Nurses’ Policy Influence: Self-defeating by Design
In case you haven’t noticed, nurses desire to influence policies and decisions. There is both a strong latent frustration about the perception that nurses don’t have the influence they deserve and a continuous call to do more and better in order to get some political traction.
It will soon be ten years since I have been adopted by the academic-nursing tribe, and in my view the tribe’s craving for policy influence is one of its very defining characteristics. Thus, as a policy analyst, I often get asked for advice regarding what could be done to increase the influence of the discipline.
However, my opinions are unlikely to win me new friends: I believe that the main reason why policy actors who self-identify as speaking as/for nurses have limited influential power isn’t that they use the wrong strategies, nor is it that there is a giant conspiracy against nursing. The reason is simply that they pull the policy rope from the wrong end.
Too often, the starting point of their policy debate is nursing’s own professional identity and craving for influence, leading with such facile questions as, “How could nurses have a say on this issue?” “What could nursing bring to this policy debate?” “What’s nursing position on this?”
But the fact is, nobody outside nursing cares about nursing. Many of my colleagues will cringe reading such a profanity; but I believe that’s the truth. Yes, nurses do absolutely essential work. And everybody knows that. However, there are quite a few other groups out there whose work is also essential and who do not insist on explaining to us their opinions about everything.
Policy influence is gained through the capacity to frame one’s position in a way that appeals to other groups (coalition building), that connects to lay people’s preoccupations (public opinion), and that is also useful to decision-makers’ efforts to deal with the inherent uncertainties of choice. In other words, the starting point of any statement should be ‘things that people care about’. (Actually, the starting point of any statement should be to state something, but that’s another debate).
“Every politician understands that arguments are needed not only to clarify his position with respect to an issue, but to bring other people around to this position. Even when a policy is best explained by the actions of groups seeking selfish goals, those who seek to justify the policy must appeal to the public interest and the intellectual merits of the case.” Majone, G., Evidence, argument and persuasion in the policy process. 1989, New Haven: Yale University Press. p.2
The advice that I often think about, but can’t share with my tribe, is that nursing should lay off the navel gazing. It isn’t a helpful policy approach. Just look around, many nurses actually do have strong policy influence. But here’s the catch: those influential nurses frame their opinions around policy issues and outcomes, not around their profession.
The best advice for nurses (and, actually, anyone) who wants to gain policy traction is to make sure to frame one’s arguments around issues that your audience cares about. If you haven’t anything to say beyond the basic fact that you want power and attention, it might be time to reflect on the old saying, “speech is silver and silence is golden.”
Influencing policy: what do we mean by it exactly?
Nursing, both professional and academic is struggling with policy, politics and influence. It’s nothing new, but it’s worth reflecting upon. There are many, many issues we could address here, but I’ll stick to just one: nursing as both a barrier and facilitator to policy influence. First of all, there is no need for conspiracy theories when it comes to nursing influence in policy. We live in a society where women’s work is devalued and despised, so anything to do with nursing that doesn’t stem from the academic or professional elite is not something politicians or the big brass of our healthcare systems are interested in.
Whether nursing helps or inhibits policy influence depends greatly what you mean by policy influence: if it’s becoming buddies with politicians or obtaining positions of power in government or healthcare, pick another discipline. Our healthcare system is built around physicians and hospitals. It barely recognizes that nursing work is actually work, so if you want to be CEO one day, get an MBA. Then you’ll be a nurse AND manager, it’s the managerial part on your resume that will grant access into the circles of “important” people.
In Quebec for example, our health institutions have spent millions on implementing management systems by paying private outsider firms to tell us how to do things despite numerous attempts at the same thing by nurses and healthcare professionals. Why listen to a nurse when you can get a dude in a suit who’s never set foot in a hospital to tell you what to do? Unfortunately, we appear to have internalized this in mainstream academic and professional nursing. We’ll encourage nurses to get MBAs, but not to listen to their colleagues about staffing issues for example. Being “just” a nurse is simply not enough to be credible. We don’t want to hear what a bedside nurse thinks is the proper nurse to patient ratio, or how mandatory overtime is hurting patient care. Even within our own profession, we strive to sound as much as possible as something other than nursing. The problem is, in a patriarchal system (the healthcare system is probably the epitome of a patriarchal system), no matter how cold and unfeeling we try to sound, the nature of our work will always lead to us being labelled as emotional and difficult. We’re mostly women, doing women’s work. I really think it’s time to embrace it instead of trying to distort what we do so it fits into the biomedical framework of our healthcare system.
Which brings us to another form of influencing policy: grassroots movements for social change Working as a bedside nurse gives us front row seats to the consequences of social inequalities. There are LOTS of nurses involved in movements that affect profound change. They may not wear fancy suits of have lunch with ministers (not that there’s anything wrong with that), but their influence is undeniable. These nurses are involved in movements to address public health or social justice issues. They write petitions, letters, occupy public spaces, organize protests, and are endlessly creative in the means they use to right social wrongs. They don’t address policy influence for the sake of policy influence, they address policy from the standpoint of making society a better place.
What our honorary tribesman is describing is (I think) a minor issue that affects only nurses who live in the ivory tower that is academia. Many of us strive to show nurses can look like and act like politicians. Nothing wrong with that, but it will do nothing in and of itself to increase the social value of nursing as work, which is the root of most nursing issues. For society to recognize our worth, we need to address the political issue of women’s work. Unfortunately, feminism is not yet taught or promoted in nursing. Even worse, radical intersectional feminism is often actively discouraged. The problem in academia (and in healthcare in general) is the very real censorship against disruptive voices like the authors here. While censorship by healthcare institutions is unpleasant, it isn’t surprising. Even in a public healthcare system, nurses and their colleagues are often muzzled to maintain a proper image of healthcare, regardless of whether that image is a reflection of reality or of the delusions of a PR executive (“patient-centeredness” I’m looking at you). It hurts a lot more when the censorship comes from within, when members of your own professional “tribe” try to silence you for no other reason than public image. In that sense, what is mentioned about navel-gazing is really academic and professional navel-gazing.
In the previous piece it’s mentioned that nursing asks:
“Such questions as : How could nurses have a say on this issue? What could nursing bring to this policy debate? What’s nursing position on this? What does nursing think of this?”
What we’re really saying here is that nursing should speak with a single voice, ideally the voice of someone who looks important (and has an MBA… I know I’m going overboard with the MBA thing here, I got nothing against MBAs btw). The problem with this is that we’re building a nursing voice on the lowest possible common denominator. We end up addressing very few political issues and instead argue whether we should address an issue rather than actually addressing the issue. We avoid debate amongst ourselves at all costs (even if it means censoring ourselves) and because of that we often remain quiet. No nurse will ever speak for all nurses, and that’s ok. While our professional organizations could do a lot more politically, we have to start looking at the nursing voices rising up on specific issues that affect nurses’ work and population health. Voices like those of the nurses in Gatineau fighting for working conditions that allow them to provide proper care, voices like the student nurses who went on strike a few weeks ago to demand recognition and remuneration for the work they do during clinical rotations. We should nurture and elevate these voices rather than argue if they are representative of nursing. That’s not what they’re trying to do. They’re simply discussing political issues that should interest all of us yet have barely received any attention within nursing. But they are influencing policy.
Until we become comfortable with debate and dissension, and the fact that nursing doesn’t fit the bio-medical mold, most of us will be on the sidelines. We don’t need one nursing voice, we need ALL of nursing’s voices.