The Policy Process

The Policy Process

Bobbie Berkowitz

“A problem clearly stated is a problem half solved.”

—Dorothea Brande

The purpose of this chapter is to provide a conceptual basis and framework for understanding policymaking. When pursued with a clear understanding of the issue, the data, the interests, and the options, the policy process can be highly effective in resolving problems. This chapter includes boxes titled “Think Like a Policymaker.” They are designed to help the reader consider policy options and to begin thinking like a policymaker. While the emphasis of this chapter is on public policy and its process, four spheres of policy development are discussed along with their context, conceptual basis, and research and practice implications. Policy terms used in the chapter are defined in Box 7-1.

BOX 7-1

Policy Definitions

Policy is authoritative decision making (Stimpson & Hanley, 1991) related to choices about goals and priorities of the policymaking body. Generally, policies are constructed as a set of regulations (public policy), practice standards (workplace), governance mandates (organizations), ethical behavior (research), and ordinances (communities) that direct individuals, groups, organizations, and systems toward behaviors and goals.

Health policy, as defined by Longest (2006), consists of the decisions (laws, rules, judicial decisions) made within government structures (executive, legislative, judicial branches) that direct or influence the actions, behaviors, and decisions pertaining to health and its determinants.

Policy analysis is the process leading to a study of the background, purpose, content, and effects of various options within a policy and their relevant social, economic, and political factors (Dye, 1992).

Stakeholders are those directly impacted by specific policy decisions and tend to be highly involved in the policymaking process.

Advocacy is a role, often performed by nurses, that works to protect rights, values, access to support, interests, and equality. Much of the policy process involves advocating for policy that if enacted, will provide protection and support.

Creating Policy: Seeking Solutions to Societal, Workplace, and Organizational Challenges

How does a problem require a policy solution? Key factors to consider include the generation of public interest, the potential of developing an effective and efficient policy solution, the likelihood that the policy will serve most of the people at risk in a fair and equitable fashion, and a judgment about the organizational, community, societal, and political viability of the policy solution. The first step is to get the problem on the agenda of those who have the power to implement a solution.

Public interest is a fascinating dynamic related to the development of public policy. How does the public become interested in a health-related problem that impacts society at large?

Taft and Nanna (2008) have classified the sources of health policy within three domains. The first is professional, such as the need for standards and guidelines for practice. The second is organizational consistent with the needs of health care purchasers (employers), payers (insurers), and suppliers (health systems and providers). The third rests with community stakeholders (patients and consumers) and public sources, including the needs of special interest groups and government entities.

Whatever the source, public awareness and concern are often necessary for political action to get the policy process moving. For example, trends associated with health behaviors, such as the increased rates of childhood obesity, smoking prevalence, or youth violence must be seen as unacceptable and generate enough interest that people will organize to find a solution. When the costs associated with accessing health care become prohibitive for not just the poor, but middle class families as well, interest and concern are generated and public policy solutions become more viable. Unsafe products such as toys, appliances, or flammable clothing; outbreaks of disease such as influenza; or environmental threats such as air, food, or water borne toxins may raise concern about exposure of large numbers of people to the risk of disease and injury.

Moving from interest in a policy solution to action can be stimulated by interest groups where people can collectively share their concerns and work together to find solutions. Unions, trade associations, and political action committees are examples. For example, professional nursing organizations have served as a place where nurses not only explore issues about the advancement of nursing but also focus on societal issues, such as the need for health reform; exposure of the public to emerging diseases; the consequences of health disparities; and other health-related problems that affect individuals, families, and communities.

Think Like a Policymaker

Nurse Staffing Ratios

Staffing ratios have been mandated in some states through legislative action as a solution to inadequate nurse staffing and concerns about the quality and safety of patient care. Opinions vary widely about whether the implementation of mandatory staff ratios in hospitals will have the desired effect. Some would say that these mandatory ratios will remove the ability of hospitals to effectively manage their costs resulting in higher costs for taxpayers and patients. Others argue that voluntary methods to improve safe staffing have not worked and nurses are placed in high risk care environments. Buerhaus (2009) has proposed several non-regulatory solutions to safe staffing including improving hospital work environments, incentives to hospitals for high quality care, and a focused effort on reducing the nursing shortage. Do you think this health related issue is amenable to a public policy solution or, could safe staffing standards be managed as a policy within the workplace? As a policymaker, what information would you need to decide whether this problem would benefit from a policy solution?

Recommended Reading: Buerhaus, P. (2009) Avoiding mandatory hospital nurse staffing ratios: An economic commentary. Nursing Outlook, 57 (2), 107-112. (Also see Chapters 53 and 61.)

The opportunity to create effective and efficient policy solutions answers the “so what do we do?” question. Identifying a problem is the first step, but it is necessary to identify potential solutions that might be used. For example, concerns were raised in Washington State about the ability of insured workers to access health care in rural areas. This resulted in delay of workers in returning to work as well as insufficient reporting of injuries. Because nurse practitioners had been restricted from performing some of the functions related to certifying worker disability compensation, workers access to these providers was underutilized. The Washington State legislature enacted a pilot program to allow nurse practitioners (NPs) to expand their scope of practice to include serving as attending providers for injured workers. Despite some stakeholder concerns, the evidence concerning NP competency in serving this population was compelling. To assure that the pilot program resulted in a more permanent solution, a study was done to evaluate the effectiveness of this approach. The study concluded that this was not only an effective role for NPs, it was also efficient in terms of utilization (Sears & Hogg-Johnson, 2009). A policy intervention that will solve the problem is dependent on a thorough understanding of the problem itself as well as viable policy options and an examination of the underlying evidence that the option will work in an effective and efficient manner.

Fairness and equity are important aspects of policy development. Fawcett and Russell (2001) consider the equity of a policy as the extent to which it allows the benefits and burdens of nursing practice to be equally distributed to all; in particular equal access to health services. This may be one of the primary drivers that inspire nurses to participate in the policy process. For many nurses, advocating for fairness and equity is an application of patient advocacy, in particular when human rights and health disparities are at stake.

Political viability is essential for a policy solution to a societal problem. Policy that is considered desirable to politicians and stakeholders will have the best chance of passage by a policymaking body. In addition, a policy that furthers the interests of multiple constituents will have a better chance of success. For example, public concerns about health effects from exposure to second hand smoke have been communicated to policymakers many times. While policymakers may want to take action to protect the public from tobacco smoke in public places, the pressure from tobacco companies not to act has been equally powerful. As a result, public policy related to second hand smoke languished for years in many states. However, when local communities changed their ordinances to restrict smoking in public, there was increased pressure on state legislators to take action.

Conceptual Basis for Policymaking

The policy process consists of a series of actions, each critical to resolving a problem through analysis and formulation of solutions. The process can involve many organizations and individuals and requires multiple steps; it is seldom logical or unidirectional. Frameworks are helpful in understanding the process. We will discuss several: the concept of incrementalism, the policy streams model, the stage-sequential model, rational decision making, and the advocacy coalition framework.


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.

Policy Streams Model

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

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.

Rational Decision Making

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

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.)

Steps in the Policy Process

The following steps are most closely related to the rational approach and the stage-sequential model. They combine the four primary stages of the stage-sequential model, but focus on the importance and value of explicit analysis of various policy alternatives. Examples are used to provide a picture of how policymakers, advocates, analysts, and citizens can engage in the policy process.

Define the Problem and Get It on the Agenda

This occurs through a series of actions to define the real issue. Policymakers need to understand what the problem is, what the concerns of interest groups are, why it requires a policy solution, what trends are supporting the growth and criticality of the problem, and what if any relationship this problem has to other issues of concern. Anderson (1997) describes identifying the policy problem as a “situation that produces needs or dissatisfaction among people for which relief is sought through governmental action” (p. 94). It requires getting the attention of policymakers.

Research the Problem

Learning as much as possible about the problem is critical to understanding it and formulating possible solutions. Evidence may range from empirical research to expert opinion and come from all sectors such as economics, sociology, health services research, and biological sciences. An important source for utilizing data to transform health practices are the outcomes from translational research. Woolf (2008) described translational research as taking knowledge gained from research and using it in the clinical environment. In relation to the policy process, translational research that provides new knowledge on incentives within health care to improve quality can help policymakers evaluate options about different incentive models. In nursing practice, for example, translational research can provide evidence that a model of care such as the transitional care model (Naylor, et al., 2004) can reduce hospital readmission rates (see Chapter 85).

The idea is to make the case that the problem is significant from both an evidence-based perspective as well as a public or political perspective. Public policy generated through political and public discourse may not always use data in a strictly empirical way. For example, new guidelines on mammography were developed by the U.S. Preventive Services Task Force (USPSTF) and released in 2009. The committee’s guidance, based on the best available evidence on the risks and benefits for screening mammography, concluded that women should access biennial screening between ages 50 and 74. The recommendation was an update from their 2002 statement that recommended screening start at age 40 (USPSTF, 2009). The ensuing debate was over whether or not the data on risks and benefits should outweigh the opportunity to save even a limited number of lives. The American Cancer Society released a statement that said, “The American Cancer Society strongly believes that screening saves lives and continues to recommend that women start regular screening through mammography starting at age 40” (AScribe Newswire, 2009). Health care organizations and providers must decide how these changes in the recommendations will impact their own practice standards and policies. Group Health Cooperative, a large integrated health plan in the Northwest, released a statement on their website on November 17, 2009, that stated “Group Health will make no immediate changes to its guideline for breast cancer screening. Our clinical experts will review the new USPSTF recommendations in early 2010 and determine if we need to make changes” (Group Health, 2009). The intent is to study the issue in more depth and decide whether or not to change practice policy within the organization.

Develop Policy Option

This step relies on evidence and opinion. For example, if we were developing alternative options for improving access to health care for uninsured or underinsured individuals, we might look at three issues related to access. Access is often characterized by its structure (supply and distribution of services), its process (financial ability to pay for services), and its outcomes (health disparities among those who seek care) (McLaughlin & McLaughlin, 2008). Any of these three factors may lead to alternative options for seeking to improve access to care. Solutions are also influenced by whether policymakers believe that one or more options are likely to solve the problem. Confidence in the ability to solve a problem is improved when the solution has a track record, the support of evidence, political and public support, and a method to communicate and carry out the solution.

The process of selecting alternative options for consideration requires considerable analysis of the various options. For example, the National Quality Forum (NQF) is a nonprofit organization that sets national priorities and goals for performance improvement; endorses national consensus standards for measuring and publicly reporting on performance; and promotes the attainment of national goals through education and outreach programs. They use a formal consensus development process to select standards and performance measures from many options submitted for review and possible selection. The process of selecting from among the many options includes: a call for nominations of candidate standards, a review of each standard, public and NQF member comment, voting process, decision, ratification, and appeal. The process is designed to ensure that each measure received a robust review and is adopted through a rigorous consensus process.

Involve Interest Groups and Stakeholders

There are many ways to think about stakeholders and interest groups. For example, some interests may be considered “public interest” rather than “self interest.” Policy development that is dominated by public interest generally follows a course of action that is based on data, information, and community values and addresses a solution to an actual or potential problem. It tends to be practical decision making. Policy generated by self interest often follows a course of action with a predominantly special interest focus connected to the concerns of individual preferences or group interests over public interest. Both are important in generating dialogue and debate during the policy process so that all sides of an issue are considered. For example, professional nursing organizations (e.g., the American Academy of Nursing, the American Nurses Association, and many nursing specialty groups) are concerned not only with public policy that impacts the health of all people, but also with policy that impacts nurses and the practice of nursing. These organizations, individually and collectively, support policies that are in the best interest of their members.

Implement the Selected Policy

How the policy is implemented will depend on the type of policy. If it is federal legislation, a series of steps will occur including the development of regulations. If it is an organizational policy, affected parties will need to be informed and educated about the decision and the issues around implementation.

Evaluate the Impact of the Policy

Once implemented, it is critical to determine if the policy worked and resolved the problem it was designed to address. It is also important to determine if any unintended consequences occurred. These may require additional policy development if they are significant.

Modify, Repeal, or Leave the Policy Alone

A policy is an attempt to solve a problem at a particular point in time. Policymakers and stakeholders always have the option of bringing a policy back through the policy process for modification if it does not achieve the desired outcome. In the public arena, repeal may be an option, if the political will changes and the policy is no longer desirable.

Communicate Policy Options

Policy options can be summarized through either a short policy issue or decision brief (generally a one-page summary with a recommended course of action; see Box 7-2) or an issue analysis paper (an in-depth analysis and comparison of options; see Box 7-3).

BOX 7-2

Example of a Policy Decision Brief

To: Chief of Staff, Senator Wynne

From: Helen Luce, Health Policy Analyst

Re: Health Care Fraud in the Military Health System

Issue Summary: Health care fraud burdens the Department of Defense (DOD) with enormous financial losses while threatening the quality of health care. Assuming that between 10% and 20% of paid claims are fraudulent, the annual loss to DOD is $600 million to $1.2 billion.


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Mar 18, 2017 | Posted by in NURSING | Comments Off on The Policy Process

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