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Policy analysis and policy implementation: can nursing manage without them?

2008; Wiley; Volume: 16; Issue: 6 Linguagem: Inglês

10.1111/j.1365-2834.2008.00944.x

1365-2834

Alistair Hewison,

Healthcare Policy and Management

It has been argued that at its simplest, policy analysis proceeds from the basis that decision making ought to be a more logical process and that analytical methods enhance rationality in the policy process. However, rationality does not best describe how decisions are made in reality (Heinemann et al. 2002). To put it another way: The problem with policy is not making it, it's doing it (Dyke 2007). The purpose of this issue is to present a series of papers that engage with the analysis and implementation of policy. It seeks to provide some insights on what is essentially a 'messy business' (Rose et al. 2007) yet one which is central to health care delivery. The International Council of Nurses (ICN) recommends that nurses must understand how health policy is made, in order to determine where and how to best make a difference (ICN 2001, p. 19), however in the UK it has been observed that few nurses practising in clinical settings are involved in policy debates or perceive health policy to be a nursing issue (Toofany 2005). Similarly in the USA it has been advocated that some 2.6 million practising nurses need to improve their level of influence in the policy process. Also given that the Chief Executive Officer of the ICN has cautioned that: We must remain vigilant and proactive to guarantee that strengthening nursing remains high on the policy agenda (Oulton 2006, p. 170) suggests this is an international issue that requires further debate and action. The need for policy analysis and policy implementation incorporating a nursing management perspective is usefully summarized by Salvage who observes: Health policy and nursing is a fascinating but neglected topic. Policy makers and policy analysts lacking a nursing background often fail to pay close attention to it. Despite the major impact that nursing has on the quality of patient care and the sheer size of the nursing workforce. (Salvage 2000, p. ix). It is important that policy analysis and implementation are regarded as central to the delivery of care. The way services are organized and the quality of work life of staff may be as important to patient care as the clinical encounter itself (West & Scott 2000). Indeed the nature of policy and the way that it is implemented by practitioners combine to create the environment in which care is delivered. Without an understanding of policy and its impact it is not possible for nurse managers to function effectively. Essentially the shape of nursing is determined by health policy (Hennessy 2000). Consequently research and debate in nursing management need to encompass the analysis and implementation of policy. The term 'policy competence' (Longest 2004) is useful here. This refers to a level of expertise that health managers need if they are to meet their responsibilities. Longest (2004) contends that the substantial impact government policies have on health service organizations, means that successful management can only occur if managers understand policy. In particular they must be sensitive to the policies that affect their organization, and the forces that can affect the policy process and its outcomes. If managers are to be fully 'policy competent' as well as understanding the policy process and the impact of specific policies, they need to use this understanding as a basis for formulating their organizations' responses to the challenges and opportunities that the policy environment presents. Furthermore they must be able to persuade policy-makers to take decisions that favour their organizations (Longest 2004). A similar line of reasoning could also be applied to nursing management. Without this level of 'policy competence' nurse managers will not be in a position to organize nursing services in such a way as to deliver appropriate care. This entails what Smee (2005) has characterized as 'analytical literacy' which involves making sense of the complexity and vast array of evidence associated with management and policy issues in health care. The development of high levels of 'analytic literacy' and 'policy competence' is the desired outcome of this research and debate. The rationale underpinning this special issue is that consideration of the processes of policy analysis and implementation can help inform effective and patient focused nursing management. This is necessary because as Hill and Bramley (1986) point out: policies are complex and ambiguous. Not only do they often appear different to different observers, they also contain different features with distinctly different aspects (p. 143). In view of this it is timely that a nursing management perspective is brought to bear on this crucial aspect of health care organization. Policy analysis can be defined in a number of ways (Hogwood & Gunn 1984) however here it is conceived in the broad sense of encompassing the application of analytical techniques to social issues for the purpose of both enhanced understanding of and improved input to the policy process (Heinemann et al. 2002). The first three papers represent attempts to critique aspects of current policy as a means of uncovering the implications for nursing management. Nolan and Hewison employ a documentary analysis approach to reveal the contradictions and inconsistencies in primary care mental health team policy. They find that the lack of precision in the terms used in the documents and the absence of clarity concerning the purpose of the teams are likely to militate against effective teamwork, the very thing the policy was intended to promote. This demonstrates how careful consideration of policy documents can increase understanding of policy. Maslin-Prothero and her colleagues present an apposite analysis of devolution in the UK National Health Service. The differences in the way health services are delivered in the four countries of the UK are beginning to emerge and the impact of this on nursing and nursing management are reviewed. The contrasting notions of convergence and divergence are used as an analytical device to draw out the key issues. The application of such approaches is essential in framing discussion about major policy initiatives that are underway. Consistent with this theme Peter Bradshaw questions the purpose of the current emphasis on user involvement in England. He reviews the conceptual and ideological basis of this strand of government action and identifies the unintended consequences that have followed. He concludes that although well intentioned, the current efforts to deliver user involvement in health care are characterized by uncertainty and a reliance on flawed market based solutions. Analysis of policy is a useful endeavour, however as noted earlier such analyses can take many forms. For example, a crucial factor in determining how effective a policy is judged to be is the impact it has when it is introduced. Yet this part of the process is often overlooked. It is only since the 1970s that implementation has become viewed explicitly as a subject of policy analysis in its own right. Prior to this, implementation was assumed to be a relatively unproblematic final stage of the linear policy process (Dorey 2005). This lack of attention to implementation means there is still much to learn about how people put policy into practice. It has been noted that the wider social science literature does not address how public workers operationalize policy (Schofield 2004), and a similar conclusion can be drawn in relation to nursing and nursing management. We need to learn more about how nurses and nurse managers operationalize policy and the remaining papers are presented with the intent of contributing to our understanding in this area. The papers in this issue which consider aspects of implementation are organized into two subsections. In the first are four papers which examine specific aspects of policy and the associated implementation issues. Tolson and her colleagues report their work to promote evidence-based practice, a central policy concern. They have developed the Caledonian Development Model as a mechanism for building partnerships with practising nurses which are seen as crucial in delivering a sustained approach to the provision of evidence-based practice. Their paper illustrates how the creation of Communities of Practice and thorough testing and refinement of the model laid the foundation for measurable improvements in the care of older adults. In the conclusion of the paper there is also a timely reminder for nurse managers of the 'need to defend their choice of development approaches in terms of theory, resource and demonstrable effectiveness at the level of the patient and the wider cultural aspects of the nursing care environment'. The demands for Evidence-based practice, management and policy are ubiquitous, however they are easy to make, much more difficult to fulfill. Tolson and her colleagues present a convincing account of one way of meeting this demand in relation to the care of older people. Advances in information technology have affected all aspects of life. This is manifested in nursing in a number of ways and one of these is the increasing use of clinical decision support systems. Courtney and her colleagues use Benner's (1984)'Novice-to Expert practice framework' to explore the implementation issues associated with these systems and emphasize the importance of involving practitioners at all stages of the process. The urgent need for policy analysis is further demonstrated in this paper because as the authors note poor design results in costly system failures. The recent history of technology projects in the NHS confirms this observation. Lorenzo, the much-delayed software package earmarked for a central role in the NHS's £12.7 billion IT overhaul, remains mired in development glitches and has not yet progressed beyond the technical design phase (Bowers 2008). This illustrates that policy analysis is much more than an academic enterprise. It is vital if effective care is to be delivered and resources used efficiently. The pace of health reform in the UK has been described as 'frenetic', 'frantic' (Greener 2004) and 'breathless' (Pollitt 2007). This has resulted in the need to make changes in the workforce to respond to a range of policy drivers. The School Health Workforce Redesign Programme is the focus of the paper by Jack and her colleagues. It examines the effectiveness of a rapid roll out model in preparing the school health workforce to deliver on the public health agenda. Whilst rapid change is not always comfortable for the workforce, it can be achieved. However what the paper does demonstrate is that this needs to be underpinned by the allocation of appropriate resources and management support. One of the crucial components in the implementation of policy in health care organizations is how it is interpreted and managed locally. This in turn is determined to a large extent by the prevailing culture in the organization. In an effort to uncover the role of management boards in shaping culture Watkins and her colleagues accessed trust board minutes to assess their clinical content. They discovered considerable variation in the extent to which different boards discussed clinical matters. They argue that the next step is to undertake further work to investigate whether the concerns at board level are reflected in care delivery. However in the light of their findings they do suggest that 'an essential part of the nurse manager's role would therefore be as a communication channel between 'front line' nurses and non-nursing managers, both 'general' and medical'. It would seem that nurse managers have the potential to play a key part in ensuring that policy is interpreted and implemented locally with a patient focus. The final three papers in this issue discuss different dimensions of one of the most serious policy concerns in nursing, the global nursing shortage. The lack of a sufficient number of appropriately skilled health and social care staff to meet the needs of an ageing and more infirm population has been identified in the UK and internationally (Rosenstrøm Chang et al. 2006, Buchan 2002, 2005). Wilson and her colleagues present a new perspective on the thorny issue of job satisfaction. Through application of the notion of 'generational cohorts' they produce a finely grained discussion of what motivates different generations of nurses. These findings indicate that a range of interventions are necessary which address the particular needs of the different cohorts. Ensuring action is taken in these areas will be extremely challenging for nurses managers and others responsible for retaining staff. However given that the alternative may be that more staff become dissatisfied and leave, suggests that such action is overdue. Lack of job satisfaction is a factor in staff turnover and Lavoie-Tremblay and her colleagues investigated this as well as the influence of workplace environment on turnover, or 'churn' as it is sometimes referred to, in their study. They provide further insights for nurse managers and policy makers more generally on what needs to be done to reduce staff turnover. In the final paper Blakely and Ribeiro ask: are nurses prepared for retirement? The short answer it seems is no. Given the nursing shortage, if it was possible to develop a creative approach to enable nurses to combine part-time work with retirement planning a contribution could be made to solving the problem of high staff turnover and the lack of planned retirement preparation. However this would only be possible with well-designed coherent policy, which in a sense brings the discussion full circle. Nurse Managers and those with an interest in nursing management need to access or conduct policy analyses which incorporate a nursing management perspective. In this way they can help shape service delivery and ensure it has a patient focus. Nursing cannot manage without it.