Running head: Policy Advocacy

A GROUNDED THEORY STUDY OF NURSE ADVOCACY IN HEALTH POLICY

by

Marilyn Longo Dollinger November 15, 2006

A dissertation submitted to the Faculty of the Graduate School of

The State University of New York at Buffalo in partial fulfillment of the requirements for the degree of

Doctor of Nursing Science

School of Nursing

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Copyright by

Marilyn Longo Dollinger

2006

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ACKNOWLEDGEMENTS I want to acknowledge and thank the bright, passionate nurses who shared their

experiences with me for this study.

Thanks to my Dissertation Committee Chair Nancy Campbell-Heider PhD RN

and the members of my Dissertation Committee: Suzanne Dickerson PhD RN and James

Wooten PhD for their patience, guidance, and critique of my work.

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DEDICATION

To my husband Richard and my children Michael, Maureen and Timothy who never

stopped believing in me.

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Table of Contents Acknowledgements iii

Dedication iv

Abstract ix

Chapter One: The Phenomena of Interest 1

Introduction 1

The Purpose of the Study 2

Definition of Terms 3

Overview of Methodology 3

Significance of the Study 4

Limitation of the Study 5

Research Questions 5

Chapter Two: Review of the Literature 6

The Evolution of Nurses’ Involvement in Policy and Politics 6

Framework for Political Action in Nursing 10

Political Science Literature 12

Nursing Research Literature on Nurses in Politics and Policy 15

Conclusions Based on the Literature Review 19

Chapter Three: Design of the Study 21

The Research Questions 21

Grounded Theory 21

Symbolic Interactionism 22

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Sample 23

Data Collection 24

Data Analysis 25

Informed Consent and Confidentiality 27

Issues of Reliability, Validity and Rigor 28

Chapter Four: Analysis of the Data 31

Characteristics of the Participants 32

Table 1: Demographic Characteristics of the Nurses 33

The Core Category 33

Diagram 1: Conceptual Model of GIVING VOICE 34

Strategy One: Learning the Culture 36

Table 2: Strategy One: Learning the Culture 37

Learning the Culture: Boundaries Within

and Between Offices or Committees 38

Learning the Culture: Boundaries Between

Branches of Government 47

Learning the Culture: Boundaries of Those

Outside of Government 49

Strategy Two: Selective Self-disclosure 50

Table 3: Selective Self-disclosure of Professional

Background 58

Strategy Three: Translating 60

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Strategy Four: Creating Access 71

Strategy Five: Invoking Others 82

Strategy Six: Careful Truth 86

Socio-Political Context Barriers: Visible and

Invisible Presence 89

Chapter Five: Discussion, Implications and Summary 97

The Research Questions 97

Implications of the Findings 106

Implications for Education 107

Implications for Practice 111

Implications for Nurse Advocacy 115

Getting More Nurses Inside Government 115

Special Interest Group Strategies 116

Limitations of the Study 119

Recommendations for Further Research 122

Process Recommendations 123

Conclusion 124

Appendix A: Interview Questions 126

Appendix B: Demographic Data Collection Form 128

Appendix C: Informed Consent Form 129

Appendix D: Background: Transition from Practice to Policy 131

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Transition: Motivation to Leave Practice 131

Transition: Access to the Government 132

Transition: Skills for New Roles in Government 133

Future Goals for Nurses in the Study 138

References 140

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Abstract

The purpose of this study is to explore how effectively nurses function as advocates in

the federal health policy process, understanding their perspectives, their strategies, and

tactics. This study examined how nurses in legislative and administrative positions

advance health policy or regulatory issues that are important to health care or the nursing

profession. Although nurses have a long history of social and political activism, little is

known about their effectiveness in achieving favorable policy outcomes. The researcher

interviewed 11 registered nurses who had experience as staff in government offices,

committees, or federal agencies to learn what processes, tactics, and strategies nurses in

these positions use in their work and how these influence the way that issues and

problems pertinent to nursing and health care appear on the policy agenda and move

through the political and policy process. The interviews were done in person, audio-

taped, and then transcribed. Grounded theory methodology developed by Glaser and

Strauss (1967) guided the sampling, data collection, and analysis throughout the study.

The core category of GIVING VOICE that emerged from the data consists of six

strategies: learning the culture, selective self-disclosure, translating, creating access,

invoking others, and careful truth. One of the strategies, selective self-disclosure appears

to be unique to nurses based on their lack of status relative to other players in health care

policy. The study determined that having nurses working inside the policy and political

system was a strategic advantage when policies and regulations were directly related to

the profession such as nursing workforce issues. Being “on the inside” offered little

strategic advantage in moving issues that were related to health care in general.

Significant barriers were identified related to the dominance of the medical model and the

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lack of recognition of the expertise and focus of nurses on broader health care issues by

those in government.

It is important for nurses to continue to create and use opportunities for influence

within the system to support culture change but also important to continue to build the

power of the profession as a special interest group that can wield influence in traditional

ways.

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CHAPTER ONE: THE PHENOMENA OF INTEREST

Introduction

Registered nurses make up the largest group of health care workers in the United

States. They are the only members of the health care team who are with patients and

families wherever health care is delivered, twenty-four hours a day, seven days a week.

Because nurses have intimate and continuous contact with people who need health care,

they are in a unique position to advocate for change to increase access, improve quality,

and manage cost. In today’s increasingly complex and costly health care system,

advocacy through legislative and regulatory change is an important and fundamental

professional role (Ballou, 2000).

Throughout the history of the profession, individual nurses have made a positive

difference in health care through advocacy and political involvement (Birnbach, 1983;

Chinn, 1985; Girvin, 1996; Glass, 1984; Kalisch & Kalisch, 1986; Smith, 1991;

Zimmerman, 1988). Over the last few decades, increased political involvement and the

growth of professional associations have given nurses greater access to the legislative and

executive decision-making process. With this access comes the opportunity and

responsibility for nurses to influence health policy decisions to improve health care.

Studies of nurses’ roles in politics and policy examine the experiences of nurses

active in health policy and lobbying as members of a “special interest” professional group

outside of government (Feldman & Lewenson, 2000; Hall-Long, 1995; Kershner &

Cohen, 2002; Winter & Lockhart, 1996). These studies focus on the meaning of the

nurses’ involvement, their motivation for becoming politically active, and the factors that

facilitate or impede involvement. There is no research on nurses who work in legislative

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and administrative agencies to study how they influence health policy decisions. In

contrast, there are many studies in political science literature about the role of different

players in the policy process including legislators, members of both personal and

committee staff, members of administrative and regulatory agencies, and special interest

groups (Hammond, 1996; Hansen, 1991; Kingdon, 1995; Whiteman, 1987; Whiteman,

1995; Wilson, 1980; Wilson, 1989). Nurses are not mentioned or studied in this body of

work. My research will fill this gap by studying nurses who leave their positions in health

care to assume formal roles in a legislative or administrative agency.

The Purpose of the Study

This study will examine whether and how nurses in legislative and administrative

positions advance policy or regulatory issues that are important to health care or the

nursing profession. To most effectively advocate for change, the nursing community

needs to know whether having nurses move to policy-making positions is an effective

strategy for influencing health care policy. To this end, this study aims to learn more

about nurses in the policy world, understanding their perspectives, their use of power, and

how they work. It remains to be seen if nurses “inside” the political and policy system

work effectively as policy advocates. If effective work is done, learning how to better

prepare nurses to achieve and function in these roles is an appropriate strategy to further

the nursing profession’s influence in politics and policy. If nurses in political and policy

positions do not advance professional nursing’s health care issues and agenda, there is a

need to develop more effective strategies for influencing the system from both the inside

and outside the system as a more powerful, special interest group.

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Definition of Terms

Politics: There are many different definitions for the term “politics”. For the purposes of

this study, Mason and Leavitt’s (1998) definition will be used: Politics is the allocation of

scarce resources.

Policy-making: The process of bringing problems to government, including agenda

setting, design, government response, implementation, and evaluation (Milstead, 1999).

Public policy: Directives that document government decisions in the form of programs,

laws, or regulation (Milstead, 1999).

Interest group: An organized group with a common cause that works to influence the

outcome of laws, regulations, or programs (Milstead, 1999).

Tactics: Specific activities used by individuals or groups to gain access or influence.

Strategies: Goal-directed plan using selected tactics suitable for the specific context to

achieve access or influence.

Legislative roles: Legislators or staffers who work for individual legislators or legislative

committees.

Executive or administrative roles: Political appointees or staffers who work in executive

branch agencies of the federal government.

Nurse: An individual who is licensed as a Registered Nurse before or during his/her

work in a legislative or executive role.

Overview of Methodology

This study of nurses in political and policy positions uses grounded theory

methodology. First proposed by Glaser and Strauss (1967), grounded theory is a

qualitative research method using inductive reasoning to study the meaning of human

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behavior by looking for, describing, and explaining processes. Symbolic interactionism is

the philosophical underpinning of grounded theory. The key methodological implication

of symbolic interactionism is the importance of getting at the meaning of individuals’

experiences in order to understand and explain their behavior (Meltzer & Manis, 1967).

Interviews with nurses who work in legislative or administrative positions in the federal

government were audio-taped and transcribed. The narrative data was analyzed using a

constant comparative process, allowing the researcher to refine and specify questions as

the research progressed. Theory that emerges from the study is the result of transforming

raw data in narrative form into theory by inductive reasoning and conceptualization.

Significance of the Study

Nurses have a unique position within the health care system. Their knowledge,

expertise, and perspective give nurses the potential to be a strong and sophisticated force

in influencing health care policy. To strengthen their impact, nurses must find the most

effective strategies for influencing health policy. If nurses within government are

effective in moving health care and nursing issues through the policy system, the

profession should encourage nurses to enter these policy-making and administrative

roles. This support can take the form of educational programs, internships, nominations

for appointed positions, recruitment of candidates for political office and administrative

agency positions, and electoral support for candidates. If nurses in legislative and

administrative positions are not effective in achieving their goals when health care and

nursing issues arise, the profession must seek access and political influence in different

ways.

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Limitations of the Study

The limited number of nurses in policy positions to participate in studies and the

nature of the qualitative methodology of grounded theory preclude generalization of the

results of this study. The frequent turnover of individuals in policy and legislative roles is

a potential challenge for researchers in terms of recruitment of participants for these types

of studies. In this case, the researcher’s active involvement in professional associations,

lobbying, and political action facilitated networking and the identification of potential

participants.

Research Questions

(a) What processes, tactics, and strategies do nurses on the “inside”, that is, in the

legislative branch or executive branch agencies, use in their work?

(b) Do these processes, tactics, and strategies influence how issues and problems

pertinent to nursing and health care appear on the policy agenda and move through the

political and policy-making process?

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CHAPTER TWO: REVIEW OF THE LITERATURE

Researchers using qualitative methodology are cautioned about reviewing the

literature before conducting their studies so that they are able to approach their work with

as few predetermined ideas as possible (Glaser, 1978). However, one of the reasons it is

necessary to review the relevant literature before undertaking any study is to establish

that the researcher’s work is not duplicating existing scholarship. Identification of gaps in

the literature allows researchers to focus on areas of interest that build on published work

or are unexplored. Glaser (1978) adds that being “steeped in the literature that deals with

both the kinds of variables and their associated general ideas” (p. 3) enriches a qualitative

researcher’s theoretical sensitivity and allows him/her to draw on many disciplines and

perspectives as the data is analyzed.

This chapter briefly reviews the history of political action by nurses and presents

an analytical framework for evaluating the political participation of nurses. In addition,

the chapter discusses work from political science literature on legislators and staff in

administrative agencies. The political science literature provides a framework for

examining the experiences of nurses in government and the ways nurses in government

can make a difference in policy outcomes. Finally, this section reviews studies of nurses

in policy roles in order to establish that there is a gap in the research literature on how

nurses function in policy-making.

The Evolution of Nurses’ Involvement in Policy and Politics

Many scholars have documented nurses’ important political role as advocates

(Antrobus & Kitson, 1999; Cohen, Mason, Kovner, Leavitt, Pulcini, & Sochalski, 1996;

Curtin, 1994; Gebbie, Wakefield, & Kerfoot, 2000; Hadley, 1996; Hall-Long, 1995;

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Hewison, 1994; Kalisch & Kalisch, 1986; Kershner & Cohen, 2002; Mason & Leavitt,

1998; McMillan, 1998; Milstead, 1999; Moccia, 1988; Spetz, 1999). Throughout history,

individual nurses have engaged in professional advocacy through social activism and

progressive politics (Birnbach, 1983; Chinn, 1985; Girvin, 1996; Glass, 1984; Kalisch &

Kalisch, 1986; Smith, 1991; Zimmerman, 1988). In the first half of the 20th century,

political action and advocacy focused on developing educational and licensing standards

and establishing nursing as a profession. Although the first professional nursing

organization was established at the turn of the century, professional nursing organizations

in the early 20th century had not yet established legislative and political advocacy

programs. These early, activist nurses demonstrated considerable resourcefulness and

commitment because the work of lobbying and activism required individual initiative and

a hands-on approach that was time consuming and labor intensive (Estabrooks, 1995).

Early nurses who were politically active appear to have been motivated more by their

personal values and experience than by their professional experience.

In the 1930s and 1940s, the emergence of hospital insurance and a boom in

hospital construction shifted nursing employment from home settings to the hospital. The

shift in practice setting significantly affected the autonomy and activism of nurses.

Grassroots activism was subsumed in bureaucracy as nurses moved from their

community base to work in hospitals. In the hospitals, nurses were not encouraged to be

politically active because their advocacy posed a threat to the hierarchy dominated by

physicians and hospital administrators. During this time, members of the nursing

profession were unable to establish control over the educational entry into practice and

the quality of nursing education due to their lack of political power. This put members of

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the profession of nursing at an early political and social disadvantage and allowed

physicians and hospital administrators to dominate the health care system (Ashley, 1976;

Reverby, 1987; Starr, 1984).

During the latter half of the 20th century, nursing political and policy activism

focused on recognition of nursing as a profession, definition of nursing practice as a

distinct science, and the educational level of entry into practice. As more nurses studied

in undergraduate and graduate programs and worked in more autonomous roles in health

care, they reasserted some of the activism that occurred in the early community-based

profession. Nursing leaders emerged who argued that professional education must

include political action and policy skills (Antrobus & Kitson, 1999; Brown, 1996; Chin,

1985; Curtin, 1994; Friss, 1994; Hadley, 1996; Hall-Long, 1995; Mason & Leavitt, 1998;

Moccia, 1988).

During this time, in contrast to the early 1900s, professional associations,

supported by leaders in academia and nursing practice, served as the main resource for

political action and policy education. They provided momentum, structure, and support

for political activism (Friss, 1994). Professional associations grew into large

organizations with legislative staff, professional lobbyists, political networks, and

grassroots activism programs. Many of the key professional nursing organizations

established or moved their national offices to Washington D.C. because their leaders

understood the importance of being close to where critical decisions about health care are

made (Mason & Leavitt, 1998). Mainstream professional organizations such as the

American Nurses Association (ANA), National League for Nursing (NLN), American

Association of Colleges of Nursing (AACN) and the American Organization of Nurse

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Executives (AONE) (collectively known as the Tri-Council) became recognized in

Congress as the voice for professional nursing (Mason & Leavitt, 1998).

While nurses have gained stature in the political process (Cohen et al., 1996;

Feldman & Lewenson, 2000; Kalisch & Kalisch, 1986; Mason & Leavitt, 1998), they

have not translated this increased level of political action into political clout. According

to Victor Fuchs (Brown, 1999) and Emily Freidman (Spetz, 1999), two noted health

policy analysts, nurses are not considered players and have not had much influence in

health care policy. Neither the general public nor individual policy makers recognize the

role of nurses as advocates in health care legislation (Curtin, 1994; Friss, 1994; Hadley,

1996; Milstead, 1999; Weissert & Weissert, 1996).

The political science literature on special interest groups confirms this perception

(Baumgartner & Leech, 1998; Kingdon, 1995; Whiteman, 1987). Political scientists often

use case studies to illustrate their findings and health care is often one of the policy areas

selected. When political scientists analyze the dynamics of agenda setting, the policy-

making process, and special interest group influence for health care-related legislation,

they never mention the profession of nursing as a player in that process. In fact, nurses

are not mentioned at all. When health care-related issues are debated and resolved

legislatively, the groups that legislators perceive as important members of the “issue

networks” -- those who are consulted and participate in negotiations-- are the medical

profession, hospital administrators, insurance, and pharmaceutical companies. This

documented and systemic exclusion of nurses raises an important and, so far, unanswered

question--what can nurses do to make a difference in the legislative debate over the future

of the health care system? The unique skills of nurses should have a larger role in the

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policy-making process. In an effort to determine how nurses may play a more

consequential role in the legislative debate, this research seeks to identify nurses who

have sought a wider role in the process and evaluate their observations on the best

strategies to succeed in influencing public policy.

Despite the activities of professional organizations and a small cadre of nursing

leaders, few grassroots nurses have overcome their sense of powerlessness in policy

advocacy. Some analysts believe the educational and socioeconomic disparity between

nurses and other health care providers is the source of powerlessness nurses perceive in

their professional lives (Feldman & Lewenson, 2000). Until the majority of nurses have

educational and socioeconomic status comparable to those of other health care providers,

changes in the social and political systems, the role of women in society, the availability

of role models, and the support of professional nursing organizations will not empower a

critical mass of nurses to exert the potential power of the profession (Winter & Lockhart,

1996). Nurses do not have the degree of political influence they want because of their

failure to translate their significant numbers into electoral clout. Political leaders who

neglect the concerns of the nurses in their constituency have not suffered defeat as a

result of losing the nursing vote. Other groups, such as unions, wield this kind of electoral

power with legislators. One purpose of the qualitative study proposed here is to

determine why nurses have failed, especially in more sophisticated political discussions,

to achieve clout commensurate with their numbers.

Framework for Political Action in Nursing

Cohen, Mason, Kovner, Leavitt, Pulcini, and Sochalski (1996) proposed a

developmental framework to analyze the evolution of nursing as a body politic (Cohen et

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al., p. 256). They describe four stages of political participation that reflect a continuum of

political skills and activism. This stage theory of the political involvement of nurses

provides a useful framework to evaluate the progress of the profession and points the way

to new and later stages of activism as nurses gain access to the political system.

The first stage, the “buy–in” stage, describes activities to raise nurses’ political

awareness that occurred primarily in the 1970-80s when leaders of the profession urged

nurses to become involved in both political and institutional power and politics. Although

political advocacy and involvement are now accepted aspects of the role of professional

nurses, the majority of nurses in practice remain uninvolved in policy and politics,

leaving this advocacy role to a small minority of activists in professional associations.

The second “self-interest” stage involves an increased level of awareness and

skills as professional nurses developed their own identity as a special interest group.

Nurses learned to embrace special interest group status by forming coalitions among

professional nursing organizations and starting political action committees (PAC) to

participate in the political process.

Stage three encompasses activities with higher levels of “political sophistication”

showing that nurses were gaining political skills with their experience. Buoyed by larger

numbers of highly educated nurse advocates, the nursing community moved beyond

nursing workforce issues to broader health care interests and gained some recognition

from those outside the profession for its expertise in health-related issues.

The fourth and final stage in this framework, “leading the way”, is still evolving.

The key dynamic in this stage is the movement of professional nursing from a reactive

and participative role to one of initiating policy alternatives and ideas for a broad range of

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health care issues. This shift, from following change to initiating it, marks a significant

threshold for the profession in its growth as a body politic. This stage which includes the

step of nurses moving into policy positions, the focus of this research, must be studied to

determine the most effective strategies for affecting health care outcomes. A qualitative

study, studying the experiences of nurses who have embarked with some success in this

area, will provide a sign post for future activism as nursing moves forward.

These stages of political involvement summarize the progress of the profession as

nurses gain access to power and become involved in shaping health policy. Today, there

are nurses at all four levels of political maturity. This research will investigate nurses

who are in the fourth stage of the Cohen et al. (1996) framework, that is, nurses who have

moved to roles inside the policy-making system. This investigation may lead to a fuller

understanding of the framework, an evaluation of the framework’s continued viability as

a tool for analyzing nurses’ roles in the political process, and perhaps reveal additional

stages as we learn more how nurses in legislative and agency roles participate in the

political and policy-making process and what outcomes they are able to achieve.

This study is an attempt to shift the focus of nursing research from calling for,

legitimizing and describing nursing involvement in political action and health policy, to

studying the processes by which nurse policy advocates affect health care through policy.

Political Science Literature

In seeking to understand how nurses in policy and legislative roles function, a

review of the political science research on staff in Congress gives some insight to the

parameters of these roles. Studies of Congressional staff, a group with significant

influence in the political and policy process, look at both personal staff (those hired by

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the legislator) and committee staff (those hired by legislative leaders) (Hansen, 1991;

Whiteman, 1987; Whiteman, 1995; Wright, 1996). There are considerable differences

between personal staff and committee staff. In contrast to personal staff, committee staff

are predominantly male, have higher levels of education, past legislative experience,

policy expertise, extensive personal networks, and ambitious career goals (Whiteman,

1995). Given the skills sets of these committee staff, it would appear that nurses (largely

female, with career goals in health care and educated in natural and physical sciences)

will find it difficult to penetrate these staff environments.

Individuals in these committee staff roles often have backgrounds in law, political

science, or economics. This study will explore whether nurses who work as staffers

perform their roles differently than individuals without a background in health care.

Nurses in committee staff positions may find it challenging to establish their health care

expertise if there is a disparity in background and level of education between them and

staff from other professions.

According to Whiteman (1987), personal staffers in legislative offices usually

have no education, training, or work experience in the issue area they cover. One of the

challenges that these legislative staffers face is establishing networks to help them

become informed in the policy area which they oversee. One aspect of this study will

investigate whether nurses working on health issues have an advantage in gaining access

to experts in the health field and can bring information from established networks that

others, without a nursing background, cannot.

Research indicates that staffers, who work on health care issues, tend to be

predominantly female as opposed to areas such as transportation, which have mostly

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male staff (Whiteman, 1987). This trend for health care staff to be female may facilitate

access for nurses from a predominantly female profession, who are seeking a position in

Congressional offices.

Despite the differences among staffers, both Congressional personal staff and

Congressional committee staff, regardless of background or interests, must function

within the boundaries of the ideology and agenda of the member of Congress who they

work for (Arnold, 1990; Whiteman, 1995). According to Hammond (1996), personal staff

function “within well understood parameters” (p. 548). Personal staff must balance their

approach to legislators so that they meet the legislators’ needs for relevant information

without pressuring legislators to take a specific stance or perspective. Staff members are

the legislators’ “surrogate” and should not use this role to advance their own agenda,

beliefs, or ideas. In the context of these practical and political constraints, this study will

look at whether and how effectively nurses in these staff roles influence legislative and

regulatory issues in health care.

Wilson (1980; 1989), studied how decisions are made in regulatory agencies and

the “relationship between private power and public purpose” (1980, p. ii). As government

regulates more of our lives, members of all professional groups have a vested interest in

influencing the decisions that government agencies make. Wilson asserts that most

members of professions have learned “distinctive ways of thinking about policy

problems” (1980, p. 379). This study will investigate how nurses in regulatory agencies

work and if a specific mindset is true among nurses.

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Nursing Research Literature on Nurses in Politics and Policy

Recent qualitative studies looked at contemporary nursing political activists and

explored and described nurses’ experiences to learn what motivated them to become

active in health policy and politics. These studies examined nurses who were involved in

lobbying and political activism and documented the increasingly sophisticated

organization, tactics, and strategies that nurses within their professional organizations

have developed over the years. There is a lack of studies, however, of how nurses who

have gained access into the policy-making process wield their influence. It is important to

know if nurses are more effective than others in moving health care issues to the political

agenda and how their knowledge of the health care system and their formal and informal

access to experts affects this process and influences health care policy.

Most studies on nurses and politics focused on nurses who were involved in

health policy as members of a special interest group (Antrobus & Kitson, 1999; Hall-

Long, 1995; Kershner & Cohen, 2002; Winter & Lockhart, 1996). These studies explored

factors that influenced the involvement of nurses who were politically active. Factors that

facilitated the nurses’ involvement in political action included family, peer, and mentor

influence that exposed the nurses to political behavior and participation. Factors

identified as barriers to involvement in politics included lack of resources, poor social

support, and previous negative experiences. All of these studies mention the importance

of political socialization by family members and educational programs as factors in the

lives of these nurses. These observations reinforce what political scientists describe as

political socialization, a process occurring over one’s lifetime that is influenced by age,

gender, socioeconomic status, high school activities, and family. All of these factors play

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an important role in developing one’s motivation to be involved in politics and the

direction of one’s political compass (Milbraith, 1965).

Professional socialization in professional education programs also appears to have

a significant impact on the degree of nurses’ political involvement in health care issues.

Several nurses in these studies mentioned that mentors in their nursing education

programs were important role models, confirming findings from the political

socialization literature that exposure to political activities and behavior and the presence

of role models promote involvement in politics (Milbraith, 1965).

Nurses serve as members of Congress and as high level appointees in executive

agencies but these accomplished individuals often are not known to be nurses either by

nurses or by persons outside of the profession (Feldman & Lewenson, 2000). In contrast,

physicians are willingly identified by their professional background when in elected

office. Senate Majority Leader Bill Frist is a physician and publicly discusses his

professional background and experience. Similarly, Dr. Howard Dean, former governor

of Vermont and 2004 presidential candidate, Representative James McDermott of

Washington and Representative Charles Norwood of Georgia exhibited the same

professional pride as they pursued their careers in government. This process by which

members of the medical profession can easily transfer their influence and power from the

domain of medicine to politics is facilitated by physicians’ professional socialization,

advanced levels of education, high socioeconomic status, and personal wealth.

The situation for nurses is different. Gebbie, Wakefield, and Kerfoot (2000) found

that most nurses who were elected to office perceived themselves to be on a lower

intellectual plane than other elected officials and perceived their professional background

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as nurses to negatively impact their status, even though by virtue of their election, they

were equal to their colleagues in the elected body. This finding of a seeming lack of self

worth among elected nurses is troubling and must be studied further. If correct, this

perspective has serious implications for the assumption that nurses in political office are

the role models who can help the profession advance its health policy issues.

Two studies have focused on nurses in elected or appointed positions but neither

has studied the specific strategies and tactics used by these nurses. Feldman and

Lewenson (2000) interviewed 45 nurses who had been elected or appointed to political

office at the local, state, or federal level. Seventeen recurring themes were identified in

the qualitative analysis as the nurses described their motivation to get involved, the

barriers and opportunities, the skills they used and developed, and the lessons learned.

Gebbie, Wakefield, and Kerfoot (2000) also studied the career paths and resources

available to nurses active in health policy in a variety of roles. The purpose of the study

was to describe nurses’ effectiveness in the development of health policy in the United

States and to provide useful information for those interested in making nursing a more

vital participant in the policy arena. The findings were organized under three themes: (a)

What nurses bring to the policy arena, (b) the career paths of nurses’ active in policy, and

(c) how to strengthen the effectiveness of nurses’ involvement.

Two interesting perspectives were identified in this study by Gebbie et al. (2000)

that require further investigation. The first was the perception by nurses that they were on

a lesser intellectual plane than other professionals. In many settings, the variety of

educational backgrounds among nurses poses a barrier to nurses’ acceptance as experts.

Even in health care settings, colleagues from other disciplines do not understand the

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differences in educational programs for nurses, nor do they always recognize the depth

and breadth of knowledge of nurses with advanced degrees. It is foreseeable that these

challenges will also be present in the legislative and regulatory areas. Although it remains

to be determined, it seems reasonable that nurses who are accepted as health care experts

will be those who have higher levels of education, closer to that of their health policy

colleagues. This research will give nurses in policy positions the opportunity to discuss

their experience in these situations and evaluate the relationship between higher levels of

education and the respect accorded nurses in public policy-making.

The second troubling finding was that the nurses in policy positions did not

consistently prioritize nursing and health care issues in their work. This was a result of

the distance they kept between themselves and the profession based on past personal

experiences. Many participants in the study did not maintain their nursing licenses and

many were not generally known to be nurses by those they worked with or those in the

nursing community (Gebbie et al., 2000). This distancing of nurses from their special

interest power base and their own health care experiences suggests that nurses in policy

positions perceive their ties to professional nursing as a liability rather than an asset. This

study will provide further data to determine if these observations are still accurate and

pervasive for nurses in health policy positions.

Hall-Long (1995) studied the 1991-92 reauthorization process of the Nurse

Education Act (NEA) and identified the importance of having inside information to be an

effective policy advocate. Although this study did not identify or focus on any nurses in

policy-making roles, significant differences were found by Hall-Long between the

perceptions of government participants and the nurse lobbyists about which efforts in

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advocacy were most effective. Government participants scored the most frequent and

effective advocacy activities done by the Tri-Council as making financial contributions to

electoral campaigns and attempting to shape the implementation of the NEA. Members of

the Tri-Council scored these two activities among their lowest frequency political efforts.

The Tri-Council’s perception was that using grassroots lobbying, having influential

members contact members of Congress, and informing members of Congress about the

influence of NEA on their districts were the most effective political methods they used.

Government participants criticized members of the Tri-Council lobby for failing to speak

with a united voice for the nursing profession’s goals for this legislation. This insider

perspective about the effectiveness of different strategies is valuable intelligence for

nurses to have if they are going to have influence in the policy process. At this point,

there is no qualitative study to probe the effectiveness of nurses in legislative debate and

decisions. A careful study, based on interviews with nurses who have participated, will

give nurses an understanding of what strategies and tactics can be used to amplify nurses’

voices in public policy.

Nurses enter the policy world as experts in nursing but novices in politics. It

remains to be seen if, as they gain experience in the political system, they can build

credibility for themselves in this new role. This research will study how these nurses

work and if they are influential in professional nursing and health care issues.

Conclusions Based on the Literature Review

Nurses have a long history of social and political activism. Currently, their

participation as a special interest group for health care and nursing issues is targeted and

sophisticated as a result of well organized professional associations. Small numbers of

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nurses are working in positions in the legislative and administrative branches of

government but little is known about their effectiveness in achieving favorable policy

outcomes. Most of the studies done on nurses and their role in politics and policy

examine the experiences of nurses who have been active in health policy and lobbying as

members of a professional special interest group. The focus has been on the meaning of

their involvement, the motivation for becoming politically active, and describing factors

which facilitate or serve as barriers to involvement. The goal of this study is to determine

if nurses in the policy-making and administrative system are effective in influencing

issues important to health care or nursing and how these nurses go about their work.

There is a neglected area in between the Congressional staffing research and

previous nursing research: There are no studies that examine the strategies and tactics of

nurses, who work on the inside of the political or policy system or that assess the success

of these nurses in achieving their legislative or administrative goals. This study fills that

gap.

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CHAPTER THREE: DESIGN OF THE STUDY

This study was conducted using grounded theory methodology. The goal of this

study is to learn more about how nurses, who are in legislative or agency positions that

give them access to the policy process in, influence health policy.

The Research Questions

The research questions are (a) What processes, tactics, and strategies do nurses on

the inside, that is, in the legislative branch or in executive branch agencies, use in their

work; and (b) do these processes, tactics, and strategies influence how issues and

problems pertinent to nursing and health care appear on the policy agenda and move

through the political and policy-making process?

Grounded Theory

Barney Glaser and Anselm Strauss (1967) developed grounded theory

methodology in the 1960s. Strauss and Corbin (1990) have extended the methodology,

departing from the Glaser-Strauss original approach by expanding the focus of the classic

microsocial process of symbolic interactionism (basic social psychological process

[BSPP])) to include macrosocial or global issues (basic social structural process [BSSP])

and their effect on behavior.

Based on symbolic interactionism, the goal of grounded theory methodology is to

generate mid-range theory. Mid-range theory explains a particular aspect of the human

experience rather than broad classes of behavior making mid-range theory particularly

applicable to practice settings (Polit & Hungler, 1995). Grounded theory is a qualitative

research method where the researcher uses inductive reasoning to study a particular

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aspect of human behavior looking for the meaning of the behavior and describing and

explaining processes that are part of the behavior.

Symbolic Interactionism

Symbolic interactionism is a theory about human behavior and an approach to

inquiry about human conduct and group behavior (Annells, 1996). It emerged as a

specific theoretical perspective in the late 19th and early 20th centuries. Meltzer and Manis

(1967) outline seven propositions of symbolic interactionism: (a) The meaning of human

conduct is based on what meanings an individual assigns to particular stimuli and their

responses to that meaning, (b) the social sources of humanness are the interactions with

others that give rise to human nature, (c) society is a process consisting of people in

interaction, (d) the voluntaristic component in human conduct recognizes that an

individual selects and responds to situations based on their interpretations rather than by

reflex, (e) the dialectical conception of the mind is the internal conversation that one has

within oneself in an effort to integrate the impulsive “I” with the socially defined “Me”,

(f) the constructive emergent nature of human conduct is how individuals create their

own destiny through exercising their choices depending on the situation, and (g) the

necessity of sympathetic introspection requires that one must understand the meaning of

things to people in order to understand their behavior. Out of these propositions, Meltzer

& Manis (1967) derive the principles for understanding human behavior, the social

setting of behavior, and the relationship between behavior and the social setting.

The key methodological implication of symbolic interactionism is the importance

of getting at the meaning of an individual’s experience in order to understand and explain

his behavior (Meltzer & Manis, 1967). This objective is based on the premise that

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people’s behavior is a result of their interpretation of what is going on around them.

Therefore, observing their behavior alone will not allow the researcher to understand the

perspective that guides their behavior.

Sample

The goal in sampling with qualitative research is depth of information rather than

large numbers. When using qualitative research methods, the sample size is related to the

number of incidents that are sampled with the participants during the interviews rather

than the number of participants (Strauss & Corbin, 1990). Eleven nurses who had

experience in positions in the legislative or executive branches of the federal government

in the United States agreed to be interviewed for this study. The inclusion criteria for

participants in the study were (a) current or past experience in the legislature or an

executive branch agency of the federal government and (b) current or past licensure as a

Registered Nurse (RN) in any state. The first participants were contacted after being

recommended by colleagues in several different professional nursing associations. Using

a snowball technique, additional participants were suggested by the first few contacts.

These nurses recommended by the original participants were then contacted and agreed to

be interviewed for the study. No nurse who was contacted and met the inclusion criteria

for the study refused to be interviewed.

The researcher determined that the sample size was adequate when density and

saturation of the core categories during analysis had been achieved and additional

interviews did not add new information.

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Data Collection

Grounded theory methodology involves a specific process for collection and

analysis of narrative data developed by Glaser and Strauss (Strauss & Corbin, 1990). All

of the participants were interviewed in person. The participants were given the option of

being interviewed in their work setting, home, or in some other setting to minimize

disruption and facilitate sharing of their perspectives and interpretations with the

researcher. Nine participants chose to be interviewed in their office or adjacent

conference room and two participants requested that the interview take place in an

outdoor café. The researcher started with a grand tour question that focused the

participant on the phenomenon of concern, that is, the strategies and tactics used by

nurses to advance nursing and health care issues in the policy & political process. The

substance of the grand tour questions (Appendix A) was shared with the participants in

advance to give them an opportunity to gather their thoughts and reflect on their

experiences. Subsequent questions that were asked allowed the researcher to explore

specific concepts with each participant. In addition to more general questions, the

participants were asked to describe their experiences using specific issues or examples to

elicit information about different situations. This not only prompted recall of specific

examples but allowed some comparison between strategies that varied based on the

nature of the issue or content.

As the study continued, different questions elaborating on the participants’

specific experiences were asked in subsequent interviews. Although not all participants

were asked the same questions, the same concepts were explored. To achieve the goals of

grounded theory, the researcher tried to ask questions in a way that explored the

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participants’ experiences and not their theoretical knowledge. It was the experience and

interpretation of the individual that was being explored, not the individual’s knowledge

of the relevant literature. To differentiate between the two, the researcher was careful not

to use terminology that reflected the researcher’s own perceptions, orientation, and

theoretical perspective (Burns, 1989). The demographic data (Appendix B) that is

included in the study was collected at the conclusion of the interview so the participant

was focused the exploration of the concepts under study.

The researcher was the only person collecting this data. Collecting data while

participating in the constant comparative process -- coding and analysis -- allowed the

interviewer to achieve conceptual density and variation (Strauss & Corbin, 1990). With

the participants’ permission, the interviews were taped and then transcribed by a

professional transcriptionist.

As each participant used specific examples of legislation to illustrate the role

played and tactics or strategies used, the researcher sought and reviewed documentation

of the process in the Congressional Record, committee testimony, newspapers and

professional journals. The plan was to use this triangulation of data to compare,

corroborate, and clarify the participants’ perspectives for validity and reliability. This

proved to be of limited value however, because most of the tactics and strategies

described by the participants were used during activities that were not reflected in the

official accounts of the process in any published records.

Data Analysis

The researcher analyzed the data after each interview using a constant

comparative process (Strauss & Corbin, 1990). The labeling of concepts and

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development of categories is an ongoing process and directs the researcher to explore

additional concepts and areas of interest with subsequent interviews. The ability of the

researcher to detect subtleties of meaning is important to the grounded theory process.

This quality of theoretical sensitivity is the “ability of the researcher to recognize what is

important and give it meaning” (Strauss & Corbin, 1990, p.46). This skill is influenced by

both personal and professional experience with the phenomenon under study, but can also

be informed by knowledge of the relevant literature. Taking time to think about the

concepts being identified and the emerging processes allowed the researcher to increase

theoretical sensitivity and achieve analytical depth by interpreting and exploring the

nuances in meaning reflected in the data (Strauss & Corbin 1990).

The constant comparative analysis process proceeds as follows: (a) Initial open

coding leads to the development of categories and core categories, (b) theoretical

sampling is done to achieve theoretical saturation and conceptual density, (c) axial coding

makes connections between the categories and then, (d) selective coding systematically

relates the core category to all other categories (Strauss & Corbin, 1990). With this type

of data collection and analysis, participants are free to express their ideas and

perspectives without all being forced to respond to the same specific questions. The goal

is to have a detailed, richly descriptive, and complete picture from the interviews about

how nurses go about supporting and advancing health care-related legislation.

Theory that emerges from the findings results from raw data in narrative form

being transformed across levels of abstraction into theory by a process of inductive

reasoning and conceptualization. This process is aided by the researcher’s memos and

diagrams done throughout the research process. The memos detail the analytical process

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and diagrams provide visual representations of the categories and relationships as the data

is gathered and analyzed. The findings should have heuristic relevance or a sense of fit,

applicability, and relationship to what is known for those with personal and theoretical

knowledge, and professional experience in the practice area (Burns, 1989; Strauss &

Corbin, 1990).

A summary of the data analysis was sent to all of the participants by email. Four

of the emails were returned as undeliverable and two participants replied with thanks for

the information. No participants offered any specific feedback or suggestions for

changes.

Informed Consent and Confidentiality

Before contact was made with any potential participants, the research proposal

was approved by the Social and Behavioral Sciences Institutional Review Board

(SBSIRB) at the State University of New York at Buffalo. A copy of the SBSIRB

approval and renewal are on file in the Center of Nursing Research in the School of

Nursing at the State University of New York at Buffalo. When potential participants

were identified, they received a letter introducing the researcher and the research project

sent by email. In a follow-up phone call, the researcher answered questions and

determined the individual’s willingness to participate in the study. Each participant was

sent a copy of the informed consent by email attachment (Appendix C) detailing the goal

of the study, outlining the process, giving permission to tape the interview, reviewing

safeguards to protect the confidentiality of the participants, and providing contact

information for the researcher to review before the interview took place. Each participant

was asked to sign two copies of the informed consent at the opening of the interview.

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One copy was given to the participant for her records and one was kept by the researcher.

The original was kept in the researcher’s locked home file and a copy of each signed

informed consent for each participant is on file in the Center of Nursing Research at the

School of Nursing at the State University of New York at Buffalo, as required by the

School of Nursing.

Data from the interviews, taped interviews, and the transcripts were kept in a

locked file cabinet in the researcher’s home office. Electronic copies of the transcribed

interviews were on the researcher’s home computer filed numerically without identifying

information in the file title. All information pertinent to the research was on the personal

computer of the researcher in her home. Participants were not identified by name,

specific worksite, or party affiliation. Because there are few nurses in the positions of

interest, there is a possibility that the identity of a participant may be deduced from

examples of the narrative data used to illustrate the findings in the research report. Every

effort was made by the researcher to minimize this possibility by careful selection of

quotes used and deletion of any identifying information from the narrative.

Issues of Reliability, Validity, and Rigor

The review of qualitative research to establish reliability and validity utilizes

different techniques than those used in the review of quantitative work. Burns (1989)

outlines detailed criteria for evaluation and critique of qualitative research using

appropriate standards pertinent to the research methodology.

The Burns (1989) standards are (a) descriptive vividness giving the reader process

and contextual detail, (b) methodological congruence which includes documentation,

procedures, ethics, and auditability, (c) analytic preciseness which reflects the fit between

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the data and the theoretical findings, (d) theoretical connectedness reflecting logical and

consistent development of theory and, (e) heuristic relevance or intuitive meaning to

practice and existing knowledge.

The researcher followed the standards for grounded theory analysis of narrative

data (Glaser & Strauss, 1967; Strauss & Corbin, 1990). Adequacy of the audit trail,

heuristic relevance, descriptive vividness, analytic preciseness, and theoretical

connectedness was validated by review of random samples of the data and analysis by

one colleague with a doctorate familiar with grounded theory methodology and by a

nursing colleague with extensive experience in political activity. One member of the

researcher’s dissertation committee with an expertise in qualitative research also analyzed

two of the interview transcripts to verify validity and reliability.

The rigor of a study or its degree of excellence is determined by different criteria

in qualitative and quantitative studies. In qualitative studies, rigor is increased by

measures that increase the probability that the data on which the findings are based is

relevant and accurate. Burns (1989) proposes specific standards for rigor in

documentation, procedural rigor, and ethical rigor. Rigor in documentation requires that

all elements of the study be presented in detail for the reader. Excerpts from the narrative

data were selected to illustrate the core concepts that emerge from the data as the findings

are discussed. Rigor in procedures must ensure that the researcher has taken adequate

steps to avoid bias on the part of the researcher and participant and that adequate training,

time, and care is taken to work effectively with the participants of the research. The

researcher was careful to focus on the perspective of the participants and not impose

concepts, frameworks, or terminology from the literature.

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Triangulation is an important strategy to promote procedural rigor that involves

using more than one method to obtain data so that findings are confirmed by more than

one source. Review of references in the Congressional Record, committee hearings, and

newspaper accounts of any legislation discussed was planned but had limited relevance to

the process. The involvement of the participants was at a formative level of policy-

making before the issues were mentioned in any print media. There was however

validation among some of the participants’ accounts when they discussed the same issues

and legislative initiatives that nurses had been involved in. This added to the rigor of the

study by providing validation of the perceptions of the individuals interviewed.

Ethical rigor requires that the researcher follow accepted guidelines for

protection of the participants’ rights and confidentiality. Consent was obtained from each

participant before the data gathering process began. The study was approved by the

SBSIRB at the State University of New York at Buffalo and the informed consent form

(Appendix C) was completed by participants before any data was collected.

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CHAPTER FOUR: ANALYSIS OF DATA

The author traveled to Washington, D.C. to conduct personal interviews with the

11 participants in the study. All nurses contacted by the author who met the research

criteria agreed to be included in the study. The inclusion criteria for the participants did

not stipulate any time limits for the dates of their work in government. The participants

included six nurses who worked in the legislative branch and five nurses who worked in

the executive branch of the government at the time of the interview or at some time in the

past. Three of the participants had experience in both the legislative and executive

branches of government. All participants interviewed remain actively involved in health

policy in a variety of jobs in the greater Washington, D.C. area.

Nine of the participants were interviewed in their offices or conference rooms

within their place of work and two suggested that the interview take place in a public

outdoor coffee shop. All interviews were audio-taped using a small portable tape

recorder. At the beginning of each interview, the researcher obtained the participant’s

signature on the informed consent form. All participants were sent the consent form in

advance by email to review when the appointments were made. Seven to ten days before

the interview and again two to three days before the interview, emails were sent to

remind the participants of the appointments. The demographic forms were completed by

the participants at the conclusion of the interview. The participants were given the

researcher’s cell phone number to contact her in the Washington area in case they needed

to change the appointment. One participant contacted the researcher to reschedule the

interview for the following day.

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Characteristics of the Participants

The participants in the study had an average of 18.5 years in clinical practice with

a range of 3-32 years (Table 1). Two participants did not provide their number of years in

practice on the demographic form. The practice sites and clinical experiences of the

participants included a wide variety of clinical specialty areas, inpatient acute care, public

health, community health, research, and military service. Their positions in practice

included staff nurse, clinical leadership, administration, and advanced practice roles. Nine

(81%) of the participants entered nursing from baccalaureate (BS) programs, one

graduated initially from an associate degree (AD) program, and one from a diploma

program. Their entry level nursing education spanned the years from the 1960s to the

1990s. Four participants (36%) attained a BS as their highest degree in nursing, four

participants (36%) attained a master’s degree (MS) as their highest degree in nursing, and

three participants (27%) had doctorates (PhD) in nursing. Six participants (54%) had

advanced degrees in other fields including law, public health, public policy, and health

services research. Ten of the nurses (90%) maintained current nursing license

registration. Eight of the nurses in the study (73%) belonged to one or more professional

nursing organizations while in their government role and nine nurses (82%) belonged to

one or more professional nursing organizations before their government work. The

American Nurses Association (ANA) was mentioned most frequently as the professional

association for membership in both categories.

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Throughout the discussion of the findings, the core category will be in capital

letters and the six categories or strategies will be italicized. The political context variables

will be in bold letters.

The Core Category

GIVING VOICE (Diagram 1) emerged from the narratives of the nurses in this

study as the core category. This core category represents the strategies used by nurses

who enter government to influence health care policy.

Table 1: Demographic Characteristics of the Nurses (N=11)

Years in clinical practice: 18.5 yr (mean) 3-32 yr (range) Initial Nursing Education: Diploma 1 Associate Degree 1 Baccalaureate Degree 9 (81%) Highest Degree in Nursing: Baccalaureate Degree 4 (36%) Master’s Degree 4 (36%) PhD 3 (27%) Highest Degree in Other Disciplines: * 6 (54%) *Law, Public Health Public Policy, Health Services Research

Current Nursing Registration 10 (90%) Professional Association Member While in Government 8 (72%) While in Practice 9 (82%)

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the political system. Many of the skills the nurses used in their professional roles in

healthcare were useful in their transition to their positions inside of government and

helped them adapt to the new environment. The participants in the study gained access to

the different jobs in a variety of ways. Some nurses applied to fellowship programs,

others applied directly for positions, and others in the uniformed services took advantage

of different opportunities as they worked their way up the ranks. A detailed discussion of

the skills, motivations, and access to government of the nurses in the study is in

Appendix D.

The model GIVING VOICE conceptualizes the different strategies used by nurses

in the study as steps: learning the culture, selective self-disclosure, translating, creating

access, invoking others, and careful truth. These strategies emerged as the nurses

described their experiences. These strategies build upon each other over time as the

nurses gained additional skills, experience in politics, and earned the trust of those

individuals who were in positions of influence and power. The variables of time, skills,

and trust indicated on the upper left of the model grow as the nurses’ time in government

lengthens.

All of the strategies used by the nurses in the model GIVING VOICE take place

in the underlying socio-political context of the political and health care systems that these

nurses experienced. This socio-political context is indicated at the bottom of the model as

the very foundation on which all of the experiences of the nurses in government rest.

Similar barriers to the effectiveness of advocacy by nurses outside of the political system

in health care exist inside the government. Nurses do not have power commensurate with

their numbers in the health care system to fundamentally influence their practice or the

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understand how the federal government works and the roles and expectations of various

“inside players”. They compared this experience to learning to live in a new culture.

There are specific rules and behaviors, mostly unwritten, that determine what can be done

by different players both between and within the legislative and administrative branches

of the government. The ability of individuals to discern these boundaries or rules has a

direct influence on the success of their transition and functioning in this new culture

inside the government. Table 2 summarizes the different lessons that the nurses had to

learn during their initial experience in government.

Table 2: Strategy One: Learning the Culture

Learning the Boundaries and Rules of Government Culture

Within the Legislature or Agency

• Learn the preferences and interests of the legislator • Negotiate when and how to have direct contact with the legislator • Learn the boundaries for individual initiative within one’s role • Work effectively within the office or committee culture • Keep pace with shifting priorities and changing political context • Learn expectations for writing memos and briefings

Between the Branches of Government • Negotiate the boundaries between the executive branch and the

legislative branch • Initiate and respond to requests for information through appropriate

channels With Special Interests Outside the Government

• Learn the importance and impact of constituent satisfaction and re-election concerns • Determine political impact of supporting different issues

In All Settings

• Recognize and negotiate the web of political constraints • Network and build relationships

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The process of learning the culture of government is complex because there are

many overlapping circles of contact and relationships that have boundaries that must be

negotiated. As one nurse in the study stated when discussing her role, “It is 100 percent

about relationships” (#2 p.7). These overlapping circles of contact include (a)

relationships within and between individuals in offices and committees, (b) relationships

between branches of government, and (c) relationships with those outside of government.

From the examples of situations given by the nurses in the study, the communication,

conflict negotiation, and multi-tasking skills they used in their nursing practice

contributed significantly to their success in learning the culture. These characteristics

prompted many of the nurses to describe themselves as “a quick study”. They were able

to learn quickly and were nimble in reacting to new situations.

Learning the Culture: Boundaries Within and Between Offices or Committees

The first lesson the nurses faced was learning the informal rules that govern the

relationships of the nurse to the legislator or administrator, other staff in the office, and

the process of working with staff in both legislative and agency offices. The term

principal will be used to refer to both legislators and administrators. The specific tasks

included: (a) How to learn the preferences and interests of the principal, (b) learning how

and when the staff member has direct contact with or access to the principal, (c) learning

how much individual initiative the staff member can take on issues within the principal’s

priority areas, (d) learning the expectations for written memos and briefs on assigned

topics, (e) learning the particular culture of the office, committee, or agency, and (f)

adjusting to the timing and phases of the policy-making process.

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As new personal or committee staff in the legislative branch of the government,

the study participants quickly learned that the boundaries for their time and attention

were determined by the priorities and preferences of the legislator they worked for. There

was little orientation to these unwritten rules. The nurses had to quickly learn these rules

to function credibly in their roles. They learned as much as they could about their

legislators by listening at staff meetings and briefings, reading about the member’s past

and present legislative priorities, and immersing themselves in the policy and political

process. As one nurse describes:

Reading … the things he has written in the past, speeches he’s given, knowing

what bills he’s put in, talking to his chief of staff who’s been with him for 30

years…. He [chief of staff] talks to me daily about things that are the Senator’s

priorities…. just listening, really listening to meetings that the chief of staff leads

with people who come in …so just listening to the conversations from people that

come in, things he’s supported. It’s just like in your personal life, wherever you

put your money or your time is your priorities, you can look at where the

Senator’s earmarks are and know what his priorities are. (#2 p. 24)

Another nurse discusses the importance of knowing her legislator’s priorities:

There are probably two main criteria. One was my antenna went up whenever I

knew it was something very close to the Senator’s heart or [Senator’s home

state’s] heart. That was probably the first. And [the second], if there were health

care issues that somebody brought to me as a very compelling thing that no one

was taking care of, some sort of nurse in me rose up and said, you know, I can get

this at that level and make it relevant to [the legislator’s home state]. But I think

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it’s absolutely essential that you understand who you’re working for when you go

there and what your job is. Even if it’s a committee job, it sounds really simple

but you really need to do your homework and pay attention. Every staff has a

meeting once a week…and during the staff meeting, everybody goes around and

everybody talks about what they’re all working on. There’s no way you can come

out of those meetings, if you’re paying attention, without knowing what the

agenda is for that office and what that [legislator] cares about. (#9 p. 43)

How much direct access the nurses in the study had to their legislator varied based

on the office hierarchy and how formal the culture in that setting was. Some nurses had

access to their legislators on a daily basis. Other nurses were in offices where the chief of

staff served as the gatekeeper for the legislator. Some nurses communicated largely

through memos that were included in the legislator’s briefcase as his homework reading

to prepare for the next day. Those who worked with legislators higher up the leadership

hierarchy had less opportunity for contact unless they were experienced enough to be in

the inner circle. Legislators in leadership positions were sometimes in different office

locations than staff. Regardless how much direct contact staff members had with their

legislator, nurses emphasized the importance of maintaining the leader’s trust in those

interactions. As one said:

When working with a member of Congress, there has to be real trust in the sense,

if you don’t have an answer, don’t tell them that you do. Because you can never,

ever, leave your boss out there with bad information because it affects their

reputation with their constituents. It affects their reputation with other members.

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You have to be absolutely honest in your assessments. Don’t hide the bad news

because eventually it comes out and you could be gone. (#1 p. 11)

The nurses in the study had some opportunities to take individual initiative on

issues they were interested in. The overarching rule however, was whatever issue they

worked on could not contradict the legislator’s agenda. As they staffed meetings with

groups coming to their legislator’s office, the nurses in the study differed on the extent to

which they might openly disagree with people on controversial issues. This nurse, who

was fairly new in her job, states:

It’s not my job to get into fights with these people or to try and rebut them and

change their opinions. My job – they were all constituents from [the legislator’s

home state]. My job, as I see it, is to listen to their concerns and communicate

them to the proper chain authority here and I did. (#5 p. 22)

The next nurse, who had more experience, comments on a more proactive role of

staff in influencing the decision-making process while representing a legislator in

committee negotiations:

You have to recognize that you do influence it [the political agenda] to a degree

because there are things that you could pick up on that you don’t, because you

don’t want to. Everybody knows three-quarters of the stuff that’s done in

Congress is negotiated by the staff. So-- what do they fight on? What do they not

fight on? It’s an amazingly complex but very interesting combination of technical

constraints, office constraints, and political constraints. There are certain things

that Republicans can’t do and there are certain things that Democrats can’t

do….and then, there are friendships and relationships on The Hill….and that

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sets a lot of what’s fixed before you even get in a room, what’s really not on the

table to be negotiated. (#11 p. 32)

One of the nurses in the study described three situations where she learned about

the unique culture of politics in her legislative office by “stepping in holes”. In the first

situation, the nurse was sent to a meeting of staff from a variety of offices to represent her

legislator. After carefully recording and distributing minutes to all involved, she quickly

learned from her chief of staff that you never want to put anything in writing when

discussing issues with others outside of your office. Her concern for efficiency--a valued

skill in practice-- lead her to take actions that could have put her legislator in the position

of having to potentially make denials. She was not enough of an insider to officially

speak for her legislator in this circumstance or even know this unwritten rule.

In the second situation, the nurse realized by the changes in her assignments and

responsibilities that she was unintentionally breaching norms in this setting by her travel

schedule and absences at (what had been explained as) optional events. As she explains:

It’s like being in a foreign country…an extremely different culture. And while

we’re talking about ways in which I stepped in holes, I realized recently that I had

done something to incur some disfavor because … I was being asked less often to

be involved in some critical meetings and I was getting less what I would call

really interesting assignments…And what I have concluded from some off the

cuff kind of little remarks-- nobody’s been rude, nobody’s been direct-- it’s all

indirect, and I’m inferring all of these [but] I think I’m pretty accurate. This

culture is one where people thrive on thinking that they are pretty important.

There’s a lot of sense of self importance and some of it is because they’re so

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damn young and have no life experience. I come from an ER [emergency room]

environment and nothing is that important unless somebody’s getting ready to

die….I have no problem leaving on time because nothing is earth shattering. I

mean if there’s a deadline, I’ll get it done… I’ve been gone quite a bit and what I

realized is that I wasn’t playing along… and I was sending a really bad message

to them in their culture….In this office there’s [a regular event]…well it had been

presented to me as, you might want to come or not. I am there now. I am there

and I make sure that my health staff people see me because I realized kind of late

I was sending the message-- it’s just not important and that I don’t care…And I

didn’t mean to. (#5 p. 35)

The third situation occurred at a meeting with staff from several different

legislative offices. Some staff members thought that their legislator’s position was being

discounted in negotiations on a bill. Rather than directly confronting the issue with their

colleagues, they used an indirect way to make their point and take a more prominent

position in the negotiations:

We’re sitting in these meetings, we’re meeting morning and night, morning and

night…. And then suddenly one Senator’s people aren’t coming. And I’m

looking, so why aren’t they here. Oh, they’re just not here. Two days later they

show up and they’ve got their own bill written. They’ve gone to leg [legislative]

counsel in the meantime and they were pissed off. They didn’t like how fast it

was going. They didn’t think their boss was being included correctly and they

just opted out and went and wrote their own bill. So now there are two bills. Now

they had everybody’s attention and they forced everybody to kind of stop and the

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two bills had to be merged…. There should be some cooperation. This is highly

inefficient.… Efficiency is only something they want health care to be…. I said

something about, will leg counsel do this? Doesn’t leg counsel say, “I’m sorry,

we’ve already written one bill, go work it out? No, I’m not doing this. This is

ridiculous”. And they said the legislative counsel has to do what we ask them to

do and they’re bound by privacy and confidentiality that they can’t even tell us

that they’re working on this one for them….So sometimes I just have to take it on

faith that this process seems to have worked for 200 and some years. (#5 p. 40)

Another challenge the nurses faced in government was having the agility to get up

to speed quickly on new issues, then shift focus quickly based on new circumstances and

leave projects behind that were not moving. This was particularly demanding on the

legislative side where priorities tended to change rapidly in response to the political

landscape. For some of the nurses, their investment in certain issues made this need to

quickly change priorities a challenge:

For some things, …it’s not going to happen right now …[but it] might become the

basis for something in the future, so you keep it . . .sort of tucked away and, you

keep it nursed in a drawer, but you keep going on what’s going to happen because

you have to follow the agenda. And the agenda moves so quickly that, I’m not

kidding, you really do need to have that sort of ability to move from one

participant to the other participant without getting too mired in--I really wanted to

do this, this one I really care about! And it wasn’t that you don’t care, it’s that

you are part of the process and you’re almost a tool within it [the process], this

one’s not going to happen, we’re going to have to do this [other] one. (#11 p.52)

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The same nurse comments on the rapidly changing pace:

Most of what you work on doesn’t get anywhere. I mean, it’s just really true…

you have to get comfortable with that. A lot of stuff is start and stop. Timing is

everything. Some things certainly line up and it goes through the chute…. a lot of

what you have to do here or you go insane … [is] to be able to say, okay, I did all

this work and it’s not going to happen now, so you go to where something is

going to happen. So you have to be able to drop it and that’s hard for people that

have worked for a long time on something and have a particular issue …. But you

have to be able to say, it didn’t work and you don’t keep pounding your head on it

or keep resurrecting it. (#11 p.51)

On the administrative side of the government, staff members must be loyal to the

executive agenda presented by the president through his budget and programs. Serious

conflict or disagreement with the executive branch priorities that they need to work on

was a reason for an individual to leave his or her position if the individual could not work

effectively within these boundaries. As one nurse in an agency stated:

I have a personal agenda but my personal agenda has to be consistent with the

framework in which I’m allowed to operate….I work for the administration. I

espouse the administrations views. Congressional views may be very different

from the administration – so when Congress and the administration work together,

it’s within the parameters that are set. It’s not just, let me call up Senator [name]

office and say I really think we ought to do this. …We don’t do that. Senator

[name] is Congressional. I’m part of the administration. So most of the time the

way it works is, Congressional staff will come to us and say, we’re doing this,

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that, and the other thing. Can you give us information on this particular program?

So we respond to Congressional inquiries. Or when the administration says, you

know so-and-so is working on something, we would like to work together on it,

then we work together on it…. There are strict boundaries because the

administration puts forth its view on what the budget should be and Congress puts

forth its view…the president presents his State of the Union speech in January or

February, along with its budget, and that’s the administration’s point of view.

(#8 p. 34)

The same nurse continues:

[How do you handle an experience where the administrative line or budget or the

parameters that you’re given that you have to work within pose a personal conflict

for you?] It depends on how great that personal conflict is. But if I can not handle

that, then I cannot work. And it’s no different than anybody else. You fight for

what you believe. You fight for what is right...you’re fighting for what you

believe is consistently what the administration wants and then you have to just

accept the decision. That’s life and if you cannot, then it’s time for you to

leave…When the administration cut the budget, I was hoping that the nursing

community would rally, although my position was that this was the

administration’s position. And that’s hard but that’s the way it is and…if you

cannot do that, then you have to get out. (#8 p. 34)

Participants who were in positions of power or leadership within agencies had

some opportunity to pursue individual initiatives by initiating new programs or creating

changes through regulatory channels. These were constrained mostly by budget

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limitations if the individual programs of interest were not part of the agency’s fiscal

priorities (as determined by the legislative appropriations).

Learning the Culture: Boundaries between Branches of Government

Unwritten rules also have a significant impact on the flow of information between

the two branches of government. All of the participants interviewed discussed these

important ground rules that they learned by experience. Individuals who work in

executive branch agencies typically do not have the freedom to contact elected members

or members of their staff to volunteer information about programs or policies or to lobby

for changes they have determined would be beneficial. Although each agency has a

legislative liaison to facilitate communication with the legislative branch, the usual

practice is for those who work in administrative agencies to wait for a specific request for

information by those in the legislative branch before they share information. Based on

the experience of the nurses in this study, agency staff going directly to members of the

legislature is a breach of this protocol and could be a risk for the individual in the

executive branch. This protocol is discussed by one of the participants, “It’s difficult …

being in the executive branch because you really can’t lobby. You can’t come up here

and say, we’re having a problem with this. You really are not supposed to do that” (#2

p.22).

From another nurse in the executive branch:

One of the comments that was [made to] me the other day is, why don’t you go up

and brief the Senate offices on what you did with that $10 million? You’d get

more. Well, we can’t go unless we’re asked. If they request a briefing, then we

can go. But we can’t just say, can we come up and tell you what we did with your

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money? …That’s the way it works…you can’t lobby The Hill…we can educate

The Hill but only on their request. So could I go around behind the scenes and

call [name], the head of the [specific] Committee, and say, …how about asking

me to come up and let me tell you about it? I could probably do that. The first

time I got caught, we’d be done.…it’s inappropriate….You know, anybody that

crosses that line, it’s because they’re not paying attention. It’s very clear [they

are] separate role[s]. (#9 p. 84)

This need for an invitation to provide feedback between the branches of

government may limit the political influence that agencies have on policy makers but, the

one-sided control of information sharing appears to be inefficient at best, insulating

policy makers from relevant information.

Nurses who had experience inside the administrative branch before moving to the

legislative side were more aware than others about this dynamic and more savvy about

asking the right questions of agency staff to give them the opportunity to tell them things

they needed to know. One nurse describes an experience where her previous work in an

agency allowed her to save time by targeting an appropriate contact for her legislator in

order to get an answer to a specific problem:

The Senator will say, what’s going on with such and such? I think we need to

ask that question. I’m like, I don’t think they’re going to want to answer it but

okay….The Senator wants to send a letter to someone…we’re going to send it to

the secretary of the [military branch]. And I’ll be, we can handle it at a lower

level than that. How about if we send the letter here because it’s ultimately going

to get down there anyway? ...Maybe we should try there first. So they do ask for

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my opinion… [because] the Senator doesn’t have that personal experience with

the executive branch. (#2 p. 22)

Learning the Culture: Boundaries with Those Outside of Government

Nurses in the study who worked as legislative staffers often had the opportunity to

work with individuals and groups outside of government in meetings with constituents

and members of special interest groups. As staff, the nurses quickly learned that the needs

and interests of the member’s constituents are always a priority. Constituent needs are

closely tied to voter satisfaction, and reelection is never far from the day-to-day concerns

for all legislators. These constituent priorities were revealed during the significant

amount of time the nurses in the study spent meeting with constituents and members of

special interest groups in their staff positions.

In addition to knowing what issues the legislator supports, the staff members need

to have a certain amount of political savvy to understand the political ramifications of any

issue they bring to the legislator’s attention for consideration. The staff serve as

gatekeepers who make decisions about prioritizing what issues they pass on to their boss

Anything that will have negative political consequences is unlikely to be put on that

legislator’s agenda. One nurse described her observations about this process:

There’s a spin to it that sometimes people coming to The Hill [to work] don’t see

that [I]… from my previous life knew. It’s got to be spun on a re-election issue. I

mean [the] bottom line is, he’s going to have to stay there and run for re-election

and they have to generate money. So you don’t ever want to push an issue

forward to them that’s going to jeopardize their position, be contrary to how they

stood before, or in some way get their neck out there too far….I’d seen some of

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colleagues who preceded them to be selective about with whom they shared their

professional back ground. Other participants deduced this from their own experiences.

This warning was given to help nurses new in government understand that on the inside

there was little recognition or respect for nurses’ knowledge and expertise. Nurses were

viewed by many as having a narrow and technical role in health care and nurses were not

relevant to issues other than those with specific occupational impact.

Some of the nurses in the study, who were warned about the disadvantages of

disclosure of their professional identity, refused to accept this advice because they felt it

was demeaning. These nurses had their professional nursing credentials on their business

cards and made it clear to those they met with that they were nurses regardless of who the

audience was. These participants tended to be working in legislative or administrative

positions on fellowships where they were selected or hired specifically because of their

professional background. Their nursing credentials were part of their expertise and an

integral part of their position. Others, who used no nursing credentials on their business

cards (but often listed non-nursing degrees), tended to be in positions where they

competed against individuals from a variety of backgrounds for fulltime, long-term jobs.

Some of the participants in both categories revealed their nursing credentials because

they also had doctorates or higher degrees in other fields that sufficiently established to

their audience that they were not “just a nurse”. For most participants, the titles on their

cards reflected their role in the specific setting and not their professional credentials. This

allowed them to function in their policy role and left the self-disclosure process to their

own judgment after strategically analyzing each situation.

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As the participants related their experiences, specific conditions emerged for

choosing whether or not to reveal one’s status as a nurse. The decision about whether or

not to disclose one’s professional nursing credentials was strategically determined based

on the issues under discussion, the audience, and the perceived advantages and

disadvantages of disclosure in each situation. When participants chose to disclose their

credentials as a nurse, they were then free to directly share their knowledge and expertise

from clinical practice with others. In most situations, if their credentials were not relevant

to the audience or issues under discussion or there was no positive strategic advantage to

sharing their professional background, the nurse would not disclose them.

The conditions that promoted disclosure of the nurses’ professional background

were: (a) The nurses’ knowledge and clinical experience were relevant to the situation,

(b) revealing their professional credentials would not lead to unfavorable status or power

differentials with the audience, and (c) the nurse’s status or credibility would be

enhanced. An example of this occurred when nurses met with families, constituents of

their legislator, who needed help with barriers in the system such as dealing with a

specific health problem or with negotiating regulatory barriers within the health care

system. In these situations, many of the participants believed that their experience as

nurses allowed families to connect with them in positive ways and allowed them to be

empathetic and supportive as they worked with the families to advocate for them. The

disclosure of their professional background increased their effectiveness in their role. One

nurse relates her experience:

It helps immediately break down that huge barrier with a lot of them …especially

the constituents who come in with health care issues and want to talk about their

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disease. Whether it’s [chronic] disease or MS [multiple sclerosis] or whatever, if

I tell them immediately, thanks for coming, this is who I am and I’m a nurse, it’s

a much more beneficial meeting because then they don’t feel like they have to

explain a lot of things to me and they feel like I’m an ally already. (#2 p. 11)

Another condition that supported disclosure was when nurses in the study

determined that sharing their professional background would not have any negative

impact and it might save time when dealing with members of special interest groups. This

occurred when meeting with members of health professions other than physicians or with

those in the business side of health care related to pharmaceuticals or medical products.

In these cases, the participants did not want to take time having terminology and basic

issues related to disease states, the health care system, reimbursement, and patient

dilemmas explained to them. Sometimes this disclosure occurred at the beginning of the

encounter. This nurse explains her rationale, “I almost always tell them up front…. So for

the health care ones I want them to know immediately I’m a nurse because I don’t want

them to waste time telling me things that I already know” (#2 p. 11).

At other times, the nurses assessed the need for and potential impact of revealing

their professional background during the encounter. If there were advantages, they would

disclose at some later point during the meeting. In these situations, the participants gained

credibility in their role as they met with groups who benefited from their knowledge

about the health care system.

One nurse cautioned that her professional background proved to be an unexpected

disadvantage with colleagues in professional nurses associations who met with her

knowing she was a nurse. Her nursing colleagues assumed she knew all the ins and outs

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of specific issues the group was lobbying for and did not provide her with the information

she needed to be an effective advocate inside the system. Other nursing groups counted

on her support without even contacting her directly. She resented this approach that

required her to do the footwork herself and take all the initiative if she was going to be

adequately prepared to support the specific nursing issues. The nurse relates her

experience:

The other issue is some organizations thought-- we don’t have to be in touch with

your office because there’s a nurse there and so you would take care of it. One of

the Deans of my Alma Mater, she just said to me,…I know you’re going to take

care of these issues and ….when I come to town, I’m going to meet with other

individuals that I have to work on persuading more and I know you will [take care

of these] in your office….Although she was available if I had any questions on

different things…the thing about it is…. that the people that are on the ground

working these issues, they have more of the knowledge base and they need to

educate us on this, on both sides of the issue. So you just don’t sit there in your

ivory tower thinking I have all the knowledge because, I don’t. (#3 p. 22)

These excerpts reveal that the participants accepted that others from outside the

profession could make common assumptions about nurses so that they could move more

quickly to the business at hand. However, when fellow colleagues were involved, they

appreciated the being educated about the nuances of the issues to enhance their

effectiveness by having access to the full resources of their nursing colleagues.

There are also specific conditions that support nondisclosure of professional

credentials by the nurses in the study. The conditions that promoted nondisclosure were:

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(a) The nurses knowledge and clinical experience were not relevant to the situation, (b)

revealing their professional credentials would have an unfavorable impact on the status or

power differentials with those in the audience, (c) the nurse’s status or credibility would

be subject to prejudice or bias, and (d) the people they were meeting with would filter

their message or pitch it differently to them because of their professional background. For

some of the nurses, knowing that the message was not being slanted to a specific

audience allowed them to listen more objectively to people who were lobbying. One

nurse describes her approach:

Usually I wait [to reveal that I am a nurse] because I just want them to tell me

what they’re going to tell me and not package the message for the audience. I

know that’s what we do; we package the message for the audience….I want to

hear the way they’re presenting it to everybody else first. ….If they start kind of

trying to explain [health-related issues], I will do that [tell them I am a nurse], to

save them [time]. (#10 p.14)

Most of the nurses in the study agreed that when meeting with physicians on any

issue they did not disclose that they were nurses. This was true whether nurses in

legislative staff positions met with physician special interest groups, worked with

physicians on committee staff, or worked on projects in an administrative agency. A few

of the participants in the study described the reactions of disbelief that occurred when

physician colleagues, who had assumed they were physicians because of their knowledge

and the quality of their work, found out they were nurses. One nurse relates her

experience:

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And even today, people will always make the assumption that I’m a physician and

not a nurse….They call – Doctor [name] and assume I’m a physician. And I’m

not a doctor. I’m a [rank in uniformed services]….but they just make the

assumption. And when I tell them I’m a nurse, they are shocked…They just –

their faces, the eyebrows go up and the look of surprise on their face and then it’s

– you’re a nurse?.... They [the people in her agency] changed my title. They do

not have nurse in my title here because they are concerned… I will not get the

respect deserved having nurse in my title. Isn’t that interesting?... On the one

hand, I have things to get done and it does allow me to get things done easier and

then I can educate people along the way without hopping over the barrier first. I

can cross it when I come to it. (#6 p. 28)

The nurses in the study believed that in cases like this, their working relationship was not

jeopardized because they had already proven themselves but, it did reinforce their fear of

losing status and opportunities for input if they revealed themselves as nurses at the

outset of a project or collaborative working relationship.

One nurse who came from academia stated that this reaction by physicians was

reminiscent of the same lack of respect she experienced from members of the business

school at her home university. They treated the faculty and students in the school of

nursing as less prestigious and less worthy of their attention or collaboration. This loss of

social status and prestige relative to other professionals in academia is the same process

that occurs with nurses in health care and politics discussed in the socio-political context

of visible and invisible presence.

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The underlying rationale supporting this strategy of nondisclosure is related to

the lack of status, respect, and knowledge of the profession by others. Some of the

participants admitted that they approached meetings with physicians defensively because

of their experiences that being identified as a Registered Nurse reduced them to a

technical role in the eyes of physicians. One participant mentioned her distress at a public

relations campaign that was currently in the media that stressed the “caring” message.

She believed that the focus of this campaign exacerbated the problem with other

professionals and the public not recognizing or valuing the cognitive and intellectual

aspects of nursing, only the softer, more emotional side.

As part of the strategy of selective self-disclosure, nurses with doctoral degrees

would sometimes use the title “doctor” during introductions when meeting with

physicians, academics, or scientists. The nurses perceived that it gave them greater

respect in the group. Even though the individuals they met with might have no idea what

their specific degree was or in what field, the participants in the study who did this

believed that it provided an even playing field for them to be listened to more objectively.

An example of this follows:

I have to admit and I confess, I used my doctorate and I became Dr. [name]. And

it was often times when I was dealing with the deans at medical schools because I

didn’t want to have to go through the – another stupid, young kid on The Hill kind

of stuff when talking about how you calculate graduate medical education funding

and whether or not I could actually compute the formula for doing that.….In front

of a medical school dean, I wasn’t going to use my nursing credential. That was

not going to be – what I was using was my doctorate as a health services

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researcher which gave them a quantitative notion rather than a subservient in the

hierarchy notion. [So it would have been a negative for the doctors you met with

to know your nursing background?] Oh, absolutely….You have to be strategic

about it. (#11 p. 39)

Table 3 summarizes the decisions and rationales discussed above about nurses’

selective self-disclosure based on the specific audiences they are dealing with.

Table 3: Strategy Two-Selective Self-Disclosure of Professional Background

Audience Decision to Disclose

Approach Advantages Disadvantages

Members of the public, constituents

Yes-up front or during visit if relevant to topic of discussion

Direct sharing of knowledge, clinical experience, support, & empathy

-Positive view by public trusted & caring -Seen as ally

-May assume nurses have less knowledge

technical role but not systems knowledge

Other staff in same office, agency

Yes-background usually known by others when hired

Direct sharing of knowledge & clinical experience

-Used as resource for health care issues -given difficult people on calls to handle -Lots of respect -Little threat

-May have limited view of nursing knowledge & competence -May not assign to work on nursing issues conflict of interest

Staff in other committees, agencies: Young, inexperienced staff, no previous working relationship

No-do not share nursing credentials even if topics relevant

Indirect sharing of knowledge & clinical experience through posing questions

-Listened to with greater credibility -Accepted as colleague -Avoid the perception of heavy-handed or attacking

-Indirect approach self–effacing & less professional -Perpetuates lack of status & continues invisible

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Seasoned staff with previous working relationship

Yes- if relevant and relationship established

Direct sharing of knowledge & clinical experience

-Less concern with titles

Nurse respected for history of contribution -Promotes positive image

presence -Others not educated on nursing role -Can be defensive unless mutual respect for their policy knowledge -Takes time to develop

Audience Decision to Disclose

Approach Advantages Disadvantages

Physicians No-nursing credentials never disclosed even if issues relevant May disclose other professional degrees or doctoral credentials

Indirect sharing of knowledge & clinical experience

-Maintain status & credibility -Avoid prejudice -With PhD perception of collegiality

-No challenge to technical, hierarchical perceptions -No education about nursing roles -Unable to advocate for APNs

Other Special interest groups

No-not up front May disclose during visit if relevant and based on impact of status differential

Initially no or indirect sharing of knowledge & clinical experience Direct sharing of knowledge & clinical experience

-Get unfiltered version of their “pitch” -Save time by skipping background issues -Credibility

-Information pitched to nurse

Professional Nurses

Yes Shared background

May assume knowledge & experience that is not there

-Saves time -Can get to key issues quickly -Can help with strategy and inside info

-Assumes support -Assumes knowledge & background support materials may not be

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As the nurses described their translating experiences, two distinct activities

emerged. In some situations, the nurses were directly involved in situations as agents for

both parties when they were invited or expected (based on their position) to facilitate the

exchange of information between the individuals or groups that did not have a common

knowledge base or language for discussion of health care issues.

At other times, when the nurses were in roles or situations where their knowledge

and expertise were not known or recognized, they took advantage of advocacy

opportunities. Based on their own initiative, they indirectly shared their knowledge about

the health care system, making suggestions to improve the policies that were under

discussion. In these cases they were agents for professional nursing and also acting as

principal by promoting issues important to themselves. These situations are examples of

the participants creating access (strategy four) in situations where the involvement of

nurses would be relevant but not recognized. In these circumstances where they used

indirect strategies, they often used self-effacing language and communication tactics.

These were usually instances when the nurses made the decision to not reveal their

professional background as discussed in selective self-disclosure which reinforced the

invisible presence of nurses.

In the following scenarios, nurses discuss some of the situations where translating

was done openly as part of their role. When done directly, the nurses were willing to self-

disclose and reinforced the visible presence of nurses. Nurses involved with specific

policy initiatives conveyed to policy-makers how changes in policy and regulations

would affect real patients and families based on their practice experience. One of the

nurses in the study described this “putting a face on policy” as the ability she had to recall

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people from her practice who experienced the difficulties she was explaining to people

working on policy (#10 p. 20).

What the nurses translated depended on the situation and the players. They used

knowledge from both their formal, professional education and their day-to-day

experience of working with patients and families in clinical practice. For the nurses in the

study, both their health care backgrounds, as well as their knowledge of the political

process, were factors in successful translating. For example, they could explain complex

health care issues to policy makers in straightforward terminology to help them

understand and clarify what the problems the policy they were crafting was trying to

solve. As one nurse in the study describes:

I think being a nurse had a very significant role in my ability to be a translator. If

I didn’t understand something clinically, it was pretty clear to me that the

policymakers weren’t going to understand it…I figured if you couldn’t explain it

to somebody who cared a lot about anatomy and physiology, then we needed to

go one step further in doing a better job of communicating what we thought were

important issues. So, in that regard, I found myself to be valuable because my

clinical skills helped me in a translational sense. I view myself as being much

more effective in translational roles, which is why that job was very good. (#11

p.8)

In other situations, when the nurses met with constituents in legislative offices,

they relied on their practice background and communication skills to listen and then

translated the peoples’ concerns into problems that could be understood by policy

makers. They then worked with other staff members who crafted the legislation to clarify

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the issues, interpret technical language, and make sure the legislative intent of the

proposed solutions was not lost in the process. In the words of a nurse in the study:

So when [the legislator] wants to turn it around and deliver the message, I know

her audience in a way that’s different…Translation – …that’s what nurses do so

well, translating, and that’s the reason I wanted to do policy because we translate

the patient in the health care system….I think that the nursing helps that. And so

my translating the patient issue to the policy-- the policy to CMS, who’s got to

implement it…--and then coming back and translating it back to her [legislator].

So that translation thing is just something that I do. (10 p. 23)

The nurses in the study believed that they were effective translators in health

policy issues because they were fluent in both the language of health care and the

language of policy. As the nurses gained more experience in government, they not only

spoke the language of both groups but they understood both cultures. These nurses in

government used their political skills and health care knowledge to play a unique role in

influencing policy. Their biculturalism facilitated this role as translator as described here:

I think it’s an important role in policy and I think that nurses…. have been doing

it in a different way and can probably bring that translation, [and] see the

importance of it.… It doesn’t mean the other folks haven’t learned it [language of

policy and health care] but we’ve come to it … in a different way. We bring it

[health care knowledge] with us when we come. Other people had to learn it when

they got here. (#10 p. 24)

For example, as the nurses listened to constituents who came with problems

caused by barriers in the health care system, knowledge gained from their professional

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practice with patients and families helped them clarify the issues, provide support, and

express empathy. They then could move from this clinical perspective to the systems

perspective in the policy arena to determine how best the legislator’s staff could help

meet people’s needs.

When they met with members of special interest groups, the nurses could sort

through the mix of facts, figures, and feelings presented by those who came to lobby for

specific programs or problems. The nurses had experience with how specific details of

program administration and implementation affected real people’s lives. Based on this,

they identified and clarified the issues under discussion and translated their needs to those

who were making policy. In these situations, the nurses had a visible presence in this

process. This specific and more detailed articulation of problems provided specific

information to policy-makers so they could craft legislative or regulatory solutions that

accurately matched the problems.

In other situations, the nurses in the study were involved in activities as part of

their job where translating was not expected because it was not part of their role or

because their expertise and experience were not recognized, that is, they had an invisible

presence. They often used these opportunities for advocacy when they determined that

they had a contribution to make even if they had to do so indirectly. One nurse talks

about her experiences during negotiations for a health care bill. She learned the

importance of having someone at the negotiating table to continually advocate for

patients and protect their interests throughout the complete policy cycle. The negotiating

process can be insensitive at times and cuts are often proposed that may have unintended

consequences that can undo the benefits or reverse the intent of the original policy.

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Sometimes those negotiating lose sight of the basic issues. Nurses can reiterate and

reinforce the needs of health care consumers during this process as she describes here:

You sit down with the policy experts and you start to get a feel for how they

negotiate on this stuff…They come in with a very – I don’t want to use the word

draconian because it’s been used to much-- but a pretty painful fix that would

really cut it [funding] back….that sort of gets their [the others] attention. It’s

called a two-by-four up side the head…. then it begins to get worked out….I think

it’s because we only have blunt tools at the federal level and a cut is a cut ….and

so you’d start with these dollar things and then very terrible policies that it starts

with. But, it starts the process and it’s the place holder. And then you kind of

fine-tune it to minimize the damage to various groups. (#11 p. 22)

One aspect of the translating role that some felt was more important than all

others was the ability to put a face on policy for those making tough policy decisions.

This means that when policy issues were debated and cuts in services proposed, the

nurses used their experience in practice to anticipate and share with policymakers the

effects these policies would have on real people. Often, the nurses could recall patients

they worked with who were in similar situations as those under discussion. By telling

their patients’ stories, the nurses helped the policymakers understand the consequences of

their work and make decisions that would have a more positive effect. A nurse in the

study explains this:

I can picture an individual in each of those times and where they would be and

why the decision [will affect them]. And I can picture when someone says, it’s

hard to get to a doctor to get the prescription…. a flood of images goes through

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my head where I can picture all of those people who aren’t able to get to the

doctor and why and what it would mean….So when we talk about the statistics or

the data, it’s not just on paper for me, there’s a whole picture that goes along with

it. (#10 p. 20)

The nurses in the study could advocate indirectly for patient needs by telling their

stories of how patients and families might be affected. They also shared these stories with

legislators who used them in their negotiations and discussions with colleagues and the

public. The same nurse continues her account:

I think I probably bring a different passion to it. That it’s not just the goal of

getting the rule passed, it’s the goal of what that rule means…I was working as a

nurse in the emergency room at Children’s Hospital the day we went from

Medicaid fee-for-service to Medicaid managed care. And on Saturday and Sunday

that weekend everyone that had a Medicaid card could come to the emergency

room. And Monday morning, when that same person came back to the

emergency room, we then said to them, you can’t come here any more because

you’re managed care. You’ve got to go see your doctor….and they didn’t even

know who the doctor was. So I think of those moments where a policy change

isn’t just something on paper, it means the whole way of getting health care was

changed because of this thing that no one took the time or thought about how to

make sure that everybody who was the ultimate recipients of this policy change

would react to it. (#10 p. 21)

At times, this strategy of indirect translating required sophisticated skills of

negotiation and savvy about the system and the players involved. Some of the nurses

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described situations where their success as a team player (and ultimately on the outcome

of the policy process) depended on their ability to contribute in very low key and self-

effacing ways so others involved did not resent their input. For example, one nurse in the

study related how she changed her style to work more effectively with a young and rather

prickly physician on staff of a committee. By posing questions strategically to lead the

members of the committee to certain conclusions, she was able to indirectly use her

knowledge to influence the process. Because her expertise was not respected by the

doctor in this case, her more direct style of making specific suggestions had earlier

created a defensive and nonproductive working environment between the two. As she

explains:

[I was] in a one-on-one encounter with a young physician who was in one of the

staff offices who clearly thought he was pretty hot and that he didn’t need to

spend the time talking to a nurse on an issue…. We worked on a bill together

where he really had very little expertise because he’d never really practiced. He

came straight there. Kind of young, hot shot with an MD PhD and he fancied

himself quite the doctor…And so as we worked out some of the details of it. I was

able to sort of pull out some of the issues and go-- if you put that in there, you’re

going to get this back. Or this is very unrealistic because, you’re not taking into

consideration [that] most of the people that have this disease could be homeless.

You’re building unrealistic expectations in there. What about this? What about

that if you’re going to put that in your bill? [Because] he was in charge of it, it

made him look good. He had also showed, in front of a large group, that he

wasn’t quite as smart as he thought he was. And I think over time….we learned

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to work together… It was difficult because you just wanted to say…. we’re all in

this together. It doesn’t matter that I’m a nurse and you’re a doctor. But,

wherever he was trained, that was the culture at the time. (#9 p.16)

Although this tactic proved effective for her in achieving the policy goal, for

experienced nurses including the nurse in the study, this was reminiscent of the doctor-

nurse game played by nurses in past decades which perpetuates the perception that nurses

are not critical thinkers and independent decision-makers and reinforces the nurses’

invisible presence and lack of influence in health care. A similar tactic used to translate

indirectly involved phrasing suggestions in general terms about how they might benefit

patients and families without referring directly to the nurse’s practice experience so other

members of the work team did not get defensive. This nurse gives her experience in a

similar situation:

Some of these physicians or providers will say, well in my experience as a

provider, and sometimes they [the staff are] like, yeah. Sometimes that kind of a

comment is kind of looked down on…So I don’t usually go boasting about my

experience – but often times I’ll ask a question that I think that it’s evident that

the question I’m asking is because I had a different role [one in health care]. I

think when you present it that way, people kind of appreciate that there’s a little

bit of experience behind it. But you don’t want to flaunt – because one of the

things I think the folks on the Hill are probably – if you had to be insecure, is the

fact that they don’t have any experience on this [health]. So I think the worst

thing to do is to flaunt that you have it [experience]. But I think that having…

informed questions is probably seen as a good thing. (#10 p.17)

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This need to be indirect and self-effacing when referencing one’s practice

experience related in the example above, is an example of one the potential barriers to the

effectiveness of the nurses in the study. Many of the nurses believed that their health care

experience had the most credibility if it was not identified by others as coming from a

nurse. This is the same dynamic described under the process of selective self-disclosure.

Most of the participants agreed that although this barrier was real, it could be overcome.

In each situation where a nurse makes the decision to conceal her professional

background, she reinforces the barrier of invisible presence of nurses in the larger socio-

political context inside and outside of government. Once others worked with the nurses

over time, they gained the respect and credibility of their colleagues by doing a good job

and working effectively as team players. This experience then leveled the playing field

for them with these players in future projects. When the nurse’s expertise was recognized

and she was trusted, she no longer needed to be self-effacing to achieve influence. One

nurse in particular explained that her success in this process was related to her

observation that the less she needed the spotlight and the quicker she learned that policy

issues are not personal, the better able she was to use all of these tactics to make a

difference and gain the respect of her colleagues.

Another tactic for translating was used effectively by some nurses in the study

when they were working with seasoned committee staff or long-term agency colleagues.

The nurses were open about asking for the staffs’ help and expertise with the policy

process and this in turn helped the staff feel comfortable in recognizing and using the

health care expertise of the nurses. An example of this is described here:

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I think they [committee staff] are, for the most part, very territorial because that is

their piece of pie, that committee. And anything that is going to get put in an

authorization bill or an appropriations bill, whatever the committee does, that’s

their baby, so to speak. And so you really have to earn their respect….You go in

there and say, this is brand new to me….I think this issue is important…you don’t

go in there slamming them with your nursing knowledge because they don’t really

care about that….they will use your expertise once they learn to respect you. But

again, it’s just like building relationships and not going in there with a know-it-all

attitude but saying, I really don’t have a clue how to write this report language but

I think this is an important issue, can you help me? (#2 p.14)

Some of the participants believed that nurses are good at indirect tactics and

strategies this because this is a common mode of operation for nurses who are

accustomed to indirect strategies for using power and authority in their sites of practice in

both hospitals and academia. The decision of nurses to selectively self-disclose their

professional background while translating perpetuates the barrier of invisible presence

when others do not know or understand the nurses’ experience.

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In the first instance, nurses on the inside learned very quickly that the more

contacts they had throughout the government, the easier it was to access information that

was not available to others outside of government circles. Greater access means greater

power. Most of the participants attributed their success in doing this kind of networking

to the skills they brought with them from their professional nursing background. These

included skills in verbal communication, listening, negotiation, conflict resolution, and

developing successful working relationships with all different kinds of people. The nurses

also learned that if they maintained these relationships as they moved among positions

inside and outside the government, they maintained access to much of this information

through these networks of contacts. Greater access to information made them more

valuable players in the policy and political process as they moved in and out of

government and private sector work and among different offices, committees and

agencies. As this nurse in a legislative office describes:

It is 100 percent about relationships that we have and that’s big. The first thing

that I learned, it is more about the time you spend with people. And some people

like to be communicated with through e-mail. Some people would like to sit

down and have coffee with you. Some people would like to see you drop by their

office every now and then or if you see them in the hall say, hey, you know, have

you thought any more about this bill? So it’s constantly knowing who the

decision-makers in the different positions are and negotiating with them. (#2 p. 7)

A nurse in one of the agencies describes how she has successfully networked:

Those are the really important things, to get out to the conferences, to get out to

the field.… I’ll say can you educate me about what you’re doing? I want

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understand what you’re doing better…. Tell me about yourself. And so I

would… go and spend time with them in their job and then they saw that I really

cared, I really wanted to understand. I wanted to see how I could help them better

and I was just approachable….So a lot of networking time… just building these

informal relationships, getting people to relax, getting people to trust you. It

makes it so much easier to call them up on the phone when you’re in a crisis if

you already know them and you say I’m concerned about this. These are my

thoughts on it and then you’re able to just get them [directly] because they know

who you are. (#6 p. 20)

One nurse cautioned that there were some boundaries on political networking that

must be respected to prevent ethical breaches. In the process of networking, one must be

careful not to share information indiscreetly or receive favors intentionally or

unintentionally. She described an experience she had when information in an informal

conversation with a legislator for whom she had worked, lead to a boost in funding for

the current program she was working on. She only realized after the fact that her

comments were probably related to the funding and she expressed regret over the

inadvertent use of this personal relationship. This situation is unique from the perspective

that most of the nurses interviewed had not been on the Hill long enough to have

relationships of this level of personal and informal power. It does demonstrate that

personal relationships are important sources of power that must be cultivated but used

carefully to avoid abuses of power.

Nurses, who stayed in administrative agency or legislative positions for longer

periods of time, had greater opportunities for creating access. As they developed personal

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relationships with members of the legislature and executive branch over time, they

established mutual trust and respect. This trust and respect allowed the nurses to take

advantage of opportunities for advancement and advocate more openly for different

health care programs or ideas without the need to mask their contributions with selective

self-disclosure or be as self-effacing when translating.

More than one participant pointed out an additional skill that nurses brought with

them from practice. This was their ability to do much of the work while receiving little of

the credit. In the world of policy and politics, this made them valuable team players in

settings where many were motivated to get credit, whether they deserved it or not.

Although this may have facilitated their short term success in specific projects, this

reinforced the problem in the larger socio-political environment of nurses having an

invisible presence in health care policy that was discussed earlier.

In the executive branch, different tactics could be used to create access. For

nurses in the uniformed services, rank was an important factor in opportunity. A nurse in

one of the uniformed services noted that too few nurses achieve high enough ranks to

allow them to move to higher positions where their skill set and not just their nursing

credentials qualify them for the promotion. She describes this:

[So there are fewer admirals in nursing than there are in the other groups?]

Yes. [Why do you think that is?] Well, I think it is partly due to the nature of what

we do. Most of the flag officers are physicians and if you look at the way we’re

constructed, like [government agency] and [government agency] they are looking

for experts in scientific areas and many of them are physicians or PhDs. So I

think it’s just the way that our system [works] . . . [That] doesn’t mean that it

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couldn’t change. [Are there nurses qualified to be admirals based on expertise?]

I would say yes and so then the challenge would be to get them into a position

….that was rated at that level…and certainly by just the way we’re constructed,

there are fewer of those positions than there were. [Do you think there is

resistance from physicians to see more nurses in those positions?] I think it’s

more that they just don’t think about it. I really think that that’s part of what the

challenge that nurses have to overcome [the way] people think – well, first of all,

people think a nurse, is a nurse, is a nurse. And we have done ourselves

absolutely no good by having two-year nurses and three-year nurses and four-year

nurses…. they say, well you’ve got a license as a registered nurse, why can’t you

do this? Well, because they don’t have the education and skills and the training.

So I think it’s more of a…. mind set and so part of it is educating people about

[the profession]. (#7 p. 39)

The failure of nurses to aspire to and achieve higher ranks limits the ability of nurses to

move into positions where they would have the power and authority to be decision-

makers and therefore be more effective advocates.

A nurse in one of the uniformed services in the executive branch agencies

described her persistence and assertiveness to move up the ladder when told that nurses

were not eligible to advance in her agency, regardless of rank. She responded to the

challenge to create advancement opportunities for herself by successfully demonstrating

her ambition and desire to learn rather than waiting for doors to be opened. She changed

the policies that prevented her advancement by proving her ability to do the job well and

provide leadership. She describes her experience:

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This one doctor [was] saying you can’t be a branch chief. Physicians won’t listen

to you because you’re a nurse. So my blood is boiling. I worked on educating

these gentlemen over the year that nurses are quite capable, that we are bright and

that we are qualified and that they would be short-sighted not to allow us to apply

for this position because what incentive would there be for us to stay here and not

only did I impress upon them that. They were so impressed with nurses and what

we could do….they opened up the division director, which is right under the

associate administrator, which is right under the undersecretary, to us. [Can you

tell me a little bit about the strategies you use to do that education, as you called

it?] Hard work. I worked hard just at my own job to show them the quality of the

work. I worked hard to demonstrate my thought process so that they could see

how I think….That’s basically what I did, I just pulled in the different skills that I

learned from nursing, the whole nursing process….I just tried to really show them

how we worked, what our thinking process is and how do we make logical

conclusions and I was able to impress them with that. (#6 p. 10)

In politics, partisan concerns could potentially be a limiting factor on one’s

networking boundaries and opportunities. In most of the situations in this study, the

nurses’ ability to qualify for their initial position, create access for others, and network

did not appear to be affected by political party affiliation. Several of the nurses in the

study mentioned that their party affiliation was not openly discussed when they initially

entered their positions. This nurse describes her experience:

No interviewees asked us how we were registered. No one asked us how we voted

in the presidential elections. If they made statements about it, they would be…you

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know what the party’s platform is, you know if you’re in this office you’re

expected to either support it or at least be neutral – quiet. You’re a mature person .

. . that was about it– there was no litmus test. (#5 p. 15)

Some of the participants believed that political party affiliation became more

relevant the longer one stayed or the higher one moved up in the system. On the

legislative side, one nurse stated that she would not be able to work with the passion she

needed to stay engaged over time if she did not share some of the core the values of the

legislator she worked for and she believed that having the same party affiliation was

important in this determination.

In the executive branch, some nurses were cautioned by mentors to downplay

their past political ties in order to appear more neutral so they would be able to advance

within their agencies regardless of what party controlled the executive branch. One nurse

shares an experience where her political party affiliation was referred to:

She [the nurse’s boss] came in to the meeting and sort of bragged that

[participant’s name] has just come to us after two years with Senator [name].

And I’m going… I can’t believe she said that. And [the agency head] actually

looked up and he went, well, you know what, you might not want to just put that

out there the next time. He goes, but don’t worry, a year with us and we’ll

sanitize that right off your resume. So people knew. It wasn’t a big deal [but] I

would never have been an [higher position in the agency] coming from that

background. (#9 p. 77)

In both legislative and agency settings, nurses in this study stated that they were

not required to endorse any specific political views but if they had any differences with

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the leaders they were working with, they were expected to keep the differences to

themselves.

In the process of creating access for other members of the profession, all of the

participants used a common tactic. This tactic was to alert colleagues, usually through

professional associations, of opportunities for involvement. Participants in different

agencies sometimes made suggestions to professional colleagues outside the system that

they might want to ask certain questions of the executive agencies to prompt the

disclosure about relevant information. This was done openly in some cases and very

confidentially with trusted colleagues in other situations. All of the nurses were careful

when relating their experiences to stipulate that they would not knowingly cross legal or

ethical boundaries. The politics of many situations required discretion.

This early warning system activated by members of the profession inside the

government to alert nurses outside the government about potential opportunities for input,

allowed nurses to be proactive and seek inclusion. Too often in the past, nursing

advocacy has been reactive, identifying after policies have been proposed and negotiated

that opportunities had missed to make a contribution. This tactic to facilitate access

allows nurses to be involved early in the political and policy process and thus, have

greater influence.

Usually the nurse on the inside of the government determined that nursing

expertise was relevant in a specific situation but this was not recognized or sought by

others. These situations included opportunities for appointments to positions on advisory

committees, commissions, or providing testimony at hearings that were dealing with

health care issues. At other times input was needed from nurses when specific policies

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were formulated, regulations promulgated, or issues debated. In the example below, a

nurse in one of the executive branch agencies explains how she worked to consult with

nursing colleagues about specific regulations before they were written:

We try to be very aware of what the nursing community is doing. We meet with

the nursing community. [Is that on a formal basis? On a regular basis?] Formal,

regular and informal, I would say. We meet with them. In terms of legislation,

when the [specific piece of legislation] was passed, we brought in something like

30 nursing organizations or representatives from nursing organizations and we

said, okay, this is what the law says. What did you mean? How did you think we

should interpret this law? What are your views? (#8 p. 25)

Sometimes the participants would directly suggest specific colleagues for

membership on advisory committees or to give testimony. For this tactic to be successful,

the nurse on the inside had to be able to link the special expertise of a specific colleague

in nursing to the needs of the target group. This required a significant network of

professional colleagues with a variety of backgrounds who had the acumen and expertise

to participate at this level. For most nurses in the study, the most frequent tactic used was

to alert leaders in professional associations that they should put forward a nurse for

appointment to a specific group. For both of these strategies, the conditions that

supported success were good communication between nurses in the government and

leaders in the professional associations and ready access to the nurse leaders in the

organizations by those on the inside. Nurses in the study had to know who to contact and

be able to make contact in a timely way. Their colleagues in the professional associations

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had to respond and not need reminders or prodding to act on these opportunities. One

nurse describes how this can work effectively:

They [head of a federal agency] spent days down in the capital screening people

and thinking, if you needed to do this on a large scale, how would you do it? And

so we approached the ANA and they readily agreed. We already had a good

working relationship. It fit in with their priorities and they saw it as a win/win

situation. So because I had already taken the time to establish the relationship, it

was very easy to get an appointment pretty quickly with the senior nurses, the

senior leadership there to talk about it and then to move forward with it. (#7 p.48)

If contact was made with nurses in professional organizations by the nurses inside the

government and no action was taken, the opportunity was lost because they did not have

the time to follow-up and push the implementation of their suggestions.

In some circumstances, access was created more indirectly. One nurse in a federal

agency had concerns about the paucity of nurses who work on interdisciplinary research

projects. She was in the position to grant funding for a variety of research initiatives and

she was very interested in funding research done by nurses. However, few if any

proposals she reviewed had nurses either as principle investigators or involved as

members of research teams. Based on her estimation that nurse researchers had the

required expertise for the projects she was reviewing, she used her influence to suggest

that the research teams might want to get nurse researchers involved in order to best meet

the criteria for funding. In her opinion, nurses are too parochial in their approach to

research projects and funding. Unless requests for proposals are specifically directed to

the professional nursing community, few nurses respond. Nurses tend to seek funding and

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support for a fairly narrow range of activities in health care research specific to nursing

studies. This trend reinforces the general perception discussed earlier under invisible

presence that nurses lack involvement and expertise in broader health care issues.

One nurse urged that the efforts to have nurses involved inside the government

needed to be studied and expanded:

I think [we need a] better understanding [of] how they [nurses on the inside] got

here and [we need to work on] creating those venues early on. I have met so

many nurses who probably would love to do something here and don’t have a

sense of how to do it. And there’s so many of us, over 2 million…would it make

a difference? Maybe. Would it hurt? Absolutely not. So I don’t think that we do

a good enough job helping nurses understand how to get here and the importance

of it. I’ve done the run doing talks to groups and there’s so much interest, there’s

so much that they could lend. There’s so much experience and background that

they would do a great job. And I think that we’re not doing a good enough job

offering [jobs in the government] that as an option. (#11 p. 34)

It is important that nurses who work in government have opportunities to serve as

role models for other nurses and motivate them to take advantage of advocacy

opportunities to become involved at all levels. This means that the nurses who are

working in government need to be known and publicly acknowledged by the profession,

and invited to speak at forums of all kinds where nurses in practice and students at all

levels of nursing education can interact with them.

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ego, personal relationships, understanding of the issues, knowledge of the political and

policy process, ambition, and hard work. One nurse describes this strategy:

You can’t function here if you can’t seize the agenda, if you can’t make things

[happen] – if you can’t nose yourself into a debate, into a conversation, into a

critical moment when you suddenly stand up and have to [give] a point of view …

you don’t talk about --I think and I want-- but you talk about the leader – the point

of view from the leader’s office and what the agenda is for the committee. And

you invoke others instead of yourself in the process. And you invoke that in a

very honest and credible way because you can’t go speak for others unless you’re

empowered to do so. So that trust has to be built up. It’s not something that you

can just automatically decide to do. But you build up enough trust so that you can

speak credibly.….I mean it’s not me that’s speaking but it’s me that’s the vehicle

for communicating and educating about a process that has gone before. That

makes you really powerful if you can pull that. If you can pull in all that’s behind

these issues and concerns at the federal level and not make it an ego trip, it’s my

sense that you’re much more powerful in Washington, DC. (#11 p. 29)

Some of the tactics that the more experienced participants in the study used early

in their journey to reach this status included being quick to seek approval for any

decisions they made, being prepared before meetings by doing their homework,

analyzing the options they anticipated would be discussed during negotiations, and

knowing the limits and boundaries of their position. They also needed to understand the

complex variables that determined the political and policy constraints of each situation

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that they might be in while speaking for their leader. This nurse describes how she moved

to the position to be able to use this strategy of invoking others:

There’s really a gradual buildup of your recognition as a player and ability to

make things happen, to deliver, and that slowly evolves over time as you get the

trust and the support of your boss…. It was very clear that I wasn’t going to do

anything that I didn’t get approved before I did it. So I was very quick to seek

approval and to try and anticipate if we’re going to go into this meeting, what are

the parameters for what I can do and what I can’t do and what’s the range of

options that are available? And so you’d go to the Congressional Research

Service, you’d go to the Congressional Budget Office, you’d look at what the

budget alternatives are and you’d know your stuff before you went into a meeting

so that you could say, well, these are the numbers that the budget committee gave

to the finance committee, and you’d talk from fact. So that was fine. And then

you’d have to have your facts straight…that always makes you better off in any

discussion when you know what the facts are. …So one is a fact-based piece--

your power base is your information. The second piece is where you can go

within your office. I worked for a [political party] that was the [leadership

position] of the Senate, which meant that you had to be very careful what you said

was going to happen and what wasn’t going to happen. Because once you say

something and it doesn’t happen, you lose your credibility…people tend to

reciprocate and you’re not a negotiator anymore. So you have to be very careful

that you can deliver what you say you can deliver. So you have to get that

squared away before you go in. If I hear my boss say, we’re not doing this and

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we are doing this, then I came in and said, we’re not doing this and we are doing

this. Period. It never varied from that point. (#11 p. 31)

As the nurses became players and gained the trust of those with power, they had

to make sure that they followed through on any commitments they made. Those who

used the strategy of invoking others had to gauge their advocacy carefully. They did not

vary substantively from the leader’s positions and as surrogate, they did not go any

farther on a particular issue than the leader at any point in time. As one nurse cautions,

“You have to be careful that you’re not getting out in front of the secretary of the

[agency]” (#7 p. 52).

Only a few of the participants interviewed were in their positions long enough to

achieve this status. Many of the nurses in the study did describe a few well known nurses

who had used this strategy very effectively as they related different examples of

successful role models and mentors in their health care policy advocacy experiences. The

use of this strategy is related more to an individual’s position and skills than specific

professional background. Once this status is achieved, the recognition and power that

accompany it preclude the need to use selective self-disclosure and some of the indirect

strategies for influence discussed in translating and creating access as those strategies

are no longer as relevant. Achieving this status also gave nurses greater access to those in

power. With this came the opportunity for nurses to advocate more directly for their

issues based on the respect and expertise of those around them.

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the politics of the situation change. One nurse describes this strategy and the influence of

her mentor:

The most important strategy that I learned was how to talk about it [issues]

without revealing things – how to be appropriately disclosing and honest without

being naive. You know, there’s this concept of truth and you cannot work here

without being truthful. It’s authenticity—[it] really is a virtue in this town. And

people, if they don’t trust you, you’ve lost it. It’s being trustworthy and being

responsible and being smart. You have to be a quick study otherwise you’re

never going to make it….But [even] if you’re trustworthy, it goes beyond being

trustworthy. You’re able to convey a lot of information without giving away

strategies that would be counterproductive. So you’re strategic…But you’re

truthful in your strategy and it requires some understanding and thinking and

really grounding yourself so that you always speak to truth, but you always speak

to truth in a way that gets you where you ultimately want to go….I think that’s

really what makes people fit in here, there’s a lot of people that come through

here. But [this is] what makes people stay....because it lets you still be truthful and

to be authentic and to be a part of it…. And it’s got to become second nature,

because otherwise you can’t be authentic. It was really learning from the best

person. I think it was watching [her mentor] and how she was able to be in one of

the most challenging [positions] –talk about swimming with sharks, one of the

most risk-filled environments. We were full of attacks and full of really, high-

stake games. I mean high-stake games and being able to get through the day with

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honor and watching how she did that was a real lesson. I think you just need to

have the right people to mentor you in doing it. (#11 p.36)

The conditions that support use of this strategy are having a depth and breadth of

understanding of the complex web of issues, alliances, and political nuance that are

involved in dealing with controversial issues in politics. The nurses who use this strategy

need to be privy to confidential and inside information to set appropriate and strategic

boundaries for their discussions. They also need to have power and authority as the

surrogate for their leader, as described in invoking others, to be credible with those they

negotiate with. As differentiated from all of the previous strategies discussed to this

point, careful truth appears to be at the common boundary of strategies used by political

leaders themselves as well as those who speak for them. The influence of the nurse at this

level is acknowledged by virtue of her status as an insider and is less related to any

specific expertise. Whether or not this influence is based on her expertise in health care

issues is less important because she has both access and power to achieve her goals.

Whether nurses at this level maintain their focus on health care advocacy is difficult to

determine because of their small numbers.

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experience are not recognized by those in positions of power and influence as relevant to

larger health care issues. According to the nurses in this study, the dominance of the

medical model in health policy culture is complete. For most policy makers, health care

in this country is the same as medical care-- acute-inpatient centered care emphasizing

the cure of disease. Power and influence in health care policy is wielded by those with the

most to gain in protecting their economic interests: physicians, hospital associations, and

the insurance and pharmaceutical industries. With selective self-disclosure, the nurse

made the decision about whether or not to reveal her professional background while

influencing and advocating. With visible/invisible presence, the recognition of nurses is

determined by others. Whether or not the nurses have relevant knowledge or experience

is based on the judgment of others and not the desire or interest of nurses to be involved.

Participants in the study, both inside the legislative branch and executive branch

stated clearly that nurses, inside and outside of the government, are only recognized and

involved in the process when a policy or program being worked on is directly related to

nursing. When broader issues dealing with health care are discussed, nurses are not

involved and not considered to be interested or knowledgeable players. One nurse

describes this reality:

But no one’s included nursing groups [on advisory groups or to give testimony on

health care issues]. If I suggested one and why, they probably would be included

but no one thinks to go [to nurses], unless it’s [a nursing issue]. [So am I hearing

you say that nurses really aren’t considered a go-to group by people on The Hill?]

I knew that before even coming up here…It would make a difference if the nurses

who were on the outside were more organized, here I am on the inside and I’m

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just as frustrated as everybody else and I don’t have time to fix the problems (#11

p. 31)

The same nurse relates another experience in her legislative office:

There are two [sets of] companion bills in the House [and] Senate. One has to do

with mandatory overtime; one has to do with nurse staffing ratios. I brought both

of those up to my health director. What is the Senator’s position and do you want

anything done on these? And he wrote back and said, ignore these. That was it.

Two words, ignore these….and I have to tell you, I have a lot of respect for this

guy… but nursing is not on the agenda….and nursing is not a player, period. (#5

p.55)

A nurse in the study relates an experience she had that reinforced this lack of relevance of

nurses to her:

[Nursing] is not on the political agenda, therefore it will not be discussed as

policy.…I can’t even begin to tell you the look on the face of the physician from

CMS [Center for Medicare and Medicaid Services]. We had a briefing and there

were five physicians from CMS. Somebody may have been a PhD but most of

them were physicians. They got through talking about their plans for these 10 or

12 demonstration projects that they’re funding for pay-for-performance and they

were all about physician group practices. And I raised my hand and I said, so

what about nurse practitioners and what about nurses? You know, nurse

practitioner practice should be measured with pay-for-performance. And he gave

me some la-de-da about it and I said, no, you’re almost single-mindedly saying

that physicians are the health care system and they aren’t. I mean there’s just no

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getting around the fact that nurses are the largest group [of] any one group [in

health care]. And he just looked at me and I wasn’t sure if he thought I was just

an idiot and that he didn’t know what to say to me or – you could tell – this was

just not even something that had occurred to him. This was a brand new thought.

That in all of their discussions, it had been all physicians, all the time. And his

look and complete cluelessness, I mean it was so deep that it even reached to me

that I thought, maybe I am so out of sync….I questioned even why I asked the

question. That physicians think of physicians as the center of health care in this

nation is so profound in Congress that nursing issues are cheap, tangential. (#5

p.54)

Another nurse shares her concerns about the future of health care with the current

physician-centered model:

I keep looking at this baby boom generation and the kinds of care that they

need….We need nursing care. I’m going to need nursing care. And I don’t think

that physicians are the ones that are really good at deciding how that plays out,

quite frankly, and by not showing up, you [nurses] are abrogating those decisions

to the physicians. There are a lot of physicians on The Hill and I think a health

care system that’s physician-centric is going to neglect a lot of what we need as

we age. And we really need nursing care….I don’t know why we don’t value

nursing, but we don’t….it just troubles me that we’ve trained all these wonderful

people and then they walk in to this profession and they become so frustrated and

disappointed with the ability to do their jobs. Its [nursing] not integrated from a

policy perspective. It doesn’t have its place in the team….There’s no sense that

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this is a team… It’s either the HMO, it’s all about the money, or it’s the egos of

the particular specialist within it but it’s not about a team caring for people. (#11

p. 55)

One nurse voiced another concern related to the issue of visibility and presence of

nurses in politics and health policy. In her experience, nurses reinforce the perception that

they are disinterested in broader health care issues by their failure to engage in and seek

funding for collaborative interdisciplinary research projects. Her experience in a

government agency that distributes funds for research initiatives, many of which are not

specifically restricted to nursing projects, is that few nurses apply for funding. Nurses are

rarely involved in collaborative interdisciplinary projects with other professionals as

principle investigators. She relates her experiences:

The disappointment in the portfolio is, we put out requests for contracts and we

got one nurse group that applied for funds. We had 65 proposals. We had one

from nursing. Does nursing have a role in this issue? Yeah, I think so. I’ve

spoken all over about how to get involved. We have these integrated delivery

system research networks. You have an entire hospital system. [large university],

combined with [another large university], combined with four or five hospitals in

the [state] area. Not one nurse on one of the projects. I don’t know. Are they not

at the table? Do they not think they’re involved? Are they precluded from being

involved? I am like a broken record when a proposal comes in and I ask why

isn’t there a nurse on this RFP? My first proposal [from a nurse] in five years just

came through and I had to abstain from even reviewing it because she’s a good

friend. And she showed up on one of the proposals. It’s the first time. So I have

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one grant funded to a nursing group at [large university] and this new contract that

will be awarded actually has a nurse on the project. But otherwise, it’s all

physicians….And that’s very hard because people come back to me and they go,

well you don’t give nursing any money. Well, you aren’t exactly out there to give

money to either. (#9 p. 67)

One of the impacts of this lack of visibility and credibility of nurses in

government can lead to the political process being resilient to the influence of compelling

data and professional lobbying by prestigious nurses using this data to back up their

issues. One of the nurses in the study shares a particularly chilling episode that occurred

during a meeting she attended:

[Two Deans] came and folks from [another large academic institution] ….were

coming to plea for federal money that was equivalent to the community health

center dollars for providers for nurse-managed clinics and they presented all sorts

of very crisp data about the types of patients at their nurse-managed clinics.

There are 14 of them [clinics] in [the state] we’re serving…and the dent they were

making in care for the uninsured…I thought they did fabulous….I was just kind

of the hanger on--the person that was assigned to the issue is not a nurse and she’s

twenty-three. We walked out and she says to me, do you think everything they

said is true? We’re going to have to really check into this. I just can’t believe

that nurses are doing what they said they’re doing. I said, check into it. I think

you’ll find that they’re doing exactly what they said they’re doing. And then I

wrote to one of them, because I know her personally, and I said, you need to send

something else…. But the stunning piece was, simply because they’re nurses,

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there was a lack of belief by this 23-year-old who was the gatekeeper, that they

might be delivering the fabulous amount of care that… they are delivering. (#5

p.63)

If this nurse had not been there to validate the contributions of these nurses with the staff

member and then alert the nurses to the need for additional information and pressure, the

whole process could have been derailed. A young staff member indoctrinated by the

prevailing culture that nurses do not have the education or knowledge to be providers of

health care that is making an impact was not willing to believe the evidence.

A nurse in an executive branch agency discussed another reason for nurses’ lack

of visibility. From her experience, nurses restrict their search for jobs to those positions

that specifically recruit nurses rather than using their project management experience,

administrative skills, and policy acumen to look for advancement opportunities. When

nurses who are interested in government work restrict their search to “nursing” positions,

they are limiting their opportunities. Broadening their options, based on their skills and

not their professional title, would open up more jobs. By having more nurses in a wider

range of positions, their influence could multiply and reach a critical mass or “tipping

point” more quickly. When nurses are routinely working a variety of settings, there is

greater potential for them to be influential. This failure to get out of the nursing

“stovepipe” is described by the nurse:

Nursing needs to be educated and I think that’s another piece of advice. Nurses

can get involved in a lot of things. It may not have the term nurse but that doesn’t

mean a nurse shouldn’t be involved and an advocate for whatever it is. Let me

give you an example. Somebody may look at government positions and say there

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are no nursing positions here but there are program analyst positions. So why

wouldn’t you fill a program analyst position because you can be a program

analyst? But they only look for nurse consultant. You know a program analyst

works side-by-side with a nurse consultant, it’s just that they’re not a nurse but

the functions are identical….Well, look at the concept of glass ceiling. How

many times have you heard when a dean moves up in to being a president or a

vice chancellor that she’s left nursing because of this sort of view that nursing has

to be a nursing position? But some of us successful people are nurses and you

find out about it….what their contribution can be and that they don’t have to have

a position that says nurse. It could be something else but they could still bring

their nursing background to it. (#8 p. 47)

The experiences of these nurses substantiate that the medical model is firmly

entrenched as the prevailing perspective for health care in the federal government. This

means that whatever strategies the nurses inside the government use to promote health

care and nursing issues, their effectiveness is limited by this culture. This dominance by a

single group of health care providers marginalizes the influence of all others. The reality

in the current policy and political environment is that the medical model is pervasive and

powerful, and the presence of nursing as a force in health care policy is invisible to those

in positions of power. Despite the best advocacy efforts of nurses, it is this socio-political

context dominated by medicine that determines whether the profession of nursing has a

visible or invisible presence, not the interest or effort that nurses put in to a particular

initiative.

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CHAPTER FIVE: DISCUSSION, IMPLICATIONS AND SUMMARY

The purpose of this study is to explore the strategies and tactics used to advocate

for nursing and health care issues by nurses who work inside the federal government. The

strategies and processes used by the nurses in the study to influence the health care

system from inside the federal government are conceptualized in the model GIVING

VOICE. Moving through these processes, nurses were able to learn the rules of

government culture, use their skills to influence the policy process, and for some issues,

move the influence of nurses from an invisible to a visible presence in government.

Although the participants in the study believe that their advocacy from positions

inside the federal government have some influence in promoting a more patient-centered

health policy in the United States, their influence is not significant. The complexity of the

political process and the dominance of the medical model of care are powerful barriers to

the attempts of nurses to represent more holistic and patient-centered focuses both inside

the health care system and the political system where health care policy decisions are

made. The dominance of the medical model inside the government was experienced as a

barrier in both the legislative and executive branches.

The Research Questions

The first research question is: What processes, tactics and strategies do nurses on

the “inside”, that is, in the legislative branch or executive branch agencies, use in their

work?

The processes, tactics, and strategies used by the nurses in the study are

summarized in the six steps of the conceptual model GIVING VOICE. These steps trace

the progress of nurses as they learn about working in government and use different

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strategies to accomplish the goal of GIVING VOICE. This goal is to “give a voice to” or

incorporate the expertise of nurses in health policy to improve and humanize the health

care system. As the nurses gained experience and skill over time, they used the different

strategies: learning the culture, selective self-disclosure, translating, creating access,

invoking others, and careful truth.

The importance of revealing the different steps and strategies in this process of

GIVING VOICE is the ability to use this information to delineate the skills and

knowledge that are needed to better prepare nurses to work inside the government in the

most effective way possible. Nurses in the future will have the opportunity to enter well-

prepared and develop skills at the most sophisticated level as they seek opportunities and

positions of greater influence in the health policy advocacy process.

The first step, learning the culture describes the initial experience of the nurses in

the study as they learned how the federal government works and the roles and

expectations of various “inside players”. The nurses had to learn and understand the

impact of unwritten rules, traditions, and perceptions of government. What the nurses in

the study learned about how government functions is consistent with the findings of

political science studies that describe the roles played by legislative and administrative

agency staff. Even the initial culture shock experienced by the nurses is consistent with

the detailed description Redman (2001) gives of the experience of new staff chronicled in

his book The Dance of Legislation. In the legislature, as the nurses settled into their roles

in both personal and committee staff positions, they had many of the same experiences

described by those who studied Congressional staff (Hammond, 1996; Malbin, 1980;

Redman, 2001; Whiteman, 1987; and Whiteman, 1995). The same was true for nurses in

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the executive agencies. The work by Wilson (1989) on the functioning of government

agencies describes many of the same roles and rules that these nurses encountered.

Some of the political lessons that the nurses were exposed to helped them

understand the importance of reelection and successful estimation of electoral

consequences (an important variable in this process) on the policy choices made by

legislators. These same factors are discussed and their importance reinforced by Arnold

(1990) and Bessette (1994) in their work on decision-making in Congress. The nurses

needed to work carefully within these parameters for any issue that they advocated that

the legislator support or prioritize. These variables (electoral consequences and reelection

concerns) differentiated good policy from good politics for the legislators.

A challenge described by the nurses in their process of learning the culture in

government was adjusting to the fast pace and abrupt changes of direction they

experienced in the legislative and political process. The nurses invested their time and

energy into issues and then needed to quickly move to other topics when the issues did

not move or the political landscape changed. This is consistent with Polsby’s work (1984)

where he talks about the importance of response time in his discussion about different

types of policy initiation in government. When events move quickly and acute innovation

happens, policy makers are forced to make decisions quickly to take advantage of

opportunities.

Although the nurses in the study believed they brought many relevant skills with

them from their nursing education and practice background, they recognized that they

had a limited knowledge of insider politics that influenced how government really works.

Even the nurses in the study who had doctoral degrees in health policy commented that

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they had only a superficial understanding of policy and politics and they experienced

culture shock upon their immersion in government. The experiences of these nursing

leaders with the politics of practice and academia were not sufficient to prepare them for

the level of political skills needed to function in government. If newcomers to politics fail

to anticipate this steep learning curve, their progress to fuller participation in the policy

process could be delayed or stymied, easily leading to frustration or disillusionment. It is

important that nurses who make this transition to government are aware of this process so

they can anticipate and cope with this dissonance and acquire these skills. The process to

do this includes not only greater hands-on experience in government but mentoring and

support from those inside the system with this expertise.

The nurses in the study learned the rules of politics by vigilant observation and

attention to everything that was going on around them. The culture of the political

process that maintains the lack of clarity among the webs of different networks and

contacts may serve as a strategic advantage for those with enough savvy in the system to

use them to their advantage. Understanding the overlapping boundaries of the different

groups in government conceptualized in learning the culture can help newcomers to

negotiate these boundaries and strategize more effectively. Nurses in government want to

be in this position of advantage by understanding these networks.

It may be helpful for those approaching this orientation process as a newcomer to

politics and policy to anticipate and develop the specific skills that will be most useful for

them. Communication skills of all kinds: written, verbal, listening, presentation, group

process, and conflict resolution are important. In addition, assertiveness, confidence,

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initiative, and motivation are needed to fuel the energy level needed by those who work

inside the system.

Although the nurses in the study were experienced and well educated, some did

not feel well prepared to research and analyze issues in different policy areas. When

working on issues outside their area of expertise, it was often difficult to capture the

salient factors and make recommendations in a concise memo. These critical thinking and

analysis skills that are valuable for any advocacy work need to be learned and practiced

by nurses throughout education and practice settings. Mastery of content, so often the

focus of initial nursing education programs will not create the critical and reflective

thinking needed by those who want to work at this level.

Illuminating this transition for political novices may help them as they adapt to

the new culture inside of government. If they have an understanding of the process, they

may be able to better tolerate the culture shock and move with greater ease to function

effectively. Understanding the process of learning the culture may also sensitize those

seasoned members of any profession on the inside who work with passionate but

inexperienced advocates about how they might assist these new comers with their

adjustment.

The next step in the process of GIVING VOICE is selective self-disclosure.

Although used commonly by the nurses inside the government, the political science

literature did not identify this among the activities used by Congressional or agency staff

members in any of the studies reviewed (Hammond, 1996; Hansen, 1991; Malbin, 1980;

Whiteman, 1987; Whiteman, 1995; Wilson, 1989; Wright, 1996).

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The need for nurses to use selective self-disclosure as a strategy to maximize

their influence has its roots in the lack of status of nurses in both the health care system

and government. Nurses needed to make strategic decisions about revealing their

professional identity to government colleagues and others based on their calculation of

benefit versus harm. The nurses rarely revealed their professional background when

meeting with physicians unless their nursing experience was a specific qualification for

their position. It is unlikely that physicians, lawyers, economists, or other professionals

have the same concerns for loss of credibility based on disclosure of their professional

identity during the advocacy process. This need for nurses to strategically determine

whether or not to reveal their professional background is consistent with the findings of

Gebbie et al. (2000) that nurses inside government distanced themselves from the

profession and at times found their ties to nursing to be a liability rather than an asset.

The underlying issues of the systematic devaluation of a group’s experience and

contributions are analyzed by Roberts (1983) in her application of Oppression Theory to

nurses in their role in health care. Freire (2000) discusses the self-depreciation of those in

oppressed groups as they interact with those who they view as the oppressor. The

dominance of physicians (oppressors) in health care and their influence over the

education and practice of nurses (oppressed) are well documented (Ashley, 1976;

Reverby, 1987; Starr, 1984). Additional studies across other disciplines are needed to

evaluate if this phenomenon of selective self-disclosure is specific to nurses and part of

the experience and strategies of other professionals inside the government.

To counter this status differential, nurses who had doctoral degrees sometimes

used these credentials to bolster their status with others when they estimated that there

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was a significant educational differential between them and their colleagues. This tactic

allowed them to meet their colleagues with greater confidence. Feldman and Lewenson

(2000) and Winter and Lockhart (1996) discussed the problems with collegial

relationships when there is a disparity in the education and socioeconomic status between

individuals. If nurses had comparable education to most of the other professionals in

health care, this lack of respect and status would be less of a barrier.

Translating and creating access were strategies that nurses inside the government

used to compensate for the absence of nurses in deliberations that they believed would

benefit from the nurses’ input, experience, or perspective. These strategies to remedy the

absence of nursing input were done openly at times and discretely at other times. It is not

enough to rely on nursing colleagues in government to identify these opportunities.

Nurses in major professional associations have government relations staff who must

watch for opportunities to involve nurses who have the knowledge and relevant

experience to make better policy. Improving their relationships and networks with nurses

and others inside the government will increase the effectiveness of this process. The lack

of knowledge about nurses and their potential contributions by those inside the

government must be openly addressed and challenged. As these challenges are made,

there must be adequate numbers of nurses to step forward who have the knowledge,

skills, and presence to serve in public positions of influence. Having a critical mass of

nurses who have experience in politics will make this pool of experts a more powerful

resource to draw from. In addition to encouraging nurses to compete for positions in

existing policy fellowship programs, professional nursing organization can increase the

access for nurses to positions inside government by creating their own fellowship

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programs at both the state and federal levels. This would provide more opportunities and

also give the professional nursing community the ability to directly prepare and mentor

these policy fellows.

The final two strategies, invoking others and careful truth were symbolic as

markers of status in government. The nurses in the study in legislative offices who used

these strategies had moved beyond entry level positions and were trusted and skillful

enough to be engaged in broader negotiations and deal-making. In the executive branch

agencies, these were nurses with formal authority and power who used these strategies to

negotiate within the constraints of the executive agenda and budget. Although these two

strategies have not been described specifically in the political science studies reviewed,

there is nothing inherent in these strategies that make them more or less relevant to nurses

than any other individuals inside government. It is important that nurses be at least as

skillful as others in using these strategies as they move into inner policy circles so that

they are using every advantage they can to have an impact.

The second research question is: Do these processes, tactics, and strategies

influence how issues and problems pertinent to nursing and health care appear on the

policy agenda and move through the political and policy-making process?

The key strategies in GIVING VOICE used by the nurses in the study that were

most effective in directly bringing the nurses’ concerns about health care to health policy

were translating and creating access. Although the strategies themselves may not be

specific to nurses working in the government, what is unique to nurses is the type of

information and insight that was shared based on the nurses’ knowledge and practice.

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The nurses used the strategy of translating to facilitate communication about

health issues between different groups by using their knowledge of nursing and their

practice experience in health care. This requires that nurses have both depth and breadth

in their education and practice background to do this in a way that is effective and

relevant. There is a risk that those with limited experience might make generalizations

that lead to faulty assumptions and ineffective policy advice.

Although the process of translating could be done by any professional with a

specialized knowledge base, there were no references to this skill as a specific strategy

found in the political science literature. Additional study of members of other professions

inside the government will reveal if this is unique to nurses or if it is a strategy used by

others was well.

Nurses who want move to advocacy work in the government should use this

strategy of translating to their advantage. As they seek entry to policy positions, they can

emphasize the value-added perspective this skill gives them in their positions. Nurses can

add greater impact to this skill of translating by broadening their knowledge base about

health care systems and finance so they expand their ability to translate to more topics,

have a credible knowledge base in these topics and do not attempt address broad issues

by generalizing from limited experience in specific situations. Preparing more nurses

with advanced degrees and implementing the practice doctorate for advanced practice

nurses will give pave the way for this level of involvement. Antrobus and Kitson (1999)

discuss the importance of translating in their study of “nursing leadership within a wider

socio-political framework” (p.10) and come to many of the same conclusions. The

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populist view of the nursing role as hands-on and operational limits the profession’s

credibility for policy activity.

The nurses in the study used the strategy of creating access both directly (for

themselves) and indirectly (for other nurses) to influence health care policy. The nurses

in government networked extensively to expand their circle of contacts and colleagues.

As they developed working relationships with larger numbers of individuals, the

decisions about selective self-disclosure became less important. Those who they worked

with acknowledged their contributions and expertise based on their experiences together

and whether or not they were a nurse became less important to others.

The participants also used their position inside government to proactively include

other nurses from outside government whenever possible as members of advisory

committees, to give testimony, or work on research projects when their expertise was

relevant. In a more reactive posture, they also alerted their colleagues outside of

government to argue for inclusion when they had not been included in initiatives that the

nurses in the government believed were important opportunities. This process of

increasing the access for one’s professional colleagues is probably not unique to nurses.

What is unique, however, is the systematic way that nurses have been excluded from

participation in policy-making in the past. The well documented lack of presence they

have in the policy and political circles requires both direct and indirect use of this

strategy to increase their ability to improve health policy through their participation.

Implications of the Findings

The findings of this study reveal that well-educated and motivated nurses who

work in the government are limited in their ability to influence policy by the lack of

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status of the profession and the dominance of the medical model in government. In

specific circumstances the advocacy processes used by nurses can work effectively to

inform the debate and reinforce the values of patient-centered and holistic health care that

they bring with them as professional nurses. However, nurses do not have significant

influence and are not present in large enough numbers to make a substantive difference at

this point in time. Nurses face the same challenges in government that they do in health

care. Nurses are at a disadvantage based on their status. The majority of nurses are not as

well educated or powerful as the other players in both health care and health policy who

have considerable political and economic power. Until the underlying systemic

conditions that create these disparities are addressed, the potential impact that nurses

have on health care policy in this country will be limited. There is not a critical mass of

nurses either inside or outside the government with the levels of education, knowledge,

and skills to translate these to a compelling voice to shape the health care system at the

national level. There are specific implications from these findings for education and

practice.

Implications for Education

There are four recommendations for education based on the findings of this study:

(a) Nursing programs need to prepare nurses with the motivation, knowledge, and skills

to function effectively as advocates in all settings, (b) nursing education must include a

foundation in the arts and sciences to provide the knowledge and skills that nurses need

to participate in the global environment of health care in today’s world, (c) nursing

programs need to better educate students about health policy and politics and provide

them with role models and more opportunities to participate in the political process, and

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(d) nursing education must continue to advance the entry level of practice to the

baccalaureate degree at a minimum so there are greater numbers of nurses able to move

to advanced degrees in the profession including research doctorates and practice

doctorates.

Education programs need to prepare nurses with the motivation, knowledge and

skills to be effective advocates across the range of health care settings. Whether nurses

are advocating from inside or outside of government, the ability to think critically,

analyze complex issues, articulate and debate positions will put them on a more equal

footing when dealing with colleagues from other disciplines. Whether they are

advocating for resources to support effective patient care in their work setting or

negotiating budget allocations in Congress, they must be as well prepared as other

professionals they work with and are competing against for funding and recognition. The

quality of education and skills needed to meet the demands of these roles are consistent

with the foundation of a baccalaureate education leading to opportunities to pursue

advanced degrees comparable to other professional colleagues.

It is essential that nursing professionals have a sound educational foundation in

the liberal arts and sciences to support the level of knowledge and skills needed by the

next generation of nurses to function in roles as proactive advocates for a more

responsive and effective health care system. The importance of understanding human

behavior, experiencing different ways of knowing, and acknowledging the needs and

perspectives of those from other cultures are important aspects of the education of all

health care professionals. Nursing students must study the disparities that exist and

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challenge the current systems that dominate health care delivery that fail to provide

access and basic preventive services.

The nurses in the study had to be prepared to work on many issues outside of

health care in order to fully participate in their roles inside government. To function at

this level, nurses need a broad base of education rather than a narrow technical

preparation. All of the nurses in the study valued and recognized the need for more

education as they worked in policy. All of the participants continued their education at

some point and received masters or doctoral degrees. If nurses do not have educational

preparation comparable to their colleagues, the biases evident in the socio-political

context that result in the invisible presence of nurses both in health policy and the

broader health care system will be perpetuated.

The nurses in the study had a varied background of politics and policy

information in their education programs. Nurses who had graduated in the 1990s and later

from their entry level program consistently had some content on the importance of

political action and the responsibility of members of the profession for advocating for

changes in the health care system through policy to improve care. The guidelines for

professional nursing education such as The Essentials for Baccalaureate Education

(1998) and The Essentials for Master’s Education for Advanced Practice Nursing (1996)

from AACN and the Code of Ethics (2001) by the ANA stipulate that advocacy through

health policy is an expected part of the professional nurse’s role. It is expected and

routine for current accredited nursing education programs to have at least basic content

on politics and policy in their professional issues courses. This professional recognition

of the need for more education on policy is a start, but not sufficient, if subsequent

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generations of nurses are going to move in greater numbers to roles inside the

government and swell the ranks of professional associations to give the profession a

greater role in policy advocacy and political clout.

More sophisticated and action-oriented content needs be introduced in

undergraduate, graduate, and post-graduate programs by threading advocacy by political

action throughout the curriculum. As specialty areas are studied and clinical patient cases

discussed, identification of barriers to effective care for patients and families can be

analyzed and interventions proposed that span from direct care, to policy advocacy, and

political action. Comments made by several of the nurses in the study underline how

important role models were to them in their education programs. These role models who

were actively involved in policy were sources of inspiration and mentoring as these

students recognized the importance of political action.

Faculty leaders need to be members of professional associations so that they have

current information on initiatives at local, state, and federal levels. Faculty leaders also

need to be engaged in political action so that they are role models. Taking students to

events such as conferences, hearings, legislative receptions, and lobby days are ways to

expose nurses to these activities in a structured environment where they have support and

feel safe to raise questions, challenge the status quo, and develop skills in dialoguing with

elected officials.

The education of nurses is the most significant factor in the low status or

invisibility of the profession in the socio-political context of health care. Nurses who are

motivated by social injustice represented by the disparities in the current health care

system that they experience on a daily basis must have the knowledge and skills to act on

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behalf of their patients to change these. All nurses need an education that prepares them

to advocate for the level of care that is explicit in their social contract with the public

(ANA, 1985). The inability of the profession to establish the baccalaureate degree as the

entry to the profession is a testament to the control of other dominant players in health

care and education over nursing. The recent introduction of the practice doctorate for

advanced practice nurses will put these nursing professionals on a comparable

educational plane as other providers with practice doctorates: physicians, pharmacists,

and physical therapists. These nurses with practice expertise and knowledge of the health

care system and financing will augment the number of nurses with advanced degrees

needed to engage in responsible and compelling advocacy. The pipeline for these

education programs must be fed by greater numbers of baccalaureate-prepared nurses if a

critical mass of practitioners is to enter health care and achieve the goals discussed

throughout this study.

Implications for Practice

Nurses in direct care need the skill, motivation, and opportunity to identify gaps

and barriers that prevent patients, families, and communities from receiving the care they

need. These gaps and barriers need to be studied by nurse researchers with system

expertise who can translate their findings into mandates for public policy and political

action. Nurses in professional association advocacy programs need to position themselves

as integral members of health policy networks who consult with elected officials, health

policy directors, and staff throughout government. Nurses must be advocates who

identify and are prepared with data to support the needs of consumers to make policy that

is responsive and effective.

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Nurses as a special interest group need to be a force to be reckoned with by

government leaders to achieve this kind of change through advocacy. As Freire (2000)

urges in his work, the goal of meaningful change to fight for humanization of systems

that oppress is only achieved by action informed by reflection (praxis). This same term

praxis is used to describe the integration of the knowledge and expertise of nurses applied

to the work they do on behalf of their patients. This model of advocacy for better health

care through the humanization of health policy is the model for what nurses need to do

more effectively.

Nurses in practice can increase their importance and visibility to the public and

others by articulating and emphasizing the intellectual aspects of their role.

Demonstrating and taking credit for the critical thinking and problem solving that it takes

to provide care for patients gives nurses greater credibility than attributing their success

to “caring”.

As the feminist journalists Bernice Buresh & Suzanne Gordon (2000) discovered

in their work on nursing and the public media, nurses are too often reluctant to “articulate

the skill and knowledge embedded in their practice” (p. ix). Through this process of

moving from “silence to voice” (Buresh & Gordon, 2000), nurses not only empower

themselves but as their voices are heard and they move from “voice to action”, they

become valued by those in positions of power in health care and policy.

This change requires more than just learning new communication skills. This is a

change in professional mind set that embraces the accountability of professional practice

and rewards members for taking risks and challenging the status quo. The culture of

nursing must support nurses who are vocal public advocates and fight for a more

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powerful role in health care. Giddings (2005a; 2005b) raises some troubling questions

about the culture within nursing and oppression of nurses by other nurses. In a discussion

of her model of social consciousness, she relates the struggles of nurses from

underrepresented groups in her study as they identify with and begin to advocate for the

needs of the oppressed. These nurses are marginalized by fellow nurses as they fight the

status quo and do not follow the rules of the dominant culture in health care. This

oppression of fellow victims is described by Roberts (1983) as horizontal violence in her

work applying oppression theory to nursing. The inability of oppressed groups to directly

oppose those in power results in violence toward fellow victims. As nurses seek inclusion

in health policy, they must work to make sure they don’t in turn become the oppressors of

others within health care. As Freire (2000) advocates, the goal of nurses should be to

work along side others to achieve a responsive and effective health care system which

meets the needs of all and values the contributions of many.

Robert’s (1983) application of oppression theory to the experience of nurses in a

system dominated by doctors uses the framework of critical social theory to examine the

disparities in power between nurses and physicians. She talks about the importance of

raising the awareness of those in oppressed groups about the systemic conditions that

maintain the disparities and perpetuate oppression. Nurses must raise their awareness

about the conditions such as educational entry to the profession that perpetuate their

oppressed status in health care.

Although the professional socialization process that creates the awareness and

teaches the skills to have a full and active role in health policy advocacy starts in nursing

education programs, leaders in practice must continue this process. Leaders in practice

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must actively encourage membership and participation in professional associations. They

can serve as role models and mentors and build expectations for advocacy into the reward

structure of clinical career ladders and professional development programs. Having

nurses who are working in health policy advocacy speak to nurses in practice can

demystify the process and reinforce the importance of how health care policy and

regulations control their practice and affect the health care their patients receive. More

nurses in practice need to know about the opportunities to work in fellowship programs

so that those who have the interest, skills, and motivation can gain experience in

government. Leaders in the workplace need to encourage this activity and colleagues in

practice need to support these risk-takers.

Nurses need to be more aware of opportunities to enter health policy roles.

Students and members of the profession need more exposure to those who work in

government to see nurses successfully using their skills and knowledge to improve health

care. Nurses, both in practice and in graduate programs, need to know about and be

encouraged to compete for positions in health policy fellowship programs. Faculty in

graduate programs and leaders in practice need to encourage the best and the brightest to

take these opportunities. Nurses who are interested need active mentoring by those with

experience in such programs. They need coaching to prepare for the rigorous application

and interview process so that they articulate their skills and contributions effectively as

they compete with others from different professions. As more nurses advance their

education to attain masters and doctoral degrees, the numbers who have the skills and

interest in improving health care through policy will increase. This specialty role must be

valued and marketed as an important role for nurses.

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Implications for Nurses Advocacy

Getting More Nurses Inside of Government

The nurses in the study agreed that having nurses inside of government had a

positive influence on policy but this impact was limited to issues directly related to

nursing such as workforce issues and funding for nursing education. In these cases,

nursing input was valued and sought by others. For most other issues in health care, the

dominance of medicine persists. It will take a critical mass of nurses working inside

government as elected officials and staff and outside government as a more powerful

special interest group to achieve a significant paradigm shift from the medical model to a

more interdisciplinary health care model. Nurses used the various strategies described in

the model to maximize their influence in broader areas of health policy when they were

not included in the process.

If more nurses are going to move inside the government they need the skills to

adapt quickly to this new culture and be successful. Some of these skills can be learned

through better preparation in masters and doctoral nursing education programs and

reinforced through experience in leadership roles in practice. Nurses need to have a broad

understanding health care systems and sophisticated communication skills such as

collaboration, conflict negotiation, coalition building, analytic writing, and public

speaking. They need the knowledge and skills to articulate their stance on issues, make

decisions in the presence of conflict, debate the issues, and support their views.

The motivation for nurses in the study to enter government was their recognition

that so many factors outside of the practice setting determine what health care is available

to their patients. To assure that this motivation to improve care continues in new

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generations of nurses, students entering the profession must be socialized with the values

that demand advocacy and political action as part of the duty of any health care

professional.

Nurses must take advantage of multiple points of access to work in government

and health policy. They need to use their skills and experience to enter many different

types of positions that are a match for their skill set and not limit themselves to jobs

specifically recruiting nurses. Opportunities to work at all levels in government including

elected office must be actively pursued.

Special Interest Group Strategies

Although the nurses in the study agreed that having nurses on the inside of

government made a positive difference in the policy process, they encouraged nurses to

persist and sharpen their advocacy as an outside special interest group. Several of them

pointed out that nurses on the outside, particularly with the weight of their professional

associations or organizations behind them, could ask tough questions and demand actions

that were beyond the boundaries of their positions inside the system. The nurses in the

study had very specific ideas and advice to give other nurses to improve their lobbying

and advocacy skills as a special interest group outside the political system. The most

pressing area for attention is the need for diverse nursing organizations to present a united

front to legislators when meeting with them to discuss their issues. Many authors in both

the political science literature and the nursing literature have noted this lack of focus and

unanimity as a significant area of weakness for any group. Professional associations and

special interest groups within the profession must learn to negotiate these differences

behind closed doors, come to a compromise, and present a united front to policy-makers.

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Whatever short term gain a specialty group might have from an entrenched position will

perpetuate this Achilles heel of professional nursing advocacy and hinder the

development of credibility and clout for the profession.

Particularly disturbing was the quote from one of the nurses in the study that

others in politics knew that bringing up the “educational entry into practice issue” would

consume nursing groups with in-fighting to the extent that the others could proceed

without including them at the table where the decisions were being made. Nurses must

anticipate this decoy issue and refuse to be derailed by this. The profession must deal

with the need for a single level of entry for the profession of the baccalaureate degree.

There is no doubt the failure of the profession to deal with multiple entry levels of

education is a root cause of the inability of nurses to share a professional vision and

strategy. There are such discrepancies in the levels of education, expertise in practice, and

vision for the profession among nurses that true solidarity may never be achieved until all

nurses share a common base of professionalism rooted in their education.

Many of the nurses who worked in legislative offices mentioned that nurses did

not maximize the impact of their contact with legislators and staff because they failed to

make the “ask”, that is, make specific requests for action. When nurses or other groups

meet to express their concern with an issue, the staff listens attentively but are often

under no obligation to take any action because none is requested. When groups ask a

legislator to support an issue, they need to be specific: (a) Request the elected official to

sponsor the bill; (b) call and pressure the committee chair to get a bill on a committee

agenda or be reported out of committee; or (c) shepherd the bill through the committee

process. Simply asking the legislator to vote for a bill if it comes to the legislative floor is

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letting the legislator and staff off the hook -- most bills don’t make it that far. They know

this is a promise they will probably not have to keep.

From staff’s perspective, the easier that those who lobby make it for the staff to

help them, the greater the likelihood that they will. The participants gave specific

examples about how to accomplish this goal:

1. When requesting a letter to support an issue, come with a letter drafted that they

can send. Staff members can use it or not but you have given them the template to

accurately express your point of view and that saves them time.

2. When meeting with staff and giving them data to support your position,

summarize the information in a concise one to two page summary. Make the

studies or articles available to them if requested but don’t expect staff to wade

through research studies to pick out salient points.

3. If staff members call to request additional material or clarify issues, get back to

them quickly. Follow through if you tell them you will provide them with

additional information.

4. On a routine basis, don’t threaten to inundate them or the office with calls, letters,

or faxes. Make a point to ask staff what kinds of grassroots support will help with

promoting nursing positions. Tell them you will take information back to update

your membership after your meeting.

5. Avoid giving the impression that you are seeking any personal gain from your

involvement. Frame the issues in terms of how the public or the constituents in

your legislator’s district will benefit from the positions that you are advocating.

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6. Anticipate the political impact this issue might have on your legislator. Good

policy and good politics are two different things. Reelection pressures are real so

anytime you can put a positive political spin on your issue for the legislator, you

have a better chance of success.

7. When you work with a nurse who is inside a legislative office or agency, find out

what the individual knows. Don’t assume the nurse will automatically support you

because you are a nurse or you are advocating for a nursing issue.

8. Ask the nurse what she needs from you to be an effective inside advocate. (As one

nurse noted, she relies on the Congressional Budget Office (CBO) and the

Government Accountability Office (GAO) for information. The nursing and other

professional health care literature is not on her radar screen because of time

pressures and the diverse nature of the topics she needed to learn about.) If there

are important studies, bring them to her.

Nurses need to learn and practice these lessons about policy advocacy to maximize their

influence. Resources on political action discuss many of the same suggestions but

feedback from the nurses inside government in this study indicates that nurses can do a

better job.

Limitations of the Study

The participants in the study included nurses who had experience in both

legislative and executive branch agencies. All were in full time positions but some were

on fellowships that lasted between one to two years. Restricting the sample to nurses

from either fellows or full time staffers may have resulted in additional strategies or

tactics specific to the different roles. The initial experiences they had as they transitioned

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to their roles on staff and the first four steps in the process of GIVING VOICE—learning

the culture, selective self-disclosure, translating and creating access-- appear to be

similar for all of the participants. In this study, it was the nurses who were in staff

positions (full-time permanent) and not fellowships (full-time temporary positions) who

moved to the final two steps in the process of invoking others and careful truth. This

makes sense from the perspective that those nurses working in their roles for longer

periods of time had the opportunity to develop the knowledge, skills, and relationships to

support this higher level of functioning. They also had greater potential rewards for

increased investment in the role if this was their career path.

A second limitation of the study is that there were no male participants in the

sample. The absence of male participants was not from intentional selection bias but the

result of only females being suggested by the researcher’s contacts and by the early

participants in the study. Because nursing is a predominantly female profession, it is not

unexpected that females will be represented in higher numbers in these more specialized

roles. This raises the following questions: (a) Would males in nursing experience the

same kinds of barriers to advocacy in government positions as the females in this sample?

(b) as the number of males in the profession increases, will there be a proportionate

increase in the number of men in nursing who move to positions inside government?

Males inside the government may have different strategies based on gender influences. In

particular, the process of selective self-disclosure may have different dynamics based on

gender differences.

Although there are some nurses who hold elected office in the federal

government, they were not contacted for participation in this study. Elected officials have

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formal power and authority by the nature of their position which would fundamentally

alter the processes that were studied. For example, elected officials would not have the

challenge of determining the boundaries of the legislator’s preferences and priorities;

they would be setting these agendas themselves. A separate study is needed for nurses

who are elected or appointed to government office to see how they determine their

priorities and what success they have in influencing health policy and nursing issues.

The diversity of the participants is a strength of the study. The participants include

nurses across a range of ages. (Although the age of the participants was not asked, an

approximate age could be determined based on the dates of graduation from basic nursing

education, years of experience, and the presidential administration during which they

served). The nurses have different numbers of years in practice, different specialties, and

different types of advanced education. Their initial educational entry to the profession

includes all types of programs. The participants served in different legislative offices and

executive agencies, across different presidential administrations, and in offices of

legislators from both major political parties. The participants included both civilians and

uniformed officers.

A common factor among the participants was the nurses’ willingness to

participate in the study and their openness in sharing their experiences. No nurse

contacted by the researcher who met the study criteria refused to be interviewed. They all

conveyed their pleasure that a nurse researcher was interested in nurses who moved to

government, an advocacy role that they believed was important in improving health care.

Some participants stated that the experience of telling their story and discussing their

work was validating for them. One nurse who had experienced some frustration in her

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role stated that being given the chance to tell her story during the interview was a

therapeutic experience for her.

The researcher has experience in policy advocacy through professional

associations. Every effort was made by the researcher to interview and listen to the

participants and analyze the data without imposing her own frame of reference,

vocabulary, or experiences. Despite this awareness and strategy, it is possible that the

researcher’s personal experiences were a factor in the interpretation of the findings.

Recommendations for Further Research

This study did not include nurses who held elected office. Additional study of

nurses and members of other professional groups will determine if the strategies of

selective self-disclosure, translating and creating access are used by those from other

professional backgrounds and those with formal power and authority of their office.

As the number of men increase in the profession, more will move to these

positions in government. Study of their experiences with the strategies in GIVING

VOICE will help to delineate the influence of gender bias from other sources of bias that

appeared to make nurses feel disadvantaged when identified as nurses.

Additional outcomes research is needed that provides evidence of the impact

nurses have in the health care system and the cost-effectiveness of their services. Studies

on nursing care must measure cost, quality, and access. These three measures are used to

evaluate all types of health care services and the effectiveness of programs. Although

research data alone is not enough to achieve change, sound data used skillfully by nurses

to advocate for changes in health care can be powerful.

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Process Recommendations

The following recommendations for communicating with individuals inside

government facilitate research with this population. Because of security and safety

concerns related to anthrax attacks, all US postal mail goes through a circuitous route

before being delivered to government offices. The researcher discovered early in the

sampling process that email was the most efficient and reliable form of communication.

Email addresses were available on line through government websites for nurses in federal

agency positions. For nurses in the legislative branch, telephone contact was made first.

Staff in the legislative offices would not disclose email addresses on the telephone;

however, they did forward the caller to the individual’s voice mail. Once successful

telephone contact was made, all participants were willing to give the researcher their e-

mail addresses for further communication. Email attachments were used to send the

participants the letter of introduction explaining the study, the consent form to review

before the interview, confirmation of the scheduled appointments, reminders of the

scheduled appointments a few days before the researcher’s trip to Washington, and a

thank you letter at the end of the interview. The researcher also provided the participants

with a cellular phone number for contact while in the Washington area. The schedule of

individuals in these positions can often change on short notice. One participant called to

reschedule the appointment based on work-related demands.

The interviews were scheduled when the federal government was in session

during the late spring. The availability of the nurses in legislative staff positions might

vary when the legislature is in recess. The federal agency staff were available during this

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same time although, from comments made by some of the participants, interviews during

preparation of the federal budget might be limited by time constraints.

The researcher was required to show picture identification and pass through metal

detectors at security check points for access to all of the participants’ offices both in

legislative and agency buildings. In federal agency buildings, the researcher was escorted

to the participant’s office by the participant or a staff member from the security check

point.

All participants were in locations accessible by public transportation. When

scheduling the appointment the researcher asked the participants for the metro line and

stop closest to their office. This was particularly important for nurses in federal agencies

that are scattered throughout the greater Washington, DC area including Virginia and

Maryland.

Conclusion

Nurses who work inside government to advocate for changes in health care use a

variety of strategies and tactics. The two most effective strategies for influence used by

nurses in the study were translating and creating access. The nurses in this study also

used an additional strategy, selective self-disclosure to deal with barriers to their

influence in health care policy based on their lack of status in a system dominated by the

medical model. The issues underlying the need for this careful situational scrutiny and

decision-making are based in the underlying socio-political context of health care and

policy in the U.S. Until nurses attain comparable education and skills as other players in

health care policy, they will not have the influence or power base, supported by a critical

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mass of highly educated nurses in both government positions and elected office to openly

and actively make changes in health care.

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Appendix A Interview Questions

Grand tour (Opening) question

1. Could you tell me about an experience working in your

legislative/administrative role where you worked to move an issue to the

policy agenda and through the policy or political process?

Probes

a. What specific tactics and strategies worked well? Did not work well?

b. What did you learn?

c. What skills were most valuable in this situation?

d. What resources did you use?

i. Networks and contacts

ii. Nurses in the professional community

iii. Special interest groups

iv. Others

How did you make contact?

In these examples, what role did you play either openly or “under the radar”?

What advantage/disadvantage was it for others to know whether or not you

were a nurse?

2. Can you give me another example and discuss if you were MORE or LESS

influential than in the example already given and why was it different?

Probes

a. What specific tactics and strategies worked well? Did not work well?

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b. What did you learn?

c. What skills were most valuable in this situation?

d. What resources did you use?

i. Networks and contacts

ii. Nurses in the professional community

iii. Special interest groups

iv. Others

How did you make contact?

In these examples what role did you play either openly or “under the radar”?

What advantage/disadvantage was it for others to know whether or not you

were a nurse?

3. What major problems are (were) you and others in the health care area most

occupied with during the time you have been (were) in this role?

4. How were these issues similar or different?

5. Currently what issue is most important and why is it a priority?

6. Who decides which nursing interests are addressed?

7. Do you have any suggestions for other nurses desiring to influence a political

agenda?

8. Is there anything else I have not asked you that you would like me to know

about?

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Appendix B

Demographic Data Collection Form Thank you for participating in the study. Please take a moment to complete the information below. (For researcher use) ID Code: Name: Address: Phone: ( ) Email: Fax: ( ) Number of years in practice as a nurse: Major practice Site/Specialty: Initial program of study in nursing: Practical Nursing ____

Diploma ____ Associate Degree ____ Baccalaureate Degree ____ ND ____ Other (please specify): ______________________

Year of graduation from initial program of study: Highest degree attained in nursing: Year attained: Highest degree attained in another field: Area of study: Year: Do you maintain a current license registration in any state? Yes ____ No ____ Do/Did you belong to any professional nursing organizations while you were in your role in the government? Yes ____ No ____ Names of organizations: Did you belong to any professional nursing organizations before you were in your role in government? Yes ____ No ____ Names of organizations:

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Appendix C Informed Consent Form

Dear Nursing Colleague: Thank you for agreeing to be interviewed for this study that is being conducted for my dissertation to complete the requirements for the DNS degree from the State University of New York at Buffalo. The title of the study is: A grounded theory study of nurse advocacy in health policy. The study examines what strategies nurses in legislative or regulatory positions use and what influence this has on health care or nursing issues. By agreeing to participate in this study

1. You agree to meet with the researcher in person or over the telephone at a mutually agreeable designated location and time for approximately one hour.

2. You agree to have the interview taped by the researcher. 3. You will be available if needed to clarify topics from the interview at a later time

by telephone. 4. You understand that you are free to withdraw from participation in the study at

any time. 5. You consent to the data collected during the interview being used for possible

secondary analysis in the future with all of the same confidentiality protections. (Data from this study might be suitable for a different type of analysis. Your transcribed interview might be used at a later date for another research project by this researcher.)

To protect your rights and confidentiality

1. The study proposal has been approved by the Social and Behavioral Sciences IRB at SUNY Buffalo.

2. You will not be mentioned by name, position or party affiliation in any of the research results or reports.

3. Every effort will be made to select narrative quotes to illustrate the concepts analyzed in the research in a manner that protects the anonymity of all participants.

4. Participants will be linked to the data by an identifying code known only to the researcher.

5. All data including research field notes, participant codes, audiotapes and transcriptions of the interviews will be kept in a file in the researcher’s home office.

6. You will receive a copy of this consent form for your records that includes contact information for the researcher.

Possible Risks

Due to the small numbers of nurses in policy and political positions in the federal government, it is possible that an immediate peer of a participant who reads the research report might identify a participant as a participant in this study. However,

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steps will be taken to reduce this risk. No participant will be mentioned by name, position or party affiliation in any of the research results or reports. In addition, every effort will be made to select narrative quotes to illustrate the concepts analyzed in the research in a manner that protects the anonymity of all participants. If politically sensitive issues or sensitive personal matters are discussed by a participant, no information related to these will be used in narrative quotes or related to a participant by name, position or party affiliation anywhere in the research results or reports.

Participant Statement: I have read the explanation provided to me. I have had all my questions answered to my satisfaction, and I voluntarily agree to participate in this study. Signed: ____________________________ Date: ___________________ Audio Tape Consent Form I consent to being audio taped during this study. Signed: ____________________________ Date: ___________________ Researcher Statement: I certify that I obtained the consent of the participant whose signature is above. I understand that I must give a signed copy of the informed consent form to the participant, and keep the original copy in my files for 3 years after the completion of the research project. Signed: ____________________________ Date: ___________________ Contact Information: Researcher: Marilyn L. Dollinger mdollinger@sjfc.edu

Dissertation Chair: Dr. Nancy Campbell-Heider State University of New York at Buffalo 913 Kimball Tower, South Campus, Buffalo, NY 14214-3079

nheider@buffalo.edu

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Appendix D

Background: Transition from Practice to Policy

Transition: Motivation to Leave Practice

The most consistent reason that the nurses in the study gave for moving into a

position in the federal government was their desire to work to improve health care in a

different way than was possible for a practicing nurse. Many factors that affected how the

health care system operated (such as funding levels for nursing education and

reimbursement policies and regulations) were out of their control, yet had a significant

influence on how the nurses were able to practice their profession.

Barriers that limited access to care for the patients and families the nurses worked

with were a common source of dissatisfaction with the current health care system.

Despite voicing this common concern from their practice experience, none of the nurses

in the study came to their positions in government with this or any other specific agenda

for policy change. All of the participants agreed that in order to survive inside the

government, one needed to have a broad focus on policy that encompassed more than

nursing and health care issues. One of the challenges they faced in their government jobs

was becoming knowledgeable about issues in many areas other than health care. The

ability to work across many different issues and topics was important in establishing their

credibility among those they worked with. Anyone who came to government hoping only

to advance issues particularly affecting nursing would not survive the dynamic and fast-

paced world of policy-making.

In addition to their common concern for access to care, some nurses expressed

frustration with working conditions. Others perceived that the health care system was too

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slow in responding to the needs of patients and families. One nurse stated that her efforts

to advocate for change from her role within the bureaucratic and hierarchical health care

setting was ineffective and created conflict. The barriers she encountered led her to seek a

role in government, which she believed would give her a more effective voice for change.

Other participants had been involved in projects funded through federal grants. Based on

these experiences, they wanted to learn more about the grant-making process and have

some influence on how these funds were awarded. Some of the nurses had become

involved with advocacy and politics in professional associations. They found that they

enjoyed policy advocacy and through their successes developed an interest in regulatory

issues that led them to move to work in government.

Some nurses worked in a variety of settings in and around government in

Washington and eventually found roles that fit with their interests in health care. One

nurse commented that her interest in bioterrorism seemed to “follow her around” in her

different roles. As she worked on this issue from different perspectives in various jobs,

she eventually found a niche in a specific role that allowed her to use this expertise that

suddenly became extremely valuable. Another nurse, who had been in Washington for

years in a variety of agency and government roles, was committed to political action

advocacy and now works in a role fostering these opportunities for others.

Transition: Access to the Government

Once the decision was made to move from professional nursing practice to

government, the nurses in the study gained access to these roles in a variety of ways.

Some entered legislative offices as fellows of different programs; others were promoted

to positions within the uniformed services which gave them advancement opportunities in

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the executive branch; and, others were offered jobs based on personal relationships that

they had made working in state government. A few participants heard about openings in

legislative offices or agencies through their professional and personal networks while

they were in practice and they decided to take a chance and apply for the positions. Some

of the nurses in the study entered government through positions that required a nursing

background; others entered positions based on their general qualifications for the job.

Transition: Skills for New Roles in Government

The transition from being a nurse in the health care system to a nurse working in

government was challenging. Although the nurses came with many skills (good listening

and communication skills, experience with conflict negotiation, the ability to prioritize,

and work as a team player), all of the participants said they faced a steep learning curve

that required intense effort to understand the world of politics and policy. Reading,

listening, asking questions, and attending hearings and briefings were mentioned as

important ways to learn more about the political system and the policy process.

Many of the nurses in this study had learned about politics and the policy process

as part of their nursing education. The extent of this background was determined by when

they were last in school. Nurses, who had been to graduate school or done doctoral work

in the last five to ten years, had some content on policy-making and politics in their

education programs. Those who had not been in school since their entry level preparation

in the 1960s through the 1980s did not get any content on policy and politics. All of the

nurses in the study said these concepts and skills were important to include in

professional nursing programs. Even those who had some policy content in graduate

school commented on how much more information they needed to function effectively in

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the government. The basic content covered in most nursing education programs about the

legislative, regulatory, and lobbying processes was very different from the reality they

confronted on the inside of the system.

Some of the nurses believed that negotiating the politics of practice and academia

was good preparation for their work in government but they soon realized that they were

dealing with a completely different level of politics in Washington. Three of the nurses in

the study comment below on their experiences:

[There was] a lot of depth that I had not gotten in my doctoral program. In fact, if

there’s one thing that I really was surprised [at] at the end of my orientation, I

found myself saying, how could I have a doctorate in health policy and not know

all this stuff? (#5 p.50)

The second nurse comments:

And I thought, our hospital is pretty political and I worked through a lot of the

political things but, Washington, D.C., is political like nothing I had ever seen in

my life. So I was very naive. I was so much a neophyte in all of this. (#3 p.25)

The third nurse compares her experiences in academia and government:

I think that an awful lot of my political strategizing I learned in the universities

that I worked in. At least here [in government], it’s on the table and it’s out

front….I made mistakes back in universities that I think I learned from….

realizing that there are certain people that are just out for themselves and you need

to figure out that they’re not going to bend and you need to know what their

hidden agenda is in order to move something along. And I think if you’ve been

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through the politics of a university, sometimes that-- regardless of this nursing

piece--that those skills helped. (#10 p.11).

A consistent challenge identified by all of the nurses was their need to develop a

broader, more global awareness about how things were done in the government and the

agencies. This was a significant shift from clinical practice and academia where one

becomes specialized and expert in a specific area. One nurse with experience in academia

states:

[In academia] there was a little bit of a drive to get better and better and smarter

and smarter and narrower and narrower in the expertise realm, which was a total

shift from coming here, which was – you got much broader and much more global

in what you were thinking and how it all played out. (#11 p.46)

The nurses in the study had different opinions about whether or not advanced

degrees were needed before entering government work. Some nurses in the study stated

that their practice experience and knowledge of the health care system was their most

important advantage when they entered government. Once inside, they were able to pick

up policy content and political skills. Other nurses recognized after their initial

experience in government that they needed more education and returned to school to

pursue advanced degrees in policy or public health so they would be better prepared to

work in these roles.

Nurses, who came to government with advanced degrees in nursing or other

professions, believed that the greatest advantage from their graduate study was the ability

to look at health care issues with a broader world view. Regardless of their level of

education or how well prepared they felt, most of the nurses in the study possessed more

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confidence in their health care expertise than their knowledge of politics or policy.

Entering government jobs as political novices, their involvement on issues was usually as

one member on a team of staff members. This teamwork gave them an opportunity to use

their health care experience on issues while learning more about the legislative and policy

process from the other staff members.

When the participants in the study were asked if an advanced degree was an

important factor in being successful, most stated that it was helpful but that personal

qualities of perception, motivation, and passion were more relevant to their success than

any specific educational background. Their level of education was, however, a significant

factor in their strategy of selective self-disclosure. All of the nurses agreed that even with

advanced degrees, the world of politics and policy is a challenging and complex maze of

formal and informal networks, spoken and unspoken rules, visible and invisible

protocols, public and hidden agendas, and public service and self-interest.

The nurses in the study also discussed the need to stay grounded personally and

keep one’s ego out of the political process in order to be successful. They learned that

politics is not personal and having an “it is not about me” perspective is important in

order to survive and thrive on the inside of the political world in Washington, DC. As one

nurse states, “If you come there looking to set up your own reputation, you shouldn’t be

there because it’s really not about you. I never had any trouble doing that in my career

but it did cause some trouble for people” (#9 p.19).

Another nurse comments on how her nursing education trained her to keep personal

issues out of her work:

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When we were trained as professional nurses – and this is going to sound funny,

but it’s really true, we were taught that there was no place for us in the clinical

environment. It wasn’t about us; it was about the patient….That was how I was

taught…it isn’t about you…. It’s a very important stage of professional

development and it’s about how you interact with the world….that early training

of focusing on the behavior and the individuals. I think it became a natural thing

for me to build on and I’ve applied it in many different forms, in different ways.

(#11 p. 33)

Another nurse relates how her role in practice, using informal power and indirect

influence, prepared her for surviving in the political environment:

You [newcomers to government] haven’t been in the trenches; you haven’t been

there all night long on negotiations…and when you come in to these rooms [in

government], they already know that you’re kind of this puffed up, big shot PhD

whatever….It would be very easy to derail the process and completely

disempower yourself. And I’ve seen people do it…by that sort of pompous,

arrogant [approach]…. It always boggled my mind when people do that but I

think probably one of the skills that I had learned a long time ago, and I think

nurses are just really good at this, and that is to, not blend into the woodwork but

you don’t have to beat people over the head….I learned a long time ago in

nursing, you may only get one chance to earn someone’s respect, so choose it

carefully and choose it wisely. (#9 p. 33)

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Future Goals of the Nurses in the Study

Although all of the participants remained passionate about health care advocacy,

their future goals were varied. At the time of the study, all of the participants who were

not currently in legislative or agency positions were still involved in active advocacy

roles in the Washington, DC area. Some left their jobs after a period of time because the

positions that they held in either the legislative and executive branch were not family-

friendly. The demands of long hours, evening events, timing of votes, hearings, and the

significant amount of work done at receptions interfered with attention to children and

family. As one nurse describes:

Capital Hill’s not a great place for a woman with children….I often said I would

have never left the Hill if I had had a wife. I mean, that sounds very sexist…but

it’s true. It’s just not family-friendly for women. The hours are very irregular.

You have to be devoted to your member and life in the Senate. [Other] people

usually work nine to five. In the Senate, that’s when we start working, five

o’clock [p.m.]…It’s not uncommon for them [the sessions] to end up, sort of nine

[o’clock] or whatever. And in order to really serve your member, you need to be

there, at least [it was] in my job as a legislative director because who knew what

legislation was going to come up? ….I just felt I needed to be there. And when I

couldn’t go to dive meets and missed baseball games… I thought the quality of

life for my children really needs to be considered. That’s when I decided that it

was time for me to get a regular job. (#1 p. 22)

Some of the participants planned to return to professional practice in health care

after their time in government. A few of the participants had opportunities to enter new

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roles in health care that would allow them to utilize their new political and policy skills.

Others spoke of catching “Potomac fever”-- wanting to stay involved in policy and

politics in Washington-- and having no desire to return to professional nursing practice.

One nurse said she was “substituting one addiction for another” in politics by moving

from the Hill to a nongovernmental agency to continue her career.

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