Lindblom (1979) first described the concept of incrementalism in the early 1950s. Most health policy change in the United States has been incremental. When policymakers face a highly complex, theoretical, or resource-intensive decision and lack the time, capacity, or understanding to analyze all of the various policy options, they may limit themselves to a set of strategies instead of tackling the whole problem. An incremental approach is often restricted to familiar policy options related to the status quo, and the analysis may focus more on the problems than on the solutions (Lindblom, 1979). Because the development of the strategies and the analysis of options may be fragmented, the process may produce limited results. Weiss and Woodhouse (1992) stated that the concept had become associated with a process that is neither proactive, goal-oriented, nor ambitious and tends to be conservative, with limited usefulness.

Kingdon (1995) proposed a “policy streams” model to reflect the issue of “policy looking for a problem.” He described three streams of policy activity: the problem stream, the policy stream and the political stream. The problem stream describes the complexities in getting policymakers to focus on one problem out of many facing constituents. For example, early in the process of developing the language for health reform legislation, policymakers engaged in a long process to define exactly which problems associated with our health care system should be included in a legislative package. Part of the challenge was the lack of agreement about which problems were the most urgent and which required legislation. Some felt that cost was the biggest problem, others wanted to limit health reform to tort reform, and others wanted to improve access. Until the problem is adequately defined, an appropriate policy solution cannot be effective.

The second stream is the policy stream. This describes policy goals and ideas of those in policy subsystems, such as researchers, congressional committee members and staff, agency officials, and interest groups. Ideas in the policy stream float around policy circles in search of problems. The third stream, the political stream, describes factors in the political environment that influence the policy agenda, such as an economic recession, special interest media, or pivotal political power shifts.

Kingdon sees these streams as moving constantly and waiting for a “window of opportunity” to open through “couplings” of any two streams (particularly in the political stream), creating new opportunities for policy change. However, such opportunities are time-limited: if change does not occur while the window is open, the problems and options return to the soup and continue floating. For example, while health reform was a high priority for the newly elected President Obama, the economic crisis and recession became a powerful political “stream” bringing to bear a major debate about the short-term costs of health care reform as opposed to a discussion about long-term savings.

The stage-sequential model is a dynamic process that includes four stages: agenda setting, policy formulation, program implementation, and policy evaluation (Ripley, 1996). Each stage contains a set of actions and activities that produce outcomes or products that influence the next stage. Theoretically, the stages flow in a circular pattern, each informing the next with the process beginning again at the evaluation stage. While simple in design, this model and the rational decision-making model are deceptively complex. Defining the policy problem with adequate clarity so that it gains the attention of policymakers and stakeholders is challenging; each policy problem has many competitors seeking a place on the policy agenda. Though policy formulation is dependent on good data and evidence about what works, data and evidence may not be enough to outweigh the influence of special interests. Program implementation is carried out by the executive branch of government through guidelines and regulations. It is not unusual for the intent of a policy to get lost in the translation to program. Policy evaluation is the opportunity to evaluate whether or not a policy solved the problem either through a program, regulation, or law. However, if the intent of the policy was vague or if it was misinterpreted on its way to program design, the evaluation may highlight a policy solution that failed to solve the problem.

Longest (1998, 2006) described an approach to public policymaking that features a series of actions that are highly dependent on relationships among individuals, organizations, and policymakers. It assumes that policymaking is a rational decision-making process that combines influence from interest groups, data, political negotiations, and ideology. The process holds promise for major policy change because it reflects a broad view of the problem to be solved, the many options through which the problem could be solved, and a clear focus on intent and outcomes. While the model is circular rather than linear, it is described in stages that closely resemble the stage-sequential model.

The advocacy coalition framework may be most familiar to nurses as an activist approach to working on problems related to health inequity and disparities. The role of the advocate is to empower others to make informed decisions (Spenceley, Reutter, & Allen, 2006). The authors define policy advocacy as the knowledge-based action that is intended to improve health through the influence of system-level decisions. The advocacy coalition framework is primarily concerned about how interest groups are organized within policy domains. It is a powerful tool used to develop an understanding of the various policy disputes among stakeholders (Birkland, 2005). Sabatier (2007) stated that beliefs matter a great deal in policymaking. The preferences that individuals hold are deeply engrained and drive their thinking about policy options. Therefore, public opinion matters and the use of public opinion through the mobilization of coalitions to support or change legislation or regulations or to shift resources in favor of different programs is the strategy of the advocacy coalition framework (Weible, 2006). (See Chapter 86 on coalitions.)