the advancement of ANP. This view implores nurses to strive to become politically knowledgeable and to actively participate in policy decision-making. We no longer live in an era where it is acceptable for decisions that impact nursing practice to continue to be made by individuals who have limited knowledge of nursing, especially in times of healthcare reform and dramatic change taking place in the profession.
Becoming participants in politics and the policy process requires an understanding of power relationships, the use of political power, key stakeholder networks, and their spheres of influence (Buchan 2016; Schober et al. 2016). Even when the principles promoted by nursing are sincere and intended for the good of communities and their populations, nursing needs to also demonstrate its value linked to public healthcare needs aimed at influencing the policy agenda. Buchan (2016) in speaking to policy engagement for nurses emphasizes that evidence has to be compelling and have a “popular impact and policy resonance” (p. 302) with a focus on cost effectiveness and improved outcomes.
In responding to a question on alternative ways nursing can influence political decision-making, Catton (2016) suggests that nurses need to shift the techniques they use in framing their recommendations. This perspective includes thinking and operating outside only nursing and health, beyond health departments to other governmental agencies and entities. In addition, Catton (2016) emphasizes that:
Nursing is at the forefront of delivering services in new ways and through new models. We need to be more bullish and confident about advancing nursing roles and our profession’s potential to help deliver solutions (p. 311).
In order to consider how APNs can be effective in the policy process, Harris (2014) advises that there are four components to consider when developing health policy. These are identified as the policy process, policy reform, policy environment, and policymakers. To engage in health policy development, Harris (2014) recommends that APNs:
Review and discuss the identified issues based on obtainable information
Remain informed and become involved in policy activities and meetings
Maintain a visible presence that involves articulating a clear position and distribution of relevant information on the issue
Demonstrate the value of APNs to policymakers and key stakeholders
An incremental approach for nurses to increase participation in policy and policy development seems safe and sensible; however, it is likely that an emergent and pivotal topic will arise to catch the attention of APNs and motivate them to become involved. This is particularly true of barriers to optimal practice such as lack of prescriptive authority and limits to expected levels of autonomy along with obstructions for populations to access healthcare services provided by APNs.
Nurses are in a position to influence policy decisions at the government level, workplace, organizations, and in the community. Options may exist beyond country-only level, for example, nations in Europe may obtain assistance from the European Union. Moving from becoming leaders in clinical practice to assuming leadership positions in the health policy arena is not an obvious choice for nurses (Duffy 2015). Political literacy or knowing how the policy process works and identifying potential strategies for engaging at some point in the process enables beneficial representation for APNs and their relevant issues.
Policymakers and key stakeholders at multiple levels of decision-making influence APN practice, standards, regulation, and professional progression. This in turn shapes the direction of healthcare delivery and the resources needed to provide services. Duffy (2015) suggests that the skills nurses use in motivating populations to improve their health are the same skills that can influence policymakers to develop legislation and standards to support optimal APN practice (see Chap. 5 for further discussion on nursing’s participation in the policy process).
2.3 Frameworks for Implementation of Advanced Nursing Practice
Models and frameworks conceptualizing ANP provide guidance for research and for understanding actions that could be helpful in practice settings and strategic planning. Although at times the terms are used interchangeably, model and framework have subtle differences in definition. Models provide an example to follow, imitate, or emulate. Frameworks provide a conceptual structure of ideas and how they interrelate. Common language in conceptual frameworks is intended to guide and/or evaluate practice, education, policy, and research.
Integration of advanced levels of nursing practice and APN roles involves processes that call for contemplation as to what models or frameworks are appropriate for use in the healthcare environment. No single model or framework is guaranteed to be suitable for all countries and practice settings. This section describes frameworks worthy of consideration for role implementation and/or policy development. Certain aspects of any framework may be suitable for a particular context, and key points of more than one model or framework may be combined to best suit specific circumstances. Selection of context-sensitive components takes place in the process of strategic thinking and planning.
2.3.1 PEPPA Framework
Canadian researchers Bryant-Lukosius and DiCenso (2004) developed the PEPPA (participatory, evidence-based, patient-focused process for advanced practice nursing) Framework to provide guidance in the development, implementation, and evaluation of APN roles. This framework has been utilized in a variety of ways in 16 countries as nations seek to more clearly identify the issues that need to be considered when integrating ANP into the healthcare workforce (Bryant-Lukosius et al. 2016; Gagan et al. 2014; McNamara et al. 2009).
Boyko et al. (2016) in studying the utilization of the PEPPA Framework found that most frequently the framework was used in research studies and used to varying degrees as intended. Few citations refer to use in actual practice settings; however, there is documented use related to practice in New Zealand, Switzerland, and Thailand (Gagan et al. 2014; Bryant-Lukosius et al. 2016; Sathira-Angkura and Khwansatapornkoon, date in Thai). Based on principles of participatory action research, the PEPPA Framework (Fig. 2.1) is intended to establish a process supportive of ANP. Steps of the framework take into consideration the complexities of implementing a new role into an existing healthcare system.
Fig. 2.1
PEPPA Framework (Bryant-Lukosius and DiCenso 2004, p. 532)
The PEPPA Framework involves a nine-step process. Steps 1–6 concentrate on setting up role structures. Step 7 looks at role processes and beginning implementation and introduction of the APN roles. Steps 8 and 9 seek to accomplish short- and long-term evaluations of the APN role and model of care with an aim to assess progress and sustainability of agreed to target aims and outcomes (Schober 2016). The following is an interpretative synopsis of the steps in Fig. 2.1 developed by Schober (2016, p. 97) for Volume 1 of the Springer advanced practice in nursing monograph series.
2.3.1.1 PEPPA Framework Steps
Step 1 – Identify the target patient population and establish limits relative to the current model of care.
Step 2 – Key stakeholders and decision-makers (including populations and their families) representing the current model of care are invited to contribute input to the discussion of a new model of care that includes the APN role.
Step 3 – Determine the strengths and weakness of the current model of care.
Step 4 – Identify priorities for unmet healthcare concerns with an aim to improve healthcare outcomes.
Step 5 – Define the model of care and healthcare strategies including numbers and mix of healthcare providers. At this time participants in the process gain an understanding of ANP and various options for APN roles. If the decision is taken to include APNs, a job description and scope of practice are developed that are fit for purpose for the healthcare model.
Step 6 – Strategic implementation planning is done during this step to verify the readiness of the healthcare setting for ANP. This step includes identification of obstacles and facilitators that could influence implementation. Establishing timelines and goals are a critical aspect.
Step 7 – The plan developed in step 6 for APN implementation is initiated in this step. Full implementation is a continuous process that includes methods to scrutinize various aspects of changes in the approach to provision of healthcare services along with the status of APN role implementation.
Step 8 – Outcomes specific to the identified changes in the model of care are evaluated with a view to identify any needs for APN role development or further role enhancement.
Step 9 – Long-term, periodic, and continuous monitoring are emphasized in this step to assess if the model of care integrating APN role continues to be relevant and sustainable
Bryant-Lukosius and DiCenso (2004)
In considering the usefulness of the PEPPA framework, it is worth noting that the focus is on role integration and evaluation outcomes of role implementation. Although aspects of the step-by-step process could be helpful for strategic planning and policy development, the described intent is not directly aimed at policymaking and the policy process. This framework is useful from a theoretical perspective as well as use in countries that have sought its guidance (Gagan et al. 2014; Bryant-Lukosius et al. 2016; Sathira-Angkura and Khwansatapornkoon, date in Thai).
2.3.2 Schober Conceptual Policy Framework for Advanced Practice Nursing
Supportive policies are essential for APNs to practice to their full potential. The policy process is the product of a system, influenced by and influencing the context in which it operates. Literature provides various models and frameworks describing various aspects relevant to ANP (refer to Sect. 2.2.3). However, following a comprehensive literature review in preparation for conduct of research in Singapore, Schober (2013) was unable to find a specific framework to guide policy decision-making for advanced nursing practice. Knowledge gained from a study conducted in Singapore from 2008 to 2012 led to development of a Conceptual Policy Framework for Advanced Practice Nursing (see Fig. 2.2). Based on research findings andempirical inductive reasoning, the framework was developed to guide and promote a coordinated effort for policy development and implementation when considering the integration of APNs into the healthcare workforce.
