The purpose of the American Academy of Nursing/American Nurses' Foundation/IOM scholar experience was to explore how science shaped health policy and, more specifically, to conduct an exploratory study focusing on how nursing research informs health policy. Prewitt (Mecklin, 2009) encourages this line of investigation, as is obvious from the earlier quote. The general questions of interest were the following:
These questions were asked in slightly different terms with two groups of individuals, i.e., informal discussions with national health policy influencers and senior nurse scientists with long-term research programs.
This model was valuable in illustrating how research is involved with the health policy process. The model teaches several lessons, for example:
Thus, science and research become integral aspects of the health policy process. The degree of integration and attention paid to science depends partly on the health policy makers' values and beliefs.
Informal Interviews With National Health Policy Influencers
A series of informal interviews with individuals who are experts in health policy and influencing health policy was an integral aspect of the IOM experience. The national health policy influencers were Executive Directors and Senior Staff who were with health foundations and think tanks in the Washington, DC, area. These individuals viewed their organizational mission as providing factual information, systematically surveyed public opinion, and evidence-based recommendations for health policy decision makers, e.g., the PEW Foundation. Fifteen well-known, recognized health policy influencers took part in these informal discussions.
The focus of these discussions was how they perceived science-shaped health policy and why policy makers would or would not choose to use research as part of their decision-making process. The discussions involved essentially three questions:
When in the policy-making process are science and research most useful?
What characteristics of science and research make them most useful?
When are science and research least likely to be useful in policy making?
In response to the question “When in the policy-making process are science and research most useful?” the policy influencers suggested four situations:
Times of disagreement to resolve conflict and “save face”
Times of chaos when there is a need to solve a major problem and provide direction
When the policy maker is “looking for” substantiation for a previously held position
When there is a “window of opportunity” or policy receptor for the results
The health policy influencers almost all stated that research became a factor when policy makers were in conflict about a situation or did not have a clear definition of the policy problem, much less possible solutions. They sought knowledge to understand both the problem they were confronted with and how to handle it. Another aspect of this situation was that, sometimes, policy makers would take a stand without good information and then needed to change their stance on an issue. Using research provided a socially acceptable way to make such a change and save face, a term used by several of the health policy influencers.
Consistent with Milio's (1984, 1989) early writings on health policy, a time of chaos with a policy situation that has many unknowns is an opportunity for research to be valuable in the policy-making process. One of the health policy influencers cited the 9/11 situation as one of chaos. Research relating to disaster response was valuable while new policies following this situation funded new university centers and other entities on disaster preparedness.
Birkland (2005) suggests that, often, policy is driven by the values and biases of the decision makers or their constituents. However, the policy makers wish their decisions and policies to be creditable. Thus, using research to substantiate a previously-held position is understandable.
A number of policy scholars (Block, 2004; Harrington & Estes, 2004; Milstead, 2004) address the relationship between a policy window of opportunity and research. The creation of the NINR was an excellent example of a window of opportunity policy and subsequent new science program. The legislation for the NINR (then the NCNR) was passed in the Fall of 1985, and the national center was established in April 1986 at the National Institutes of Health. The middle of the 1980s was a time for health policy makers to be supportive of women's issues and legislation for women. The NCNR legislation provided an opportunity to vote for a positive women's issue; in addition, it involved health, science, and nursing, all positive attributes for the Congress men and women. How much the Congressional voters understood about nursing research was debatable, but the window of opportunity was there for nursing research to move into the mainstream of science at the National Institutes of Health. Planning a research program to provide information and data for windows of opportunity is one of the most challenging issues for investigators. L. H. Aiken (personal communication, Fall of 2006) is an example of one who strategically plans her team's research to provide data for future policy issues.
In relation to the question “What characteristics of science and research make them most useful?” health policy influencers provided five general responses. These included the following:
The research is credible
Information is clearly presented in understandable lay terms
Data are provided in quantitative mode
Results give clear suggestions for actions to be considered
Findings are framed in a policy context
Research credibility is a crucial characteristic for the results to be useable in policy decisions. Dickson and Flynn (2009), in their text Nursing Policy Research: Turning Evidence Based Research Into Health Policy, discuss the use of evidence-based decisions in organizational, health services, and patient safety health policy. As with other evidence-based practice texts, they discuss the characteristics and levels of evidence needed for policy decisions. They also address the second characteristic; information needs to be clearly presented in understandable lay terms, i.e., in terms that well-educated but nonhealth professionals are able to relate to and use. Gebbie, Wakefield, and Kerfoot (2000) interviewed leaders in nursing who are involved in health policy of the problems with leaders using research is the lack of its availability in common sources and in understandable language. Thus, it is important to present substantiated research for shaping health policy in understandable terms for both educated colleagues and policy makers.
Providing research data in a quantitative mode might seem initially problematic in nursing because of the discipline's strong support of qualitative, as well as quantitative, research. However, discussing this idea further with the national health policy influencers suggests that policy makers first value a “snapshot” of the information about the issue, then need to have stories and examples illustrating the policy issue and possible strategies. Thus, the quantitative data provide the initial snapshot, while the qualitative information is important for giving evidence-based stories and examples.
The last two valuable characteristics are related to and address the need for research to provide solutions or strategies for handling the policy issue. Furthermore, the solutions need to be framed in terms of a policy context that is relevant and valuable for society. Just providing strategies that are not interpretable for policy or policy makers is not helpful (M. Wakefield, personal communication, Spring of 2006). Dickson and Flynn (2009) address this research characteristic, suggesting that ongoing collaboration with policy makers is necessary to ensure that the research is relevant to specific policy issues, and results in recommendations that can be implemented in policy.
For the third question, “When are science and research least likely to be useful in policy making?” health policy influencers consistently provided four responses. Several of these responses were the negative counterpart to the answers given to Question 1:
When information does not address critical public health issues
When there is no window of opportunity for the information
In times when policy makers hold strong values and beliefs
When there are hidden agendas in the policy situation
For research to shape health policy, it must focus on critical public health issues. In the nursing profession, this is often the case, as nurse investigators ask many questions that focus on their clinical practice and the issues that their patients and families have to confront. As will be noted later, this is an important characteristic of the body of nursing research; the explicit targets are relevant clinical, societal problems. However, research can focus on an important public health issue, but not one that is of policy concern at the time, and thus, there is not a window of opportunity for the use of the findings. For example, patient safety issues are always important health issues but did not come to the attention of policy makers until the IOM (2000) published the report To Err Is Human: Building a Safer Health System. This report identified the critical nature of patient safety issues and the need to take a new systems perspective toward adverse events.
There are also times when research is more highly valued by policy makers in some organizations, administrations, and/or congresses than in others (Mecklin, 2009). When such groups hold strong values and beliefs, then research results may be of less value and use. In addition, in some situations, the policy maker(s) may hold a hidden agenda; that is, there is a particular outcome that is desired for the policy issue, e.g., a pet program. In these cases, research is less sought and is not valued unless it substantiates and supports the “hidden agenda.”
In summary, discussions with the national health policy influencers were valuable in understanding when science and research are most and least valued for informing health policy. Surfacing a number of the characteristics that allow policy makers to relate to research as being useful and valuable helps to strategize how nursing research might more deliberately shape health policy.
Exploratory Study With Nurse Researchers
The purpose of this exploratory study was to consider more specifically how nursing research shapes health policy. The study used a qualitative approach with a randomly selected sample of nurse researchers with long-term, extramurally funded research programs. These were defined as nurse researchers holding a first or second competing continuation grant award from the NINR from 1986 to 2006. There were a total of 109 such investigators. A random sample of 32 such investigators was drawn. Ultimately, 23 nurse researchers participated in this exploratory study, for a response rate of 72%. The reasons for investigator nonparticipation were the following: an inability to contact the Nurse PI and/or an inability to set up a telephone interview within the time frame of the exploratory study. None of the nurse researchers who were able to be contacted directly within the study time frame declined to participate.
A semistructured questionnaire was used in eliciting the data. Content analysis (Neuendorf, 2002) was the qualitative method of choice. The content analysis was done by question; data responses were categorized with the frequency estimated for how often each type of response was recorded. Three to five of the nurse researchers had to provide a given type of response for the category to be reported. The categories are presented from the highest to the lowest in terms of frequency. The study was approved for human subject protection at the University of Michigan and the IOM.
To explore how nursing research was shaping health policy after two decades of stable, ever-increasing research financial support through the NINR, nurse investigators with long-term research programs were asked four questions. These included the following:
What characteristics of their nursing research facilitated shaping health policy?
What external factors assisted their nursing research in influencing health policy?
What are the barriers that limit their nursing research in shaping health policy?
What are the various ways that their nursing research has shaped health policy?
What Characteristics of Their Nursing Research Facilitated Shaping Health Policy?
Five categories of characteristics were identified from the nurse investigators' responses to Question 1: “What characteristics of their nursing research facilitated shaping health policy?” (Exhibit 1.1).
EXHIBIT 1.1 Characteristics of Nursing Research Shaping Health Policy, Ordered by Frequency of Response (N = 23)
Addresses major public health issues
Research of interest to multiple disciplines and audiences
Interdisciplinary team of investigators with multiple bodies of knowledge
Research focused on clients/patients, families, and communities
Research integrates complexity of health issues
The PIs' responses varied from the importance of the public health issues studied to the value of the strong focus on clients, families, and communities in the research. The most frequently cited characteristic of nursing research shaping health policy was that the research addresses major public health issues. This category of responses is consistent with the information elicited from the national health policy influencers, as they also considered one of the most valuable characteristics of research for policy makers to be its relevance to public health issues. As Leavitt et al. (2006) suggest, policy and politics are consistently integrated; thus, research addressing the concerns of policy makers and their constituents is a critical criteria. Nursing research that focuses on major public health issues will, by default, be targeting a number of voters' and society's concerns.
The involvement of interdisciplinary colleagues and ideas in nursing investigations is consistent and observable in the PIs' research programs. Two outcomes of this orientation are evident in the second and third characteristics categories of nursing research characteristic categories shaping health policy. The second category addresses the breath of interest in nursing research that results from the involvement of interdisciplinary colleagues; that is, multiple disciplines are vested in the results and their use. The science that flows from nursing research is also richer because of the several disciplinary perspectives that are involved with the investigations, which, in turn, enhances the science's ability to inform health policy.
The fourth category of responses suggests that an important characteristic of nursing research is the focus on the client, family, and community. This is one of the nursing research characteristics that caught the attention of the New York Times report in 1991. The IOM (2000, 2001, 2004) has recommended in a number of reports the need to focus healthcare on the patient and their context (family and community). A number of the nursing research programs were investigating patient safety outcomes and community, as well as school health promotion programs. For example, Gebbie et al. (2000) suggest that policy makers respond to the experiences and perspectives of nurses on health and illness, as well as their focus on clients and their families.
The final category focusing on nursing research characteristics that are valuable in shaping health policy is that the research integrates a complexity of health issues, e.g., a focus on the merger of biobehavioral concepts and indicators. As cited earlier, Gebbie et al. (2000) found in their study of nursing leaders in health policy that they were aware that policy makers appreciate and are attentive to the broad perspective that nursing brings to health and illness experiences. This category reinforces the richness of the evolving nursing research base.
What External Factors Assisted Their Nursing Research in Influencing Health Policy?
Four categories of external factors were cited as facilitating the nurse investigators' research programs to influence health policy (Exhibit 1.2).
EXHIBIT 1.2 External Factors That Facilitate Nursing Research Shaping Health Policy, Ordered by Frequency of Response (N = 23)
Based in strong supportive research university environments
Partnered with multiple disciplines with visibility and access to diverse networks for dissemination
Timeliness of research in informing major health issue or “window of opportunity”
Strong visibility by public and colleagues through media attention and marketing of research
A strong supportive research university environment was cited most frequently as assisting nurse investigators in being able to inform health policy with their long-term research programs. Many of the PIs who were interviewed were faculty in research-intensive universities. The presence of research infrastructures such as offices/research centers that assist with the identification of funding sources, grant submission, and grant management facilitated the investigators' success with their research programs. The fourth category of external factors, “Strong visibility by public and colleagues through media attention, marketing, congressional testimony, and other examples,” is also a factor of being in a strong research-intensive environment where resources are heavily invested in highlighting the faculty's research programs.
Being able to partner with multiple disciplines in their research programs was cited often by the nurse investigators as an important external factor to success in using their research to shape health policy. Linking with other disciplines brought access to diverse networks for research dissemination and use, thus increasing the visibility and communication opportunities for sharing their scientific findings. The PIs suggested that this led to opportunities to discuss their research with policy makers and to incorporate their work in organizational and national guidelines for healthcare.
The third most often cited external factor that helped nurse investigators use their research was when the findings from their research program coincided with a policy window of opportunity. Most of the investigators saw this happening by “luck” and were not involved in strategizing or planning for such an event. Just as nurse investigators have targeted their research programs to impact specific practice issues, they need to adopt the same approach to shaping health policy. Nurse investigators need to strategize their research programs to inform policy issues that will evolve from health and healthcare challenges for the next several decades. Such health challenges become policy and policy programs over time.
What Are the Barriers That Limit Their Nursing Research in Shaping Health Policy?
The nurse investigators of long-term research programs identified four categories of barriers that limited their ability to use their research in informing health policy (Exhibit 1.3).
EXHIBIT 1.3 Barriers To Nursing Research Shaping Health Policy, Ordered By Frequency Of Response (N = 23)
Lack of congressional interest or no “window of opportunity”
Research not focused on major health concerns
Lack of economic outcomes
Lack of research visibility to broader public and policy makers
The most frequently cited barrier was lack of congressional interest, which the nurse investigators interpreted as not having a window of opportunity. It could be theorized that although nursing research has matured dramatically in only two decades of stable funding, the field is just entering the stage of investigators planning for long-term research programs that can shape health policy. Another factor involved in being able to take advantage of policy windows of opportunity is to have a larger body of scientific knowledge that nursing leaders can access in providing information for numerous policy situations. This is a matter of the continuing evolution and maturation of the scientific body of nursing knowledge.
“Research not focused on major health concerns” was the next most frequently cited barrier. This finding contradicts the result reported under the nursing research characteristics that are most apt to assist in the use of the science to shape health policy. Several explanations may help to understand these findings. One, early in the establishment of the NCNR (now NINR), nursing research was scattered and focused on individual practice issues that may or may not have reflected major public health issues. The development of the National Nursing Research Agenda and the subsequent NINR Strategic Plans and Areas of Emphasis facilitated the nursing scientific community in defining major public health issues that were also of concern to the nursing profession. Some nurse investigators focused their research programs around National Nursing Research Agenda priorities and the current Areas of Emphasis, whereas others used as criteria for forming their research programs the importance of selecting major public health concerns. A second explanation may be that this barrier seems to refer to not having the right research at the right time. It could relate more to the concept of a missed window of opportunity.
A number of the nurse investigators cited lack of economic outcomes as a barrier to being able to use their research in informing health policy. Many of their research programs provided data on quality outcomes in relation to nursing interventions being tested, but they could not speak to cost–benefit ratios or the cost of their interventions. In the judgment of the nurse investigators, policy makers required economic as well as quality outcomes in considering new health promotion or healthcare programs. The transitional care program of Naylor et al. (2004) for elderly patients and families provides information on the quality indicators for the clients and identifies the costs of transitional care.
The least frequently cited barrier was the lack of research visibility to the broader public and to policy makers. This was considered a major challenge for the future, how to enhance the visibility of nursing research and present it in a manner that it attracts the attention of health policy makers and those who influence such decision makers.
What Are the Various Ways That Their Nursing Research Has Shaped Health Policy?
The nurse investigators with long-term research programs suggested that their research had informed health policy in a number of ways. The manner in which nursing research shaped health policy was categorized in five areas, which are presented in order of the most to least frequent (Exhibit 1.4).
EXHIBIT 1.4 Ways of Shaping Health Policy Through Nursing Research, Ordered by Frequency of Response (N = 23)
Informed local practice in acute care organizations, such as hospitals
Informed national health guidelines and standards
Shaped health science policy
Informed national health policy through federal agencies, congressional testimony, and Institute of Medicine citations
Shaped state health policy
The five categories of ways nursing research informed health policy are indicative of the level of health policy that was influenced, except for one area, i.e., shaping health science policy. The most frequently cited way of informing health policy was informing organizational patient care policies. Often, these studies were also influential at a broader level. Metheny's chapter in this book, “ From Bedside to Bench to Practice,” changed a number of organizational patient policies on nasal-gastric tube placement while also being written into nursing and healthcare textbooks for several disciplines. Thus, the informing of health policy was at a local organizational level for hospitals across the country and at the national level through influencing educational processes.
A number of nurse investigators provided information on how they had been involved in developing different national health guidelines and standards. They were asked to be part of such processes based on their research expertise and programs of research. In addition, they were able to use their research findings in forming national guidelines. From a broad perspective, examples included shaping National Quality Forum documents, developing cancer pain guidelines, and generating national and international ambulatory guidelines for urinary incontinence (UI).
The third most frequently cited way for shaping health policy was different. This category refers to nursing research that influenced science policy. By definition, science policy refers to decisions and statements articulating the scientific directions and programs of institutions, associations, and/or local, state, national, and international governments. Such policy directs priorities for research programs and resource distribution. Examples from the interviewees generally related to aspects of an investigator's research that stimulated a Call for Proposals based on the importance of elaborating understanding of the scientific area. Another example was an institute intramural program of research that began in order to enhance one of the nurse investigators' program of study. In both of these examples, the nurse investigators had important programs of research that needed expansion in multiple directions and were involved in planning for the new science policy programs. Feetham's chapter in this text, “The Role of Science Policy on Programs of Research and Scholarship,” provides multiple examples of how science policy is shaped and how, in turn, it informs health policy.
The fourth most frequently cited way for nursing research shaping health policy was to inform national health policy. The investigators cited multiple examples for this category, including consulting for federal agencies, providing congressional testimony on behalf of different professional associations, and having their research cited in IOM synthesis of research reports. In these cases, the investigators' involvement in consultation or testimony for congress or the IOM was based on their research expertise and sharing their research findings.
The least cited category of ways nursing research informed health policy was through shaping state health policy. The research program of Aiken et al. (2002) on the effect of organizational work environment on nurse and patient outcomes is an example of influencing state health policy. Several states, such as California, have passed legislation for patient–nurse ratios based on this scholarly work.
In summary, experienced nurse investigators provided a number of ways in which nursing research is shaping health policy at multiple levels. The ability to identify the nursing research characteristics that assist in informing health policy as well as the external factors and barriers that are part of nursing research's relationship to health policy are critical features in being able to explicitly plan and teach the processes for future generations.
General Themes Identified in Exploratory Study
Two broad themes were identified by the nurse investigators regarding nursing research and health policy. First was the need to educate nurse scientists about health policy. More specifically, they were concerned that as investigators, they did not have explicit knowledge of strategies and processes through which their research program findings could be used to inform health policy. Although doctoral programs in nursing do offer courses and content on health policy, models, strategies, and processes, understanding their relationship to individual research programs and planning for shaping health policy, as well as nursing practice, are rare. Only a limited number of the experienced nurse investigators interviewed stated that they consistently strategized and planned for how their research program findings could be influential over time. A number of nurse scholars have been concerned about this issue (e.g., Gebbie et al., 2000; Leavitt et al., 2006). This is an issue for both research and advanced practice doctoral graduates in nursing because the research-prepared doctoral individuals need to plan how the findings of their evolving research programs can inform health policy while the individuals with advanced practice doctorates will be teaming with them to translate research findings into health policy at multiple levels.
Second, the nurse investigators were concerned about needing a “Broker” system for moving research into health policy. Such a broker system could take multiple forms, e.g., organizational think tanks, professional associations, and doctorally prepared advanced practice nurses, who have an explicit objective for translating science to practice and health policy. An example of a formal organization that assumes this role is the IOM. The mandate of the IOM is as “Advisor to the Nation's Health.” A great deal of their activity is directed at synthesizing multiple research studies from numerous disciplines to provide information for and elucidate what is known about specific policy issues and strategies as well as recommendations on how to handle them. The report Keeping Patients Safe: Transforming the Work Environment of Nursing (IOM, 2004) is an example of providing models, synthesized research, and recommendations on how the work environment and conditions of nurses influence patient safety. Sampselle's chapter in this text illustrates how a professional association was able to translate nursing research on UI into organizational patient care policies and into national guidelines on UI. In the future, as the cadre of Doctorate of Nursing Practice clinical scholars increases, these individuals, teamed with their research doctorally prepared colleagues, could also serve as brokers for moving the science of the discipline into both practice and health policy (Hinshaw, 2009).
Science shaping health policy is of concern to multiple disciplines and to society in order to be assured of health policies based on evidence from research. Whereas health policy reflects the influence of many factors, it is important in considering health decisions to have one of those factors be research. In addition, the research needs to bring multiple perspectives and reflect many disciplines. Nursing research, after almost 25 years of stable federal support, is clearly addressing important public health issues and providing information both to elucidate the health policy issues but also possible strategies for resolution.
Nursing research seems to have several of the major characteristics that national health policy influencers suggest make the information useable by policy decision makers. These characteristics include addressing major public health issues; focusing on the person, on his or her family, and on communities; and teaming with other disciplines to reflect a richness in the knowledge and perspective available to the policy process. The early promise of nursing research, as pointed out in the 1991 New York Times article “Beyond Tender Loving Care, Nurses Are a Force in Research” is being fulfilled. There is now evidence of the growth of the evolving knowledge base for the discipline and the ability of nursing research to shape both nursing practice (Hinshaw, Shaver, & Feetham, 1999) and health policy.
