Improving Nursing Practice
The Policy Making/Changing Process


Policy as a Process

As a process, political scientist have established a number of conceptual models that provide varying perspectives on the process of making policy. (Dye, 1992).   The following slide depicts 4 of these models.

The rational approach is much like our familiar nursing process: define the problem; identify goals and rank social value of each goal; examine each policy alternative for positive and negative consequences, costs, and benefits; select the policy that most closely achieves the goals.  However, such a rational approach requires a rather ideal world where rationality alone prevails (rather than influence, power, emotion, special interests).

Incrementalism is how policy change in the US typically occurs.  Small changes are made at the margins of existing policy rather than systematically overhauling “bad” existing policies.  Hence, it is not an approach/model that is likely to achieve the desired health outcomes.

Kingdon’s policy streams model presents a description of what tends to happen in actual policy development at the macro level.  Though few of you will be directly involved with macro-level policy in this course, you may well be in your professional career.  Thus, it is useful to consider Kingdon’s three policy streams as a “window” into the politics of making macro policy.  His three streams are:

  • the problem stream
  • the policy stream
  • the political stream

During the problem stream, the goal is to get policymakers to focus on your one problem (such as the high cost of prescription drugs) among the many problems that constituents want addressed.  You have to use creativity, personal examples, and your commitment and passion to make your problem of interest.

The policy stream is comprised of policy “ideas” that researchers, congressional members, agency officials, professionals, etc. have..  These “good ideas” are often just floating around in search of a problem to attach to.  For example, wouldn’t it be a “good idea” if all children had hearing tests before beginning school.  Well, if no teachers are complaining about a “problem” with hearing impaired children, the “good idea” will float around until either the “problem stream” or the next stream, “political” catches it.

The political stream describes factors in the political environment that influence the policy agenda, such as an economic recession, special interest, media campaigns, etc.  In our hearing screening, what if the Speaker of the House was an audiologist?

Kingdon sees these streams as “floating around” and waiting for a “window of opportunity” through the coming together of any two streams – and viola!  -- a policy is born.  A bit cynical, perhaps; but, often true.


The Stage-Sequential Model of Policy Making as a Process

The stage-sequential model of policy as process has the four steps depicted below:

Stage one (agenda setting) includes identifying the problem/demand, getting the problem to the “governing body’s” attention, and refining the problem/demand to a policy issue through careful analysis of what is underlying the presenting problem. 

Nurses often underestimate both the effort it takes to get the attention of whatever governing body is in control of correcting the problem (i.e., just because you see something as a problem/demand does not mean that the “powers to be” will.  It involves both your data and your passion to influence others to “adopt” your problem.)  Further, it is often easy to identify the surface symptom, but getting to the root cause of a problem (the policy issue) demands critical thinking and data analysis – your defining of the nature and scope of your chosen problem.

Stage two (policy formulation) includes the important steps of:

  1. information collection, analysis, and dissemination;
  2. alternative development;
  3. advocacy and coalition building;
  4. compromise, negotiation and, ultimately,
  5. decision. 

All of the above steps are the key to being effective in influencing policy at any level: your nursing unit/practice setting, your educational institution, and your local, state and federal bodies.

  1. You, no doubt, have collected adequate information about your problem.
  2. I will assume that you also have considered a variety of alternative interventions before “landing” on the intervention plan you have proposed.  However, you may now wish to consider why you rejected other alternatives.
  3. The need to build coalitions, negotiate from a position of strength, and compromise where necessary to achieve your objectives can not be overstated!  If you believe there is a need for a policy change or for a new policy, surely someone else agrees.  Find that “someone else”.  Include their participation in your intervention.  Determine if that “someone else” has ties to others – particularly other “key influents”.
  4. Be willing to consider changes, additions, modifications to the policy you propose.  Just don’t loose the basic idea of what you need to accomplish in any rush to compromise.
  5. If steps 1-4 are successful, you should find that your policy change is “accepted”.  However, having a policy “accepted” and having it implemented fully are two different things.

Stage three (program implementation) is where it is often said “the rubber meets the road”.  Because a policy “passes” or is “adopted”, if implementation is not carefully planned and tracked, the policy stands every chance of being “hollow”.  In this stage, necessities include adequate resource acquisition, full interpretation, planning for how best to introduce the proposed change, organizing the implementation, and providing benefits (carrot) to those who will be asked to change. . .hopefully, avoiding sanctions (the stick) for those who resist.

Stage four ( policy evaluation) includes not only evaluation of desired outcomes, but also, importantly, evaluation of the implementation – i.e., outcomes cannot be expected to improve if the policy was poorly implemented. (Ripley, 1996)  You will move next to a plan for evaluating your chosen implementation strategy.