4.2 Policy Agenda Setting and Policy Decisions
4.2.2 Participation in the Policy Process: Direct and Indirect
Even though nurses are not usually viewed at the elite level of policy decision- making, the author proposes that participation in the policy process provides nurses an opportunity to advocate for specific policy agenda items and influence policy development. In describing a political influence model, Porche (2012) defines polit- ical influence as the ability of an individual or group to influence the policymaking process and proposes that nurses have the ability to influence the policy process within four spheres. The four spheres of influence identified by Porche (2012) are
“government, workplace, organizations and community” (p. 16). Involvement of nurses in these settings provides an opportunity to advocate for specific policies from a nursing perspective.
Walt (2006) defines policymaking as a “series of more or less related activities and their intended and unintended consequences” (p. 41) rather than a distinct decision. In addition, the structure of the political system affects participation and the potential to influence policy decisions. The political system in a country encourages or discour- ages participation and results in significantly different healthcare politics. A great deal depends on the country context and the stability of its political structure. In addition, beliefs and attitudes about participation impact nurses’ participation in public policy- making. Two types of participation are identified by Walt (2006): direct and indirect.
4.2.2.1 Direct Participation
Interest groups may try to lobby or influence policy and decision-makers at various stages of the policy process. Direct participation refers to those methods or techniques by which individuals or representatives of interest groups try to influence policy by relating to policymakers face to face (Walt 2006). For example, members of nursing associations or interest groups attempt to lobby decision-makers directly about their views on healthcare topics or, for example, specifically professional regulation of advanced nursing practice. Interest groups might also form alliances with other groups to propose or resist policies. The impact of these groups differs in how they are viewed by the government and official decision-making bodies. Some interest groups are
given insider status and more closely consulted (refer to Chap. 6, Sect. 6.1.3, for a discussion of a process for identifying stakeholders and their interests).
4.2.2.2 Indirect Participation
Indirect participation includes activities intended to more indirectly influence the selection of government representatives and the policies they are likely to support (Walt 2006). Indirect participation is voluntary engagement in activities and networks with political implications but without clearly defined political interests or political aims. It is difficult to grasp a clear definition for indirect participation as there may be implicit political influence without political ambition (Pausch 2012). Opportunities for indirect participation depend to a great extent on political systems. Political sys- tems vary from so-called Western European liberal democracies with high levels of participation to postcolonial regimes in Africa that are seen as unstable to more authoritarian leadership (Blondel 1990; Walt 2006). Countries whose governments function within a stable framework offer more options for participation by having diverse interest groups that attempt to negotiate and influence policy to fulfill their own goals. Even in countries that appear to offer indirect participation, it is unclear to what extent the public can affect and influence policy decisions (Birch 1993).
The perspective of direct or indirect participation, as introduced in this chapter, includes nuances in definition and therefore is intended to present only a back- ground for involvement in politics and policy. External or situational factors influ- encing decisions can be infinite and unanticipated. The subject of participation in policy and politics for APNs is picked up again in Chap. 5 with the delineation of stages of political engagement for nurses along with recommendations for acquiring necessary skills for leadership.
Conclusion
Healthcare reform and changes in healthcare sectors arise worldwide from differ- ent starting points. No matter where change or modification begins, there are com- plex layers of decision-making in the policy environment. This chapter explores the concept of evidence-based policy in the context of the reality of what factors actually influence policy decisions by identifying aspects of how health policies are made, who influences policy, and how. The power and authority of influential decision-makers and their spheres or networks of influence are emphasized.
Differences between countries such as shortage of funds, scarcity of informa- tion, personal values of administrators, lack of on-the-ground communication networks, and limited structures of accountability impact engagement in policy- making and vary significantly from country to country. Nevertheless, regardless of perceived constraints, there are opportunities for advanced practice nurses to become engaged at some level in the policy process. Options of direct and indi- rect means for participation are discussed to encourage nurses to have a voice in the policy environment. As healthcare professionals, advanced practice nurses can influence and promote policy change.
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5
Politics: The Art of Diplomacy and Negotiation
Politics is often a forbidden word in nursing; however, it is a process that every nurse is engaged in on a daily basis. When defined as the process of making deci- sions applying to members of a group, specifically to achieve and exercise positions of governance, politics involves all nurses. In addition, leadership is increasingly identified as an advanced practice nursing competency. Participation in policymak- ing is a core element of leadership. Leadership aptitude implicitly suggests obtain- ing expertise to navigate the sometimes murky and ill-defined atmosphere of politics and political negotiating. This chapter begins by suggesting stages of acquired lev- els of political engagement for nurses. Chapter content continues on to describe skills that nurses can achieve and use in the political process to become effective in influencing policy development and policy decisions.