1. UNDERSTANDS THAT ALL PUBLIC HEALTH NURSING IS POLITICAL.

Best Evidence: Aroskar; Cohen; Evers in Farrunt and Ever

Public health nurses need to understand (and believe) that their involvement in
policy development and enforcement is a social mandate grounded in public
health nursings ethic of caring and commitment to social change and social
justice.
As Aroskar states, As nurses we have opportunities to raise [ethical] questions in
any number of arenas in policy review mechanisms, in proactive policy
development or revision of existing policies, both in our own institutions and in
the wider community (p. 270). She offers Warwick and Kelmans discussion of
the areas of policy where ethical issues should be raised before decisions are
made, noting they include:

the choice of policy goals that maximize certain values and minimize

others
the definition of the target population and their involvement
the means chosen to implement the policy (these have the potential to

range from coercive to voluntary)

a consideration of the direct and indirect consequences of a proposed

policy.
Cohen and Mason provide a continuum of the developmental stages
through which nurses progress in their

political activism:

buy-in level: reactive response to a perceived personal professional threat

or a wake-up call, with a focus on nursing issues

self-interest level: reactive to nursing issues, but from a whats in it for

me perspective
political sophistication level: proactive on nursing and other health issues
leading the way level: proactive on leadership and agenda-setting for a
broad range of health and social policy issues.

Hall-Long provides an interesting review of nursings involvement on the political

scene
and concludes with a rouser or call to action to encourage nurses involvement
in the policy arena: Following the lead of our political pioneers risk-taking
behavior, contemporary nurses need to face the political challenges of the 21st
century to guarantee representation around the public policy-making tables.
Once around those tables, political voices and power will be welded to the
nursing profession and to the consumers they represent (p. 28).

2. USES SCIENCE-BASED EVIDENCE TO INFLUENCE POLICY DEVELOPMENT AND

ENFORCEMENT.
Best Evidence: Badovinec; Conn; Hanley; Spradley and Allender; Swanson and
Nies; Milstead
Science-based evidence used for policy development should be comprehensive
and succinct and should include an analysis of financial impact. Most of the
textbook authors reviewed adapted their models of policy development from J.W.
Kingdon.
Kingdon suggests that three streams have to come together at the right
window of opportunity in order for public issues to be addressed through policy.
The three streams are:
1. The Problem Stream
This stream is marked by indicators (such as economic or health indicators) of a
problem, by a sudden crisis, or by feedback that a program is not working as
intended.
2. The Policy Stream:
Ideas for policy change come from everywhere. It does not matter where or from
whom the idea comes. What matters is what made it take hold and grow. To
stay, a policy idea must meet the following five criteria:

Technical feasibility
Value to the community
Tolerable cost
Anticipated public agreement
Reasonable chance elected officials will be receptive to it.

3. The Political Stream:

This stream includes public mood, pressure group campaigns, election results,
composition of the
decision-making board, and changes in top management. The fourth variable is
the probability that the streams will converge at the right window of
opportunity, or time. Agendas are affected more by the problem and political
streams. The policy stream is affected more by which criteria (feasability, value,
cost, public agreement, or officials receptiveness) is strongest at that moment.
Windows open for developing or changing policy, because of changes in the
political stream or because new problems capture officials attention.
Public health nursing significantly impacts policy development in the problem
stream. Data that support the existence of problems and their consequences
on health have huge importance there. Although PHNs gather and interpret

epidemiological data, they often fail to use the data to support policy
development.
Conn and Amer point out that data do not speak for themselves. Their
suggestions for presenting results to policy-makers are good advice for any data
presentation:

do not bore policy-makers with the details of how data is collected and
interpreted
present only the major points, using the most dramatic statistics
use anecdotal evidence (that is, stories) to personalize the meaning of the
results; the more they can reflect real situations from a policy-makers own
constituency, the greater their impact (p.270).

3. INCLUDES PARTICIPATION OF THOSE CONSTITUENCIES POTENTIALLY

AFFECTED BY THE POLICY.
Best Evidence: Badovinec; Evers in Farrunt and Evers; Hanley; Spradley and
Allender; Swanson and Nies; Milstead; Longest
Good policy is made better when those affected are involved. Across authors,
however, a range of opinion exists about when and how to involve constituents
(that is, members of a group sharing common characteristics, such as all persons
living in the same voting district). Longest, for instance, acknowledges that while
constituents need to be engaged in the process to reduce their resistance to
change, they often come to the discussion with unalterable mindsets.
He categorizes the four prevailing mindsets on this issue as:

True Romantics those who choose to ignore the concept of economic limits
Pseudo Romantics those who understand economic limits, but choose to

think that someone else in the future will figure out the details
Truly Self-Serving those so intent on ensuring that their own interests are

served, that other issues become secondary

Procrastinators those who understand economic limits, but choose to
delay action, usually due to the potential for political repercussions.

On the other end of the continuum are those invested in community

empowerment concepts, where the members of the community themselves are
the policy-makers. (See the advocacy intervention for further discussion of
empowerment.)
4. DEVELOPS SKILL NECESSARY FOR POLICY DEVELOPMENT AND ENFORCEMENT.
Best Evidence: panel recommendation based on practice expertise

The Expert Panel recognized that the inherent potential for conflicting viewpoints
in policy development requires PHNs to have expert communication skills,
particularly in the areas of conflict management, negotiation, and mediation.
Those PHNs involved in policy enforcement must have these skills.
5. BUILDS PERSONAL AND PROFESSIONAL SUPPORT SYSTEMS.
Best Evidence: panel recommendation based on practice expertise
Public Health Nurses need to develop both personal and professional support
systems to deal with the ethical dilemmas and role conflict occasionally
encountered in policy development and enforcement. Whenever possible, a PHN
should seek a mentor as part of this support system. The more PHNs take on the
role of advocating for policy development and becoming politically active, the
more likely they will need a strong support system.
6. UNDERSTANDS THE LIMITATIONS OF POLICY DEVELOPMENT AND
ENFORCEMENT.
Best Evidence: Longest; Milstead
The PHN should strictly adhere to the policy implementation plan. Marlene
Wilken, writing in Milsteads textbook, describes the multiple areas where policy
implementation can go awry: Tractability, or the degree of difficulty encountered
in the management and control of implementation. It includes such things as
whether or not the agency charged with administering he policy has access to:

technology required to enact and enforce the policy

staff who possess the necessary competencies
resources sufficient to deliver the program enacting the policy
composition of the target group whose behavior is to change
management competencies equal to the complexity of the change created
by the policy.

Structure, or the extent to which the implementing agency can structure or

organize the process of policy enactment:

clear objectives
causal links established between the interventions and the desired change
sufficient jurisdiction and authority to make things happen.