Nurses’ policy influence:

 Introduction
Health systems are rapidly developing and changing. Nurses, as a part of this system, should move forward along with these changes.[1] For this purpose, nurses need to influence the formulation of health policies rather than just implementation of them. Then, they need to be active in the development of health policies to be better able to control their practice.[2] In this process, nurse leaders have a very important role. They need to acquire policy-making skills in order to address professional challenges.[3] Because of their values, professional ethics, advocacy skills, and experiences, nurse leaders have unique and valuable views toward health policies.[2] There has been increasing growth toward nurses’ presence, role, and influence in health policies during recent decades. Nurses are expected to identify the issues deliberately and work with other decision makers to advance health care policies. They should understand the levels of power, and know who controls the resources of health services in their organizations.[4] Therefore, we can go ahead and say that nurses have to be involved in policies which affect patients, families, themselves, and the whole health care system.[5]

Nurses’ influence in health polices protects patient safety, increases quality of care, and facilitates their access to the required resources and promotes quality health care.[4,6] Accordingly, the concept of policy influence in nursing is a new and important concept, but there is lack of conceptual clarity with regard to what this concept really represents. Dowswell et al. (2002) in their study showed that most primary care groups in primary care centers consulted with local nurses about the key fields in care services and they believed that consultation with nurses had been effective.[2] On the other hand, results of a survey about the health managers’ and authorities’ perceptions of the effect of various health professions on revision of health affairs reveal that nurses are in the sixth (the last) grade with a dominant point interval in comparison to other health professionals.[7]

There is an ambiguous point here whether or not what Dowswell et al. (2002) reported as consultation with nurses in local fields really represents nurses’ policy influence. It seems that the extent of applying this concept is wide and not clearly addressed in literatures. On the other hand, we should state that health systems’ policies settle within three levels: Micro, macro, and meso. In the micro level, policies are just for especial parts, fields, or groups, and have not been made essentially by the government, whereas in the macro level, policies are for the whole country and have been made essentially by the government.[8] The meso level policies settle between micro and macro levels and have usually been made by official organizations
Attributes
The fourth stage is clarifying attributes. According to Walker and Avant (2005), attributes are characteristics which are with the concept or related to it.[10] Review of literature helps us to find these attributes. Instead of using many attributes which are less related to the concept, it is better to use less attributes with more relations.[12] Policy influence is accompanied with the following attributes: the spectrum of policy influence, power, and advocacy. Before explaining these attributes, let us first discuss the concepts with a close meaning to policy influence. These are concepts which have some, but not all of the attributes of the concept. These are decisional involvement, policy making, political influence, and policy involvement. The concept of decisional involvement was analyzed by Kowalik and Yoder. They stated that decisional involvement is affecting a judgment or a result.[14] Thus, decisional involvement is a means for policy making and achieves policy influence. Policy making is one of the activities which are done during the process of policy influence. Political influence refers to governmental persons who have points of authority and power. Most of the times, for individuals to be influential in polices, they require to be politically influenced. Policy involvement may have very close meaning to the concept of policy influence.

Like policy influence which can be considered on a spectrum, policy involvement has three levels. According to Boswell et al., policy or political involvement entails the use of activities and behaviors to have an effect on governmental and legislative strategies. In the first level, the individual will just be a voter. At the second level, the individual goes beyond just voting and will take a hard look at personal values, beliefs, and world views. These stimulators will make them as being an adherent for a group of individuals. In the final level, the individual reaches a level of commitment that involves the development of health policies.[22]

The attributes to policy influence have been described below.

Policy influence is moving on a spectrum which begins from policy literacy, moves forward to policy acumen, and then continues to policy competence and finally to policy influence. Policy literacy was first introduced by Malon (2005). For nurse beginners, there are two ways to practice policy literacy. One way is referring to policy documents and asking these questions: What is the problem? When was the process begun? How many are affected? And who are the stakeholders?[23] Another way is to participate in especial political courses.[16,24]

When the abilities of beginners are developed, they can involve in policy acumen. Policy acumen is the ability to analyze policies, and when nurses acquire policy acumen, they can actively analyze organizational process and health care services. Policy competence is related to management in health care. Managers who have acquired policy competence can direct their organizations in response to the challenges and opportunities related to political situations and also make policies which have desirable effects on their organizations. Finally, we have reached policy influence which refers to the nurses who are able to give especial consultation to governments about nursing issues and have important roles in development, implementation, and evaluation of government policies about health care.[23]

The second attribute of policy influence is power. Power is the ability to achieve goals. On the other hand, power is the inherent ability to influence others. Potential factors for maximum influence will be achieved by strengthening the basis of power. Power is an essential aspect for leadership. Thus, nurses should acquire enough information about the presence and place of power fields. What nurses need and should know about power is “power with others” instead of “power on others.” Indeed nurses need power as one attribute of policy influence to protect the quality of care and to change organizations.[20]

The third attribute of policy influence is advocacy. Nurses have long been known as patient advocates. An advocate should be active in political process of his/her country (i.e. by voting). Without involvement in policies, advocating role of nurses will be ineffective.[22] Nurses as advocates should know that when they want to influence decision makers, they need to understand that they are working in an “open system,” so they are affected by many factors. An advocate should ensure that everything influencing decision makers for developing a plan has been understood and considered.[24] They need to recognize conflicts as important components to success and manage them effectively
Kingdon's theory (1995) of policy streams proposes presence of some streams in the process of policy making before agenda setting and policy formulation take place. Kingdom believed that in spite of the dominant effect of governmental agents in progression of an agenda setting, some interest groups also may have a key role in acceptance or obstruction of an agenda setting through formation of a coalition. Kingdom, according to Dohler (1991), states that a united and constant coalition increases the chance for victory in policy streams.[37] The results of current concept analysis of policy influence also forebode the significance of communication and teamwork as two important antecedents for policy influence. As mentioned before, policy activists need to work together as a team and have an acceptable level of communication.

Margaret Newman's theory of “health as expanding consciousness” can be seen as related to raising political awareness. Her theory emphasizes that all people, of any health status and from any circumstance, are a part of the process of expanding consciousness.[28] Her theory defines consciousness as the capacity of the system to interact with the environment. Some of the dimensions of this interaction are exchanging, communicating, relating, choosing, moving, perceiving, and knowing.[38] In summary, expanding consciousness is a metaphor for the changing health systems. Nurses’ awareness of policies will assist expanding consciousness and change health systems.[28] In the present study, we have achieved attributes such as policy literacy, policy acumen, policy competence, and also strengthening political knowledge as antecedents, all of which build policy awareness. These are concepts which can be abstracted from some of Newman's dimensions of interaction with environment, i.e. knowing and perceiving. Meanwhile, other dimensions of Newman, i.e. exchanging, communicating, and relating, can be accommodated to other antecedents of policy influence, i.e. communication and teamwork, in this study. Finally, choosing and moving are Newman's dimensions which are related to making change in health care strategies as overall consequence of policy influence in the present study.

The other theories which the results of current concept analysis are related to are philosophical theories of nursing advocacy. Advocacy as a concept had been considered by nurse theorists, and each of them has a unique definition of nursing advocacy. For example, Gadow (1983) propounded the concept of existential advocacy. She has a moral view of advocacy and believes that the ultimate goal of advocacy is to increase patient outcomes.[39] Kohnke (1980) propounded a model of functional advocacy, in which nurses are agents who inform patients and support patients’ decisions.[19] The results of the current concept analysis are pertinent for Gadow's and Kohnke's theories, since we postulated advocacy as an attribute of policy influence and an inseparable part of the role of nurses as health care providers.

It is notable that the role of advocacy is not limited to patient advocacy, but rather it is allocated to professional advocacy too. Nurses as professional advocators are concerned about nursing workforce, nurse — patient ratio, prevention of malpractice, and the expansion role of nurses.[39] In the present study, we have also introduced pertinent activities such as adequacy of nurse workforce size and improving nursing education, congruent with social needs, as the consequences of policy influence, all of which address professional advocacy.

The aim of this article was to clarify the concept of policy influence associated with nursing management, leadership, and practice in the context of Iran. In this unique analysis, attributes of the concept, such as advocacy, power, and policy competence, were identified. Nurses have the ability to affect health policies. This effect is impossible without the required knowledge of health care system as a whole. Nurses need to be aware of policy agendas, policy makers, and political backgrounds. They are advocates for improvement of the quality of care, but many of them do not have adequate organizational and personal power for advocating patients’ rights. In fact, for nurses to be in a state of empowering patients, it is first essential for them to be empowered.[40] Their expertise, judgment, and policy influence, all together help them to achieve their goals and to facilitate the professional process and the efficacy of health care system. We hope this concept analysis addresses a clear definition of nurses’ policy influence for all nurses and encourage political influence, especially for nurse leaders. In summary, results of this concept analysis indicate that although there are some theories about policy-making process and its facilitators and barriers, there is still lack of nurses’ theories in which the main concepts are involving them or their influence in health policies. However, these are stepping stones in nursing discipline, as we can see them in Newman's model and advocacy models which have been developed by nurses’ theorists.

Conclusion
Considering the state of nurses’ policy involvement in reports and research papers identified that this involvement has various levels but not all levels indicates influencing in policies. Our definition of this concept may represent a broad theoretical understanding of this concept and may discriminate between similar or related concepts. This analysis will potentially inform nurses about how they could be really influence in policies and what they need to achieve for this purpose. Moreover nurse researchers may use this definition to increase clarity in their research. The identified antecedents, attributes and consequences of policy influence may also give guidance to nurse administrators and managers to achieve high level of leadership step by step to be influence in policies. Finally this paper may offer a theoretical framework to guide future work on this concept.
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