Keywords

A theory is often viewed as a hypothesis or system of ideas intended to explain and predict a phenomenon or justify a course of action. For the purpose of this publication, theory is also defined “generically to mean a range of approaches that specify the scope of inquiry, lay out assumptions, provide a shared vocabulary among members of a research team, and clearly define and relate concepts in the form of principles and testable hypotheses and propositions” (Weible 2014, pp. 3–4).

Theories of social and healthcare policy mean disparate things to different people. One perspective is that these policies are mostly concerned with content that includes the best method for considering financing services or service delivery. However, a look at policy requires an exploration into how policy is formulated and implemented as well as who or what influences policymaking. The theories selected for discussion in this chapter focus on policy as it relates to the processes of policy formulation and/or implementation and are considered to be classic illustrations of policy processes as referred to in additional publications (Klein 2014; O’Grady and Johnson 2014; Porche 2012; Schober et al. 2016; Walt 2006). The criterion for inclusion of a theory in this publication is not the newness of an article or reference but the quality of its insight, that is, its ability to explain some aspect of the policy process and/or policymaking. Finally, this chapter offers commentary on the relevance of social and healthcare theory to nursing.

3.1 Hall, Land, Parker, and Webb Agenda-Setting Framework

The Hall et al. agenda-setting framework (Hall et al. 1975) based on the theory of bounded pluralism suggests a compromise theory of power as it influences policymaking. The theoretical framework proposes that issues of high politics (e.g., economic issues) are decided by influential leaders but that most domestic or routine policies such as health and education are likely to be developed at a level that includes some participation of interest groups at different stages of the policy process. This theory proposes that government decision-makers may be open to influence from a variety of sources as long as the policymakers perceive the sources for the policy topic as legitimate. This idea lends itself to the notion of agenda setting as introduced in Chap. 2, Sect. 2.1.1.

The Hall et al. (1975) framework identifies three conditions that help to explain why policymakers might act on any particular concern or give precedence to a specific issue. The framework identifies the following concepts:

  • Legitimacy

  • Feasibility

  • Support

The suggestion is that only when an issue is high in relation to all three concepts does it become an item on the policymaking agenda. This provides a simple approach for assessing what issues might be considered by governments and key policymakers. Sections 3.1.1, 3.1.2, and 3.1.3 provide further discussion of these three concepts.

3.1.1 Legitimacy

Legitimacy refers to the issues that key policymakers/governments/organizations feel they should be concerned with and in which they have the right or authority to intervene. Conversely, these topics are issues where decision-makers feel people will accept, e.g., government intervention. Issues range from low to high legitimacy. The identification of legitimacy differs from country to country (Hall et al. 1975).

3.1.2 Feasibility

Feasibility refers to the potential for implementing the policy. Does the government/state/organization have the capacity to ensure implementation? Is the plan achievable? Implementation efforts face technological, financial, or personnel limitations that might, even in the early stages, suggest that a specific policy may be impossible to implement even if it is seen as legitimate (Hall et al. 1975).

3.1.3 Support

Support refers to the vague but important aspect of public support for or public trust in government or organization action. For certain issues, there may be strong support from interest groups or relatively weak visible support for a policy.

If support is lacking or dissatisfaction is high, it may be difficult to implement policy (Hall et al. 1975). For an example of this point, there is increasing evidence that the quality of care provided by APNs is positive. In addition, support for APN services in many healthcare environments is at a very high level. However, there is also evidence in various countries that factors such as opposition by medical associations can delay or totally block policies essential to support APN practice.

Findings from a study conducted in Singapore (Schober 2013) revealed that following years of formal and informal discussion, support was eventually established for the APN concept. In addition, there was an expectation that the government would develop policy and coordinate a strategic plan for further support and implementation. However, the ability to begin to move forward depended on action from three key decision-makers with power and authority to influence particularly the medical fraternity. Even though conditions of legitimacy and feasibility for ANP were met, further issues of support had to be addressed for the initiative to progress.

According to Hall et al. (1975), using these three conditions, governments and key decision-makers assess whether an issue falls high or low on a continuum. A position of high legitimacy (a view that they have the right to intervene), high feasibility (sufficient resources and infrastructure), and high support (significant interest groups are supportive or at least not opposed) suggests that the issue may likely come onto the policy agenda. However, there are times when representatives of governmental agencies will place an issue on the policy agenda to make a statement about it or to show they have a position on the topic, but they do not necessarily expect it to be put into practice. Thus, it remains policy on paper only (Walt 2006).

3.2 Kingdon’s “Windows of Opportunity”

In offering a description of the policy environment, Kingdon (2003) indicates that policy starts with agenda setting and conceptualizes an open policy window or “window of opportunity” based on a three streams approach (see Fig. 3.1). This approach suggests that complex policy processes occur in three separate streams and only when they come together does an issue make the policy agenda. This concept suggests that policies are only considered when a major “window of opportunity” opens up in the three streams (problem stream, politics stream, policy stream) at the same time:

  • The problem or issue must come to the attention of the policymaker.

  • The issue must have a menu of possible policy solutions that have potential to actually solve the problem.

  • The right political circumstances have to be in place.

This perspective emphasizes that the three separate streams of problems, politics, and policies have lives of their own. When the streams are joined, it is when policy change occurs. As a result, Kingdon (2003) provides an interactive theory that aims to take into account the dynamic nature of policymaking. This convergence of three streams is viewed as often chaotic and unpredictable.

Fig. 3.1
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Kingdon’s window of opportunity (Birkland 2005, p. 226)

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In contrast to the three conditions for policymaking proposed by Hall et al. (1975) (see Sect. 3.1) and incremental stages suggested by Lindblom (1979) (see Sect. 3.3), Kingdon (2003) proposes that policies are not made in stages, steps, or phases. What contributes to the three streams coming together may be due to individuals, media attention, a crises, or evidence of a problem. As a result, alternatives may be supported and promoted for long periods of time before the opportunity takes place for them to be accepted or placed on the policy agenda.

The streams as identified by Kingdon (2003) take place in parallel and somewhat independent streams until something happens to cause two or more of the streams to meet in a “window of opportunity.” This window is the possibility of change; however, the open window does not guarantee that policy change will occur. The origin can be a change in understanding of a problem, a change in the political environment that is favorable to change or increased focus on an issue that attracts attention to the topic (Birkland 2005).

In critiquing the Kingdon theory, Zahariadis (1993) proposes that the Kingdon approach can be applied to decision opportunities, not just for agenda setting. Therefore, a decision to make new or existing policy may be more likely when the streams come together. In addition, Sabatier (2007) suggests that the streams metaphor may be an incomplete description of policymaking as it does not describe the policy process beyond the opening of the windows of opportunity. The multiple streams theory supports the contention that policymaking is messy, complex, costly, and not necessarily logical but does try to make sense of an ambiguous process (Zahariadis 2014). In any case, the Kingdon theory provides a multilayered image of policymaking (see Fig. 3.1) from the early acceptance of new ideas about an issue to active consideration of actions by introducing the idea of focusing on events that can be examined for their influence on the policy agenda (Birkland 2005).

3.3 Lindblom’s Incrementalism and Disjointed Incrementalism

Lindblom is considered to be the creator and best-known proponent of the incrementalist policy theory (Lindblom 1959, 1979). In referring to the policy process as one of incrementalism or more realistically, disjointed incrementalism, Lindblom notes that policymaking is a process of negotiation, bargaining, and adjustment between different interest groups to influence policy. Lindblom’s emphasis is on what is happening rather than what ought to happen. As a result, it can be argued that what is feasible is only slightly different from existing policy. Beneficial points of the view of incremental change imply the following:

  • Policymakers focus on what is familiar based on their experience.

  • It reduces the number of possible alternatives to consider.

  • The number and complexity of factors policymakers need to analyze are reduced.

This description of the policy process is both a theory of how decisions are made and a description of how competing interests behave in policymaking (Birkland 2005).

Policy issues according to Lindblom (1959, 1979) are divided into two categories, ordinary questions of policy and grand issues pertaining to politico-economic life and structure. In situations of ordinary questions of policy, Lindblom sees many groups actively participating. However, on grand issues, Lindblom suggests that participation outside of key decision-makers may be ineffectual or nonexistent. Incrementalism can be seen as based on deliberate incomplete analysis of an issue; thus, this theory in turn proposes that policymakers make decisions in a political world which introduces many constraints to the process thus little policymaking is really revolutionary (Lindblom 1979).

Incrementalism views political change by small steps; thus, incrementalism varies by degree. As a result, the size of the step in policymaking can be arranged on a continuum from small to large. Lindblom (1979) distinguishes three meanings of incrementalism as policy analysis: simple incremental analysis, disjointed incrementalism, and strategic analysis. The next section explains disjointed incrementalism and proposes that it is a realistic view of some aspects of policymaking.

3.3.1 Disjointed Incrementalism

Disjointed incrementalism can be viewed as one form of strategic analysis, and simple incremental analysis is one element in disjointed incrementalism.

Stratagems considered to be descriptive of disjointed incrementalism include:

  • Limiting analysis to a few familiar policy alternatives

  • Linking analysis of policy goals with pragmatic aspects of the issue

  • Increased concern with problems to be resolved rather than only goals to be sought after

  • A sequence of trials, errors, and revised trials

  • Analysis that explores some but not necessarily all the important possibilities of a potential alternative

  • Fragmentation of work to multiple participants in policymaking

In reference to more conventional theories, Lindblom (1979) emphasizes that no person, committee, or research team can fully complete the analysis of a complex issue. There are too many matters at stake, too many possible alternatives, and too many potential consequences (anticipated and unanticipated) to fully comprehend the full complexity of any situation. The best attempts achieve a partial analysis. This perspective implies that a strategy alone does not identify expedient tasks but instead proposes an aspiration to develop improved strategies.

Although incrementalism and disjointed incrementalism were not conceptualized with nursing and healthcare policy in mind, the principles are usable in this context. Refer to the Schober APN Conceptual Policy Framework for Advanced Practice Nursing in Chap. 2, Sect. 2.2.2, for application of aspects of incrementalism and disjointed incrementalism in construct of the framework.

3.3.2 Strengths and Limitations of Incrementalism

Recognizing the strengths and limitations of any policy theory must be done within the context of the relevant political environment where the policy decisions are being made. Sections 3.3.2.1 and 3.3.2.2 discuss the strengths and limitations of incrementalism.

3.3.2.1 Strengths of Incrementalism

Identifying incremental strategies of policymaking adds articulation and organization to ideas that may already be in wide circulation. In addition, the idea of fragmentation of policymaking and consequent interaction among decision-makers has the potential of raising the level of accessible information and rational thinking that could impact decisions. For someone who embraces disjointed incrementalism, there is never a last word; the work is always in progress.

The reality is that all scrutiny of an issue or situation is incomplete and may fail to understand what ultimately turns out to be critical or beneficial policy. Disjointed incrementalism, according to Lindblom (1979), is a strategy that makes the most of the limited ability of a broad range of decision-makers to understand all aspects of an issue or case. Their mutual adjustments in the process of negotiating during the policy process will to some degree bring them together in their roles as policymakers.

3.3.2.2 Limitations of Incrementalism

There are two identifiable problems with incrementalism (Birkland 2005; Kingdon 2003). First of all, some issues require bold decisions; thus, taking slower incremental steps may not be advantageous. Secondly, some objectives cannot be met in incremental steps and must be envisioned from a more comprehensive viewpoint. If a new policy requires only marginal change from the current situation, the risks of mistakes are minimal. However, if there is a need to reach a major agreement more quickly under a specific crisis situation and in an unstable environment, the situation is not conducive to incrementalism (Walt 2006). Another critique is that incrementalism is too gradual and too conservative and as a result encourages inaction (Dror 1989).

3.4 Walt’s Framework for Policy Implementation

In response to requests for clarification on a definition for health policy, Walt (2006) developed a framework that focuses on process and power as it relates to policy development. The emphasis of the framework is in how policy is formulated and implemented and who influences policymaking. The concentration of the framework is concerned with who influences whom in the making of policy and how that happens. It can be said that politics cannot be separated from policy; however, few explanations of policy development provide explicit details about political systems, power and influence, and participation at the grassroots level in policymaking.

The intention of the Walt framework is to provide the initial step into the complex and challenging environment of policy choice and change. Those interested in healthcare, such as APNs, will find the framework helpful in understanding the policy processes associated with change and implementation of change. Walt (2006) proposes that a common conceptual framework (refer also to Sect. 2.3.2 – Conceptual Policy Framework for Advanced Practice Nursing) for the healthcare policy process is useful for representatives of both healthcare and policy. Procedures and routines in policymaking are likely to be similar from country to country, even if the setting, range of concerns, and solutions are different. However, incongruities exist in habits, in behavioral patterns, as well as in the political and social culture.

3.4.1 Principles of the Walt Framework

The eclectic approach of this framework includes theories and principles from different social science disciplines. These include:

  • Pluralism, elitism, and interest groups – political science

  • Decision-making from rationalism to incrementalism – policy analysts

  • Actors pursuing their own goals – public choice theorists

  • Interrelationship of politics and economics – political economists

This combination is thought by Walt (2006) to provide concepts derived from different theories to create an overarching framework as a way to understand the complex world of health policy. There is extensive dialogue in the political science and policy analysis literature regarding an ideal approach; however, Walt did not see a single proposal as satisfactory in its own right. Taken into consideration in this broad framework are the basic structural concerns of society-centered approaches about where power lies. Healthcare is one of the most visible products of policy, from healthcare professionals to institutional campaigns for the public to transport. Decision-making in healthcare is in a unique position in comparison to other social issues. Most individuals and populations come in contact with health sector institutions and personnel many times in their lives. In spite of this, there have been limited broad-based frameworks visible in the healthcare sector dealing with health policy.

Health policy crosses multiple sectors, some of which have little to do directly with healthcare or services (e.g., violence, climate change, pollution, sanitation). However, all have a potential impact on levels of morbidity and mortality. Walt (2006) proposes that health policy is best understood by looking at processes and power thus exploring roles of the state (national and international), actors/players in the arena, external influences, and mechanisms for participation in policymaking. Noting this focus, this framework is about the policy process, not about policy options or planning. For Walt (2006, p. 6) “planning follows policy: planners help to put policies into practice, although the planning process itself may help to develop and refine policies.”

Layers of the Walt (2006) framework explore the political system as a whole, starting with a systems approach. In this way, all different parts of the political system that affect health policy is assessed including direct and indirect participation in the process. The way power is distributed in society is explored and how it influences the policy process. The power debate revolves around the extent to which policymaking is dominated by a few influential players who control policy decisions while noting that different individuals may be influential at different stages. The structure of this framework moves from agenda setting and achieving the attention of policymakers to formulation of policy. This framework can be used as a starting point for engaging in the policy process. The finale of the policy process, as Walt sees it, is implementation (e.g., moving from intent of policy to actual implementation in practice), a phase that Walt suggests is all too often neglected by other models and frameworks.

3.4.2 The Policy Process According to Walt

Getting on the policy agenda, processes of formulation, influential actors, and implementation of policy comprise the key factors for the policy process from Walt’s perspective (2006). Political culture and structure differ from country to country and place different limitations on policymaking and the extent to which the ordinary citizen can influence the policy process. A discussion of the policy process according to Walt (2006) identifies two questions:

  • How far does the structure of the policy process allow or encourage participation in public policymaking?

  • What are the beliefs in the country about the government and politics? How far do these attitudes affect participation in the policy process?

In this framework, political power is perceived as the ability of government to decide collectively and put agreed policies into practice. An additional theme is focused on who makes policy: a small number of privileged leaders or many different groups. How decisions are made takes note of who influences policy and raises the question “is it possible to devise rational policies if many different groups are insisting on their demands being met?” (Walt 2006, p 35). A commonly held view in a democratic system of government is that there are many ways to participate in the policy process. However, this view is not universal, and it is argued that policy is decided by a small group of influential decision-makers. A research conducted by Schober in Singapore highlighted how select leaders in positions of authority and their networks influenced policy decisions and moved the APN agenda forward or impeded progress at different stages (Schober 2013; Schober et al. 2016).

3.4.3 Implementation: Do Those Who Implement Policy Decide Policy Formulation?

In discussing intent of policy to realization in practice, Walt (2006) asks the following question: “Can we assume that once a policy decision has been made, it will be implemented as intended?” (p 153) Commenting on this question, Walt sees policymaking as interactive, with formulation and implementation as two elements in a continuous loop. In other words, the policy process is not a linear process where policy formulation is seen separately from implementation. However, the idea of an interactive continuous loop of communication may be fantasy rather than a version of reality.

Implementation of intended policy is in the hands of many different groups, some of whom might be involved in policy formulation. Implementation is heavily dependent on the extent to which policymakers and key stakeholders can expect those on the ground to follow policy guidelines. As a result, because policy is understood in fairly general terms, it is left to those implementing policy to decide specifically how to carry it out.

Those managing implementation on the ground often have considerable discretion in interpreting policy because their expertise is in the interpretation of assigned tasks. In addition, the implementation process may not be visible to policymakers and the key decision-makers who orchestrated policy development. Implementing agencies and institutions are likely to be more sensitive to a range of responses thus contributing to dissimilar approaches in realization of policy.

Empirical evidence based on research conducted by Schober (2013) in Singapore found this to be consistent in the beginning phases of APN implementation in the country (see Sect. 2.3.3 for description of the Singapore context). Policy at the highest level was developed, while implementation and interpretation of APN policy were left to the management level and APNs themselves. Various institutions interpreted policy and the APN role differently. Study findings demonstrated that management felt uninformed and were ill prepared to implement policy as intended by the policymakers.

To ensure policy is implemented, legislation carries the most authority. However, regulations and published standards also carry substantial weight, especially as it relates to professional regulation (Walt 2006). Even though legislative control is less common in the healthcare environment, sometimes legislation may be necessary to ensure policy is implemented. For example, when the plan to introduce nurse practitioners (NPs) in Jamaica was decided in the 1970s, it was acknowledged that legislation would be necessary. However, the plan and related policy were implemented without legislation leaving the NPs in a difficult position. Pharmacists would not accept their prescriptions without a physicians’ countersignature. The pharmacists argued that the legal authority to prescribe had not been established, even though the medical profession and policymakers in the ministry of health at the time had agreed to it (Cumper 1986).

3.4.4 Walt’s Strategy for Policy Implementation

What seems clear to Walt (2006) in the analysis of policy is that most thought is focused on the formulation of policy and related dialogue. There appears to be an assumption that good fortune or managers will carry out the desired changes proposed in policy and that there is little reason for a specific strategy for implementation. The implication is that policymakers do not engage much in assessment of the environment to determine if conditions for successful implementation exist.

Theoretically (Walt 2006) and based on the study done in Singapore, Schober (2013) suggests that with a pre-policy analysis, many later mistakes during implementation can be avoided (see Chap. 2, Conceptual Policy Framework for Advanced Practice Nursing). Walt (2006) further suggests that policy implementation is a complex interactive process in which those implementing policy affect the way policy is executed that results in change. However, in reality too often there is a major separation between policy development and implementation with little focus on putting policy into practice. The implication is that to avoid this gap, policymakers need to include strategies for implementation in the process of policy formulation. There is often an expectation from professionals and the public that policymakers have a plan in mind. In the Singapore context, study findings (Schober 2013) revealed that there was a belief that planning and coordination for APN implementation would be provided from the ministry of health. Managers and healthcare professionals were surprised when this did not happen.

3.5 A Comparison of Theories of the Policy Process

When considering strategic planning and/or strategic implementation of an ANP initiative, comparing policy theories provides an opportunity to combine the insights they provide (Sabatier 2007). In thinking strategically, some aspects or principles of theoretical constructs are accepted and others rejected as relevant or irrelevant to ANP and the inclusion of APN roles. Various policy theories contain different foci and concepts; however, the intent of the comparison of the policy theories described in this chapter is to understand and form an opinion on the usefulness of certain aspects of different approaches. Each of the theories described in this chapter has a relatively well-defined scope and provides a different lens on the policy process. All of the theories, to some degree, address questions related to policy formulation and change (see Table 3.1 for a brief comparison of foci and principles).

Table 3.1 Comparison of policy theories
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The intent of the author is to provide a brief comparison of theories as discussed in this chapter to raise awareness and understanding of philosophic underpinnings of each theory or overarching concept. It is hoped that the reader, in gaining understanding of theory, would find ideas that are applicable to their specific issue and/or country context. Not all theories focus on all aspects of the policy process; however, elements of different theories produce an explanation of a significant component of the policy process.

3.6 Commentary on the Relevance of Policy Theory for Nursing

Porche (2012) suggests that the discipline-specific knowledge and experience of nurses and other healthcare professionals provides them with a “unique knowledge and experiential base” from which to influence the policy process (pp. 114–115). Utilizing social and healthcare theories as guides, nurses as researchers, clinicians, and educators have the potential to assume a variety of roles in the policymaking process. Based on an understanding of the nuances and dynamics of how policy decisions are made, nurses are better positioned to participate in the development of policies that affect healthcare. In addition, the influence of nursing is possible with a socially relevant knowledge base within an environment that respects the nursing perspective (refer to Chap. 2, Sect. 2.3.3, for a description of how three policy theories plus evidence from the Singapore context were combined for development of the Conceptual Policy Framework for Advanced Practice Nursing).

When integrating theoretical knowledge of policy, nurses can assume a variety of roles in the policymaking process. These include the following roles (Porche 2012):

  • Researcher in provision of evidence to support or challenge various elements of a proposed policy.

  • Members or organizers of professional interest groups that focus on specific policy issues.

  • Personal support and professional networks as legislative advocate collaborating with policymakers or policymaking bodies to influence policy development.

  • Provision of expert testimony on policy issues. Professional experiences of nurses have the potential for reinforcing relevance to the policy issue.

Nurses may articulate what they want to happen in healthcare policy, and they may provide evidence to support their suppositions; however, they must engage in the policy process to ensure the changes they support are realized. In this effort, they must envision themselves as leaders in the process. The challenge is to motivate nurses to pursue leadership positions in the policymaking process (IOM 2011). Participation may be as simple as sharing research findings and personal experiences or as complex as aspiring for a political position at the government level. If nurses choose not to participate in the policy process, politicians and officials will listen to those who have a limited knowledge of nursing and the advancement of the profession.

Conclusion

The issues of health, healthcare services, and relevant policy impact the lives of all populations at diverse levels. If we, as healthcare professionals, do not feel that we have the power and ability to influence change that affects our lives and lives of those around us, why have we gained clinical and leadership expertise as advanced practice nurses? Advanced practice nurses can be instrumental in translating the intent of policy to the realities of implementation in practice. Planning that includes options for nursings’ participation in the policy process includes insight, multiple strategies, and skillful techniques. This chapter suggests that there are various options for participation of nurses in the policy process. Understanding a context is always the first step. Through better understanding, there is a higher possibility of selecting appropriate strategies and actions.

Using a theoretical lens is essential to achieve this task. Understanding theory and thinking about the various factors that influence health policy development is a beginning in shaping change. This knowledge includes awareness of interactions among diverse individuals, unexpected events, and a complex mix of policies that span levels of governmental agencies along with contextual geographical and socioeconomic settings (Sabatier and Weible 2014).

The chapter also suggests that persons in positions of authority and power ultimately make pivotal decisions. If decision-makers with limited knowledge of nursing lack access to nursing representatives, they will likely resort to ill-informed or less-informed points of reference to guide their decisions. This calls for a transformation in nursing to become more visible and active leaders in the policy process. Policy associated with advanced nursing practice that proposes a new level of nursing and nursing roles requires a paradigm shift in thinking in the provision of healthcare services. Advanced levels of autonomy, prescribing authority and referral patterns to other healthcare professional among other issues, often raise opposition to the advanced nursing practice concept. For this reason, the author emphasizes that APN leadership and participation is essential in policy development and implementation.