The Policy Cycle, External Influence and the Role of the Chief Nursing Officer

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The Policy Cycle, External Influence and the Role
of the Chief Nursing Officer

• Dr. Judith Shamian
• President and CEO of the Victorian Order of
  Nurses, Canada
• Former Chief Nursing Officer for Canada
  (1999-2004)

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• Role of the CNO
• Provides advice to government
• Provides access to decision makers
• Participates in agenda setting
• Retains authority
• Is the visible face of nursing for a nation
• Is a unifying voice for diverse interests and
  roles

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Public Policy Politics

• Policy is focused on content
• Politics is focused on process choosing policy
  and getting it implemented

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The Policy Cycle

• 4 Major Stages
• Setting the policy agenda
• Moving into Action/Legislation
• Policy Implementation
• Policy Evaluation

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The Policy Cycle Stage 1 2 8 steps
Adapted by J. Shamian and ONP, from Tarlov, 1999
Getting to Policy Agenda
Values Beliefs
Problem or Issue Emerges
Regulation, Experience Revision
Knowledge Development Research
Public Policy Deliberation Adoption
Public Awareness
Interest Group Activation
Moving into Action
Political Engagement
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1. Setting the Policy Agenda

• Identify problem and bring to the attention of
  government
• Healthy Workplaces for Health Care Workers
• Problem identified over 20 years of research
• Large body of evidence to support findings
• Nursing Health Human Resources researchers played
  a major role in generating knowledge and
  disseminating it to policy makers
• Currently many policy initiatives underway in
  Canada

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Values and Cultural Beliefs

• Action on any policy issue must be firmly
  grounded in a supportable set of values
• Dealing with workplace and nursing issues what
  values are demonstrated by government, employers
  and others?
• Value in the policy context is influenced by
  public good, needs, demands

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Healthy Workplace Example

• 4 dominant values
• Canadians are firmly in support of the Canada
  Health Act
• Nurses are an essential part of the Healthcare
  delivery system
• To offer both access and quality, the health care
  system needs nurses
• The public trusts nurses

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Emergence of Problem or Issue

• Essential for issue to land on fertile soil and
  be nurtured
• Must have urgency
• Must be visible and important to others (not just
  those directly affected)

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How do we become aware of define the problems?

• Indicators
• routine monitoring, government studies
• pervasive, powerful, necessary
• Crises, Disaster, symbol or major event may
  highlight an indicator
• Feedback on certain governmental programs
• Values, interests, ideals influence the problem
  definition
• A lot of marketing involved in this step!

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Health Workplace Example

• Nurses were very vocal in articulating the
  effects of organizational downsizing on their
  workloads
• In 2000 frustration reached its breaking point
  and highly visible job action brought publicity
  to the issue

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Lomas Beyond the sound of one hand clapping

• Why is context important?
• We need to understand the context in which issues
  are brought forward and how they are dealt with.

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Knowledge and Development of Research

• Once issues are clear, research required to back
  it up
• Needs to be accessible and compelling

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Healthy Workplace Example

• Large body of knowledge accumulated over 20 years
• Key national reports contributed significantly to
  developing policy initiatives
• Nursing Human Resources Researchers lead the way
• Canadian Nursing Advisory Committee Report
• Major Government sponsored reports followed
• Kirby, Romanow Reports

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Public Awareness

• Creating broad-based awareness of both the issue
  and the strategy for addressing them
• Identify supportive audiences and customize the
  message
• Dissemination through print and broadcast media
  is important

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Media Public Opinion Shapers

• More than just the facts.
• Use of editorials, columns, etc endorsements
  during elections, parties elected severely affect
  the type of policies that follow
• Use of images
• Use of polls

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SARS

• Media images masks, empty streets, fear
• How did Governments deal with it?
• Why did it happen the way it did?

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Political Engagement

• Critical for success
• Know the government structure and key members
  within it
• Target those who share interest in the issue
• Person-to-person contact important
• Customize message
• Keep those interested updated on the issue
• CNAC Report

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Lomas Different decision makers

• Legislative
• Administrative
• Clinical
• Industrial

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Interest Group Activation

• Important to exploit every opportunity to repeat
  message
• Build ripples of interest into tidal wave

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Interest Groups in the Policy Process

• Role of Interest Groups
• Articulate and transform political demands into
  authoritative public policy by influencing the
  choice of political personnel and processes of
  public policy making and enforcement
• Seek support for demands among other groups
• Connect individual to political system via
  legitimate channels

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Interest Groups in the Policy Process

• Interest or Pressure Groups vary according to
• Organizational cohesion, continuity and size
• Knowledge, both substantive and of government
• Stability of its membership
• Wealth and resources

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Engaging Key Stakeholders Shaping Policy

• MEDIA
• extensive newspaper coverage, television, lay
  magazines,
• HEALTH CANADA
• Serve on numerous high level committees
• Work on health policy issues
• Network with HC leadership in Ottawa and across
  the regions

• FACE to FACE
• Regional visits
• Meet with gov. departments
• Meet with health authorities
• Meet with boards
• Facilitate meetings among sectors
• ARTICLES UPDATES
• Regular E-mail newsletter
• Share research and relevant information
• Source of expertise and advice.

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Engaging Key Stakeholders Shaping Nursing

• FACE to FACE
• Regional visits
• Conference presentations, workshops
• Teaching classes
• Meet with nurses at all levels on an ongoing
  basis
• MEDIA
• extensive newspaper coverage, television, lay
  magazines,

• ARTICLES UPDATES
• Regular E-mail newsletter
• Articles published in professional/academic
  nursing and health journals
• HEALTH CANADA VISITS
• Bringing the face of nursing into Health Canada -
  visiting scholars other invited guests

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The Players and Webs of Influence in the
Policy Process N1 to N of many

• Doern Phidd (1992) and Howlett and Ramesh
  (1995)
• Interest groups
• Political parties, elected officials (cabinet,
  legislature)
• Staff and advisors
• Official hearings and procedures
• Think tanks and policy research organizations
• Universities and disciplinary research
  organizations
• Mass media
• Mass books and periodicals
• Cultural events
• Other decision makers (colleagues, constituents,
  etc.)
• Personal networks
• Intergovernmental relationships power

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2. Moving into Action/Legislation

• The formal responses to the problem
• Has the existing evidence on the benefits of
  healthy workplaces resulted in effective policy
  change?
• Large body of knowledge on healthy workplaces
  available for the last 20 years, yet only
  recently (last 5 years) translating into policy
• Nurses have played a key role in generating
  knowledge and disseminating it to policy makers
• The Role of the Office of Nursing Policy of
  Health Canada

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Public Policy Deliberation and Adoption

• Once issue is on the political agenda, must meet
  5 criteria if it is to survive
• Technical feasibility
• Value acceptability within the political
  community
• Tolerable cost
• Anticipated public agreement
• Reasonable chance for elected officials to be
  receptive to it

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Healthy Workplace Policy

• Workplace health issues now appear on public and
  government health human resources policy agendas,
  including the First Ministers Meetings (February
  2003 September 2004), the Health Council of
  Canada and in reviews conducted by provinces and
  territories
• The move towards healthy workplaces has been
  expanded to benefit not only Canadas nursing
  workforce, but other health care workers as well.
  
• Canadas federal, provincial and territorial
  governments agreed to report to the public on
  their action plans by December 31, 2005,
  including targets for training, recruitment and
  retention and healthy workplaces for health
  professionals

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Regulation, Experience, and Revision

• Proposed action becomes a formal policy, law or
  regulation
• This becomes cultural value or norm
• Program implementation and evaluation generate
  new info to continue the cycle

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Healthy Workplaces Policy

• There have been significant policy-level
  improvements
• Have these initiatives resulted in healthier
  workplaces for health care workers?
• Over past 2-3 years several studies outlining the
  progress made at the practice level
• Evaluation of the initiatives implemented still
  required

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The Policy Cycle

• 4 Major Stages
• Setting the policy agenda
• Moving into Action/Legislation
• Policy Implementation
• Policy Evaluation

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The Policy Cycle

• 4 Major Stages
• Setting the policy agenda
• Moving into Action/Legislation
• Policy Implementation
• Policy Evaluation

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Government Nursing Policy/ Chief Nurse

• Key Strategy
• Build a national policy agenda adding one block
  at a time
• Disseminate knowledge widely
• Engage and interact with broad stakeholders
  including targeted individuals and groups

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Government Nursing Policy/ Chief Nurse

• Key Attributes
• Consistency
• Perseverance
• Focused
• Purposeful
• Backward forward