Political Competence and Social Astuteness

1. Social astuteness: Skill at being attuned to others and social situations; ability to interpret one’s own behaviors and the behavior of others.
2. Interpersonal influence: Convincing personal style that influences others featuring the ability to adapt behavior to situations and be pleasant and productive to work with.
3. Networking ability: The ability to develop and use diverse networks of people, and the ability 17to position oneself to create and take advantage of opportunities.
4. Apparent sincerity: The display of high levels of integrity, authenticity, sincerity, and genuineness (pp. 9-12).

In most cases, policymakers are generalists who make decisions on a broad range of issues. Nurses can have a profound impact on policymaking by using their knowledge to frame and define health policy alternatives. Influencing policy at all levels requires a strong set of interpersonal skills, integrity, and knowledge. According to O’Grady and Johnson (2013), political competency, at either the individual or the organizational level, can be defined by three main elements: deep knowledge, political antennae, and power (Figure 1-7).

FIGURE 1-7 Political competencies. (From O’Grady, E. T., & Johnson, J. [2013]. Health policy issues in changing environments. In A. Hamric, C. Hanson, D. Way, & E. O’Grady [Eds.], Advanced practice nursing: An integrative approach [5th ed.]. St. Louis, MO: Elsevier-Saunders.)

Deep Knowledge

Deep knowledge requires freely sharing expertise and gaining the knowledge you need from others. Subject-matter expertise without knowledge of policy and its processes is a doomed strategy. Deep knowledge involves knowing the viewpoints of others, including the opposition, and having a clear message and data at the ready to support your position and neutralize opposition. For example, many physicians’ organizations oppose expansion of practice for APRNs, citing patient safety as a primary concern. Politically competent nurses can arm themselves with a summary of decades of evidence citing no such concerns (Newhouse et al., 2011; O’Grady, 2008).

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Political Antennae

Developing political competence requires a continuous scanning of the environment, and it is critical that nurses offer solutions to policy problems that are not solely nursing focused but also address the Triple Aim. Agendas cannot be advanced without the formation of coalitions and networks. Influencers of policy must consider alternative scenario development to use if opposition develops. For example, the 2008 recession had an impact on the nursing shortage: many nurses chose not to retire during that uncertain economic period. The nursing community was able to maintain nursing education funding despite the lessening of the nursing shortage using scenario development. For example, during the economic downturn and slashing of many federal programs, nurses were able to create a scenario in which the aging population explodes, the nursing workforce nears retirement age, and there is a dire nursing faculty shortage. Projections were made predicting catastrophic hospital vacancy rates and unmet health care needs. This scenario was highly effective in preventing cuts in federal funding to nursing education.

Having political antennae requires active listening with policymakers to understand their motives and to develop strategies that fit their political objectives. So if policymakers promised constituents they would not raise taxes, the politically competent nurse would work in a coalition to help find a budget-neutral solution.

Finally, having political antennae requires the avoidance of bridge-burning. Ruptured relationships can cause lasting damage, not only to the nurse involved but also to the profession. Many wounds can develop during policymaking, and it may be crucial that one exercises restraint. Political and policy disagreements require a response of genuine warmth, a quality that can go a long way in building trust. Learning how to navigate differences and agreeing to disagree without being disagreeable are important political skills.

Use of Power

Power is the ability to act so as to achieve a goal. In the policy process, power is knowing who has it, who is on what committee, and who are the thought leaders in the community. A coalition is one important way nurses can augment their policymaking power. But an individual nurse can claim it by being articulate and having an elevator speech that can spark interest.

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Application of power requires raising one’s awareness about what is true and what is false. Being grounded in truth, such as knowing the value of human caring and the role that nursing can have on individuals and populations, is a form of personal integrity that leads to power. Using power is a choice that requires a noncondemnatory and helpful attitude. By freely giving expertise away and approaching “difficult” people with a benign attitude (they are doing the best they can), we hold onto our integrity, build trust, and keep emotions in check. To be effective in the policy arena, nurses must have a sharp focus on the evidence, not emotion. Advancing nursing’s policy agenda through such a use of power demands that we drop narcissism and nursing parochialism and focus on problem solving. Nursing narcissism is when a nurse shows an inordinate fascination with oneself, self-centeredness, and a high degree of smugness. This can include taking sole responsibility for some action or project in which a team was responsible. Nursing parochialism is when a nurse is in a problem-solving context (policy meeting) and only offers up the solution of “nurses” as the remedy to every problem. Parochialism is an approach that narrows options and interests and appears self-serving. Both of these destructive approaches do not deploy the cost-quality-access triad framework to problem solving and therefore severely constricts nursing power. They are to be avoided at all costs and nurses exhibiting these attitudes must be removed from decision-making tables. Effective use of power avoids polarization, egotism, and self-serving postures at all costs. Bringing nurses’ stories to the policy arena is, however, a powerful way to pair the human story to the scientific evidence.

Corralling the political power of the 3.1 million registered nurses in the U.S. can only occur if individual nurses join, support, and fully engage with professional nursing organizations. More than any other effort to date, The Future of Nursing: Leading Change, Advancing Health (IOM, 2011) has brought disparate nurses together to engage across associations and educational institutions, and with new community partners, to change policy. Many of the recommendations direct policy changes resonant with nurses. This effort is increasing nursing’s political competence, but more could be done: printed op-eds, blog posts, and interviews with nurses in major media outlets could capitalize on the high regard the public has for nursing.

Nurses who effectively use power are a sought-after and a valued asset. They get invited to the table, but they are asked back and often invited to more tables with ever-expanding influence. This requires a great degree of knowledge, along with humility, a problem-solving attitude, and a patient-centered lens. Such activities and attitudes strengthen an individual’s interpersonal power and integrity, which can inspire others.

E. Advanced practice nursing: An integrative approach. 5th ed. Elsevier Saunders: St. Louis, MO; 2013.

Organization of Economic Co-operation and Development (OECD). Health at a glance 2013: OECD indicators. OECD Publishing; 2013 [Retrieved from] dx.doi.org/10.1787/health_glance-2013-en.

Peikes D, Zutshi A, Genevro J, Parchman M, Meyers D. Early evaluations of the medical home: Building on a promising start. The American Journal of Managed Care. 2012 [Retrieved from] www.ajmc.com/publications/issue/2012/2012-2-vol18-n2/early-evaluations-of-the-medical-home-building-on-a-promising-start/1#sthash.7GyzblEQ.dpuf.

Petterson SM, Liaw W, Phillips RL, Rabin DL, Meyers DS, Bazemore AW. Projecting the U.S. primary care physician workforce needs: 2010-2025. Annals of Family Medicine. 2012;10(6):503–509 [Retrieved from] www.annfammed.org/content/10/6/503.full.

Rudolph L, Caplan J, Ben-Moshe K, Dillon L. Health in all policies: a guide for state and local governments. American Public Health Association and Public Health Institute: Washington, DC and Oakland, CA; 2013 [Retrieved from] www.phi.org/uploads/files/Health_in_All_Policies-A_Guide_for_State_and_Local_Governments.pdf.

U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. Projecting the supply and demand for primary care practitioners through 2020. U.S. Department of Health and Human Services: Rockville, MD; 2013 [Retrieved from] bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/projectingprimarycare.pdf.

Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998;1(1):2–4.

Walker I. Caucusing for a cause. The American Journal of Nursing. 2009;109(9):26–27.

Weissert C, Weissert W. Governing health—The politics of health policy. 4th ed. The Johns Hopkins University Press: Baltimore, MD; 2012.

Wilkinson R, Marmot M. Social determinants of health: The solid facts. World Health Organization: Geneva; 2003 [Retrieved from] www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf.

Williams DR, Costa MV, Odunlami AO, Mohammed SA. Moving upstream: How interventions that address the social determinants of health can improve health and reduce disparities. Journal of Public Health Management and Practice. 2008;14(Suppl.):S8–S17; 10.1097/01.PHH.0000338382.36695.42.

Woolf SH. A closer look at the economic argument for disease prevention. JAMA. 2009;301(5):536–538.

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World Health Organization. (n.d.). Social determinants of health. Retrieved from www.who.int/social_determinants/en/.

Online Resources

Institute of Medicine: The Future of Nursing: Leading Change, Advancing Health.

www.iom.edu/nursing.

The Future of Nursing: Campaign for Action (current efforts to implement the IOM recommendations).

www.campaignforaction.org.

The Affordable Care Act.

www.hhs.gov/healthcare/rights/law.

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1The Affordable Care Act (ACA) is the label used to refer to two laws passed by the House of Representatives and the Senate in 2010: the Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act. We use the ACA terminology in this book.

2The ACA refers to refers to both “medical” and “health” homes. Reference to “health homes” is specific to Medicaid provisions in the law. In practice, facilities are designated as “medical homes” if they meet criteria set by the National Committee on Quality Assurance. This book will use that language, while recognizing that “health home” is more consistent with a health-promotion model.

Taking Action

How I Learned the Ropes of Policy and Politics

Chelsea Savage

“This is the true joy in life, the being used for a purpose recognized by yourself as a mighty one; the being thoroughly worn out before you are thrown on the scrap heap; the being a force of Nature instead of a feverish selfish little clod of ailments and grievances complaining that the world will not devote itself to making you happy.”

George Bernard Shaw

I began my career at the bedside. But being at the bedside wasn’t enough to stoke my commitment to social justice and making change in the world. This story of “Taking Action” describes my journey so far, including the successes and challenges along the way, and my own assessment of how passion, combined with mentoring, can produce change in policy. I began my commitment to social justice in 2007 as a Fellow in Richmond, Virginia, for “Hope in the Cities,” a program sponsored by Initiatives of Change, USA, that focuses on building trust through honest conversations on race, reconciliation, and responsibility (www.us.iofc.org). From the rich discussions I had with diverse individuals and groups, I developed an ability to look for and understand the story of the “other” and to use this in conversations to facilitate peace and understanding. This has served me well in the political arena where differences can collide or lead to more creative policy solutions to today’s problems.

I was able to connect that commitment to social justice with my passion for nursing and health care advocacy as Chair of the Legislative Committee for the Virginia Organization of Nurse Executives in 2007. That chairmanship led to a 2-year term as Chair of the Legislative Coalition of Virginia Nurses. In 2009, I became a Fellow of the American Nurses Advocacy Institute, an initiative of the American Nurses Association to develop and mentor nurses into political leaders. A year later, I was selected to participate in the University of Virginia (UVA) Sorensen Institute Political Leaders Program. This program is designed for Virginians who want to learn the political ropes and become more active in public service. I am active in the Virginia Nurses Association (VNA), serving as Secretary and Assistant Commissioner of Government Affairs. However, I had no clue that I ever was going to do any of those things; they weren’t even in my realm of possibilities. So how did all of this happen?

FIGURE 5-1 Author Chelsea Savage participated in a protest against state legislation that would have mandated transvaginal ultrasounds prior to abortions in Virginia.

Mentors, Passion, and Curiosity

Three things created these opportunities. The first was my passion for social justice, the second was my mentors, and the third was an insatiable curiosity that propelled me to venture into uncharted territories. I was finishing a fellowship in Health Law when Shirley Gibson, a mentor and president of the Virginia Organization of Nurse Executives at that time, asked “Chelsea, will you chair the Legislative Committee for the Virginia Organization of Nurse Executives?” I said yes and within a couple of weeks I was networking with leaders in the state, leading advocacy on health care and nursing issues. I was one of the representatives of several diverse nursing organizations that comprised the 50Legislative Coalition of Virginia Nurses (LCVN), founded in part by one of my mentors, Becky Bowers-Lanier. Becky, a well-regarded nursing leader in health policy, and Sallie Eissler, a pediatric nurse practitioner, decided nursing needed a succession plan and I was supposed to help with that. So I was elected Chair of LCVN. Highlights of my time included meeting with policymakers and campaign managers for the governor’s race, creating legislative platforms that outlined succinctly our legislative priorities, and assisting with the passage of the Virginia Indoor Clean Air Act that banned smoking in restaurants and certain other public places.

Sallie Eissler was also head of the Political Action Committee for the VNA and a political junkie. She suggested that I learn about politics in Virginia by applying to the Sorensen Institute Political Leaders Program (PLP) through the UVA. PLP had nothing to do with nursing and everything to do with building political networks and learning to function in the system. Because of my connections though PLP, I was tapped to be Co-Chair for Nurses for Obama in Virginia. Our mission was to educate the public on the Affordable Care Act (ACA). Radio interviews and newspaper articles followed.

I was aware that, if you are not careful, working publicly on behalf of candidates in an election year can create problems with your employer and nonpartisan nursing professional organizations. A colleague advised me that nurses are certainly able to wear more than one hat. I could be a supporter of the ACA and even President Obama as an individual nurse, but it was up to me to make it clear I was not representing the views of my employer or my professional association.

I am lucky to have several mentors in my life, such as Becky and Sallie. I didn’t choose them, but for some reason they chose me, perhaps because I was an enthusiastic, “can do,” productive individual with a passion for creating a healthy society. Through their example, I look for opportunities to mentor. I look for passion in nurses. If a tree falls in the woods and no one is around to hear it, does it make a sound? Replace tree with “nurse” and falls in the woods with “has a passion for the health of their patients and profession” and ask: “Does quiet passion really count for anything?”

Let’s go back to professional organizations because this is how “it makes a sound.” Strength is in numbers and in nurses wanting to be heard. Bring this back to the bedside. I was a nurse manager of a 27-bed medical-telemetry unit when I started on my journey in health policy and politics. We had a significant number of full-time employment (FTE) positions that were unfilled; there just weren’t any applicants. The nursing shortage had reduced me to spending half of my time calling overworked nurses to ask them to do overtime. I was working with three professional nursing organizations at the time, and the consensus was that the shortage was linked to a shortage of nursing faculty, resulting in hundreds of qualified applicants to Virginia’s schools of nursing being turned away. Testifying before Virginia state legislators on behalf of those nursing professional associations, I verified the need to raise nursing faculty salaries. Two things happened that made that a success. The first was 51that my passion found a voice; the second was that the voice was backed by numbers of constituents who vote. There are over 100,000 nurses in the Commonwealth of Virginia. Together with our numbers and the respect the public has for our profession, we create a voice that gets attention and that is successful in creating change.

Where does passion and a commitment to become an agent for change in our society come from? Different places, but for me a good part of it came from adversity. I grew up in a strict religious sect and was not allowed to go to school after the 6th grade. I was supplied with books, and my passion led me to teach myself and obtain my GED when I was 15 years old. Education became my passion, and what I experienced created in me a com­mitment to social justice, advocacy for nursing, and better health care for Virginians.

Consider another example. I have a dynamic friend who was diagnosed with ovarian cancer; she immediately founded CancerDancer (www.ocancerdancer.org), an organization with almost 10,000 members, to spread the word on ovarian cancer signs and symptoms. A special characteristic of us humans is that what should discourage us often makes us a powerful catalyst for change. We are so resilient. Find your passion, then find your voice; and go out and change the world.

The Policy Process

Eileen T. O’Grady

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

Dorothea Brande (1893-1948)

The purpose of this chapter is to provide a conceptual framework for understanding policymaking. When provided with a clear understanding of the policymaking process, nurses can more strategically and effectively influence policy. By using conceptual models, complex ideas may be depicted in a simplified form to help organize and interpret information, and to this end, political scientists have established a number of conceptual models to explain the highly dynamic process of policymaking (Dye, 1992). This chapter reviews two of these conceptual models.

Health Policy and Politics

Health policy is significantly broader than nursing care policy alone. Health policy encompasses the political, economic, social, cultural and social determinants of individuals and populations and attempts to address the broader issues in health care (see Box 7-1 for policy definitions). This distinction is important because nurses need to be aware of the relevancy and significance of health policy in any position they hold. To influence the process, a clear understanding of the points of influence is essential and this includes correct framing of the health care problem itself. For example, if a nurse working in a nurse managed clinic is troubled by the staff shortages or long patient waits, they may be inclined to see themselves as the solution by working longer hours and seeing more patients. Defining and framing the problem in a broader policy context involves assessing the history, patterns of impact, resource allocation, and community needs as a first step in the policy process. Broadening and framing the problem to influence or educate stakeholders at the community, city, state, or federal level could include advocating for better access or funding for nursing workforce development. The next step is to bring the problem to the attention of those who have the power to implement a solution. Other key factors to consider include the generation of public interest, availability of viable policy solutions, the likelihood that the policy will serve most of the people at risk in a fair and equitable fashion, and consideration of the organizational, community, societal, and political viability of the policy solution.