Perioperative Nursing Clinics 2 (2007) 69–74

Health Policy Analyst: An Advanced PracticeRegistered Nurse Subspecialty

Lisa C. Myers, MS, RNSpecial Programs, The Maryland Institute for Emergency Medical Services Systems,

653 W. Pratt Street, Baltimore, MD 21201, USA

Nurses have been involved in health care

policy development and politics with little or noformal education or advanced degrees for severalhundred years. As nursing evolved from care

provided primarily by uneducated women to theirfamilies in the home in the seventeenth andeighteenth centuries to a profession in whichwomen and men with differing levels of education

and degrees practice in various specialties andsettings including the home, nurses have been partof health care policy making and politics. Nurses

were an integral part of politics and policy makingfor the establishment of community health ser-vices, child welfare, housing, and suffrage move-

ments [1]. Notable names from the 1800s such asFlorence Nightingale, Clara Barton, and DortheaDix stand out in the field of nurses who fought to

establish and improve nursing as a profession [2].In the 1900s, nursing pioneers such as LillianWald and Margaret Sanger persevered to influ-ence policy on various levels and unquestionably

strengthened the voice and presence of nursingwithin the public and health policy arenas [3].Nurses were also integral to the institution and

advancement of formal nursing education at ac-credited colleges and universities [2]. In responseto a national nursing shortage, the American

Nurses Association (ANA) testified at congressio-nal hearings in support of the Nurse Training Act,which passed in 1964 and provided $287 million infederal funding for nursing education. This en-

abled nursing to increase its numbers by providingfunding for minorities and the underprivileged [4].

E-mail address: lmyers@miemss.org

1556-7931/07/$ - see front matter � 2007 Elsevier Inc. All ri

doi:10.1016/j.cpen.2006.12.007

Rooted in a desire to advocate for themselves

as caregivers and for the patients they care for,clinicians informally participate in policy making,often unaware of the role they play in health care

policy. Nurses encompass the single largest groupof health care providers and, as such, can be veryinfluential on public and health policy [3]. This ar-ticle expands on the clinician’s informal role in

health policy and discusses the role of the ad-vanced practice registered nurse (APRN) in influ-encing health policy on various levels, especially in

the role of nurse policy analyst.

Educational preparation

The qualifications for health policy or nursepolicy analysts typically require a master’s degree

in public administration, health policy, or healtheconomics, or a lesser degree with commensurateexperience in a policy role. To be accredited by the

National League for Nursing, baccalaureate andmaster’s-level nursing education programs arenow including introductory public policy and

political content as part of the required curricu-lum [5]. This coursework is essential to begin for-mulation of thought processes that link nursing to

policy throughout nursing school. According toReutter and Duncan [1], exposure to theoreticperspectives such as critical social theory providesthe framework for the critical analysis of social,

political, and economic contexts that are requi-sites for policy change. Exposure to these perspec-tives in ‘‘nursing theory’’ courses would serve to

emphasize how policy advocacy is an inherentpart of nursing practice [1]. Several distinguishednursing schools have developed joint public policy

and nursing master’s degree/doctoral programs

ghts reserved.

periopnursing.theclinics.com

70 MYERS

for nurses to receive formal policy preparation [5].Some argue that comprehensive preparation inpublic policy for nurses is an essential element

of graduate education, preparing them to havea critical awareness of the policy process and thepolitics that are at its core [1]. In such formal ed-ucational health care policy programs, nurses are

prepared to identify, critically analyze, and evalu-ate laws, regulations, and policies at the institu-tional, local, state, and national levels that

impact patients and the profession of nursing,and to develop knowledge of the history, structure,and process of policy making in the United states.

Students are also taught to conduct and analyzequantitative and qualitative research and under-stand the role that research and data play in theformation of public policy. Students become famil-

iar with critical components of the policy processsuch as ‘‘problem framing and definition, creationof policy agendas, policy instruments and their im-

plementation, policy network and communityanalyses, and evaluation of policy impacts’’ [1].

A significant deficit currently exists in educa-

tional opportunities and exposure to basic in-formation about the policy-making process,resulting in few nurses pursuing advanced degrees

in health policy. Reutter and Duncan [1] stated,‘‘there has been minimal discussion in the litera-ture available regarding graduate curricula in pol-icy analyses and policy advocacy for nurses and

other public health professionals.’’ Many nursesreceive little to no exposure to health policy aspart of their basic nursing education and lack

the understanding that the delivery of nursingcare and health care policies enacted at the stateand federal level are intricately intertwined [5].

‘‘Nursing leaders recognize that deficits in the ed-ucation of nurses in politics and public policymaking have led to ineffectiveness in this arena,’’resulting in very few nurse analysts who can influ-

ence federal and state health policy making [5].Consequently, individuals who are not nursescontrol current practice and make decisions about

nursing’s future and the distribution of health re-sources [5]. This lack of policy education and un-derstanding by nurses may be partially a result of

a large number of nurses graduating from nursingeducation programs whose primary focus hasbeen exclusively clinical. Some participants of

one study noted the ‘‘absence of formal contentin their nursing programs related to public policyand emphasized the importance of exposure tosuch information to help students understand po-

litical involvement as essential’’ [6]. This lack of

involvement is of concern to the professionbecause ‘‘nurses’ clinical knowledge providesa unique perspective for policy decision making’’

[7]. Nurses who have strong clinical backgroundshave the ability to understand and conceptualizethe effect and outcomes of policy decisions onpatients and health care delivery [5]. In addition,

health policy and nursing have several commonal-ities such as juggling competing demands, balanc-ing priorities, strong communication and

consensus building skills, and the ability to effec-tively respond to unpredictable situations, makingnurses ideal candidates for policy roles [6]. One

study found that ‘‘once engaged, nurses seldomturned their backs on the world of policy-making’’[6]. Even so, nurse scholars have written about theneed for more policy content in education and re-

search: ‘‘nurses need to develop a greater level ofsophistication in conducting policy analysis andnursing research with policy implications’’ [6].

Hanley [8] described political participation bynurses as the most critical element in achievingpersonal and professional goals. As a route to at-

taining these goals, educating nurses for politicalaction and policy analyst roles can be a vehiclefor promoting better health care and to improving

patient outcomes.

Role

Stimpson and Hanley [5] stated, ‘‘the role ofthe nurse policy analyst is a subspecialty in nurs-

ing that is similar to other advanced-practice rolessuch as the nurse administrator or clinical nursespecialist and has been identified as a distinct

APRN role because it includes components of re-search, leadership, and change agency.’’ The firstphilosophic assumption in Fawcett and Russell’s

[9] conceptual model of nursing and health policyis that ‘‘nurses are active participants in the for-mulation, implementation, and evaluation of pub-

lic policy directed toward the improvement ofhealth of individuals, families, groups, andcommunities.’’

To understand the role of the nurse policy

analyst, it is necessary to first understand severalpolicy-related definitions. ‘‘Public policy refers tolocal, state, and federal legislation, regulation,

and court rulings that affect individual and insti-

tutional behaviors under the respective govern-ment’s jurisdiction such as state licensure for

professional practice and federal Medicare legisla-tion. Health policy refers most often to public pol-icies directly related to health care service delivery.

71HEALTH POLICY ANALYST

Policy analysis is the systematic study of the con-tent and anticipated or actual effects of standing orproposed policies’’ [7]. Policy formulation may oc-cur in various ways, including the enactment

of legislation and the subsequent development ofregulations, in addition to judicial decisions andinterpretation of law. Administrative-level policy

making also occurs within or between agenciesand may include the development of interpretiveguidelines of rules and regulations [7].

The primary role of the health policy analyst isto help create public health policies (by attempt-ing to influence public policy) that benefit the

health and well-being of society. Several notablescholars have described the role of the policyanalyst in various ways. Dror [10] described thepolicy analyst role as ‘‘an advisory staff position

in government services that should be establishedin all administrative agencies, corporations, andorganizations proximate to senior policy-deter-

mining positions.who uses methodologies of sys-tems analysis and quantitative decision theorywith a focus on political science and public admin-

istration,’’ whereas Behn [11] described the role asone of ‘‘managing conflict between interest groupconcerns and building consensus on the chosen al-

ternative.’’ Behn saw analysts working in privateor public settings. Jenkins-Smith [12], who alsohad great influence on the formulation of the pol-icy analyst role, described three policy analyst

‘‘prototypes’’: (1) the ‘‘objective technician,’’ anacademic researcher serving in a bureaucraticstructure who uses models and statistical regres-

sions to determine the most economically efficientprogram; (2) the ‘‘issue advocate’’ who promotessocietal welfare, serving the interest of society

over the individual, organization, or policy maker;and (3) the ‘‘client advocate’’ who promotes theclient’s personal interest [5]. The nurse analystrole, according to Stimpson and Hanley [5], incor-

porates various components of the three proto-types, with an emphasis on health.

In most APRN roles, nurses work within the

institutional setting; however, the role of nursepolicy analyst differs because most often, ‘‘thefocus on health care usually takes place in a setting

that is outside of the traditional institutionalsetting’’ [5]. A key role of the nurse policy analystis to provide information to individuals in leader-

ship and decision-making roles by way of thepolicy analysis process. Examples of individualsin leadership roles may include legislators andagency directors. To provide accurate informa-

tion, it is therefore imperative for the nurse policy

analyst to stay informed on current events andhealth policy issues and have the ability to effec-tively communicate the issues verbally and in writ-ing in public and professional arenas [5]. Staying

informed may be accomplished by monitoringnews articles, policy journals, and publicationsand through membership in professional associa-

tions such as the ANA.Research is also a fundamental component of

the development of health policy and is an integral

part of the role of the nurse policy analyst [5]. Topresent scientific information to decision makers,the nurse policy analyst must understand various

research methods and have the ability to deter-mine the validity of studies and to communicatedata and statistics to policy makers intelligently.Learning to conduct and understand research is

also an important mechanism in facilitating criti-cal thinking. In addition, collaboration with nurseresearchers to assure that strategies are designed

to enhance the linkage of research to policy is im-portant so that policy makers have the informa-tion they need to make ideal policy decisions [6].

Nurse policy analysts have the power to in-fluence decision making because of the knowledgebase acquired during the policy analysis process.

Leadership is therefore also part of the nurse policyanalyst role because the possession of healthknowledge provides the ‘‘potential and actualpower base for the nurse analyst and the opportu-

nity to create the environment for substantialcontributions to policy deliberations, leading toenhancement of nursing’s visibility and public

image’’ [5]. Closely linked to the role of leader isthat of ‘‘change agent’’ because activities of thenurse analyst produce change in the health care de-

livery system and the nursing profession [5].How nurses choose to participate in policy

making varies and may be influenced by ‘‘expo-sure to a key mentor or role model or it may be

a gradual evolution influenced by experience inpositions of greater responsibility or by awarenessof opportunity through policy involvement. Some

have become involved merely by an enthusiasticcommitment to making a difference in the lives ofthose around them and described activism as

inextricably linked to health care and nursing’’[6]. Mary Beachley, former president of the Mary-

land Nurse’s Association (MNA) from 1999 to

2001, is the Chief of the Division of Health Facil-ities and Special Programs at the Maryland Insti-tute for Emergency Medical Services Systems, thestate agency that oversees and coordinates Mary-

land’s emergency medical service system including

72 MYERS

the designation of trauma and specialty centers.Appointed to the Statewide Commission on theCrisis in Nursing and serving as one of the vice

chairpersons from 2000 to 2005, she now repre-sents the MNA on the Maryland Nursing Work-force Commission under the Maryland Board ofNursing. Ms. Beachley stated that her involve-

ment with the MNA legislative committee servedas an introduction to health policy. She discov-ered that as a nurse, she has a broad sphere of

influence that includes immediate family andfriends, neighbors, and colleagues in the work-place and in professional associations. Her nurs-

ing education and experience gives her directinfluence over legislators by communicating withthem and educating them on matters that involvepublic health and related health care matters. Ms.

Beachley translates that influence to her ability toinfluence the development of policies that effectthe development of legislation and regulations

(Mary Beachley, MS, RN, CNAA, personal com-munication, 2006).

Scope of practice

Nurse policy analystsmay choose froma varietyof settings in which to work. Nurse policy analysts

may consider employment in federal, state, andlocal governments, in consulting firms, in privateand public agencies, and in research foundations.

There are several agencies within the federalgovernment that employ nurse policy analysts. Oneexample is the US Department of Health and

Human Services (DHHS). Within the DHHS thereare numerous administrations such as the HealthResources and Services Administration (HRSA),

andwithinHRSA there are several areas of focus inthe form of bureaus such as the Bureau of PrimaryHealth Care, the Bureau of Health Profession, andthe Office of Rural Health Policy, to name a few.

Policy analysts may be employed at varying levels(entry level to senior level) depending on experi-ence. The following list of major duties of a public

health analystwas taken froma federal governmentagency job posting [13]:

� Respond to inquiries about agency programsand initiatives from Congressional represen-tatives and their staff.

� Monitor Congressional activity and track leg-islation of relevance to agency programs orinitiatives.

� Attend Congressional hearings, mark-up ses-sions, and floor debates on legislation of in-terest to the agency.

� Prepare analyses and summaries of legisla-tion, including identification of issues andbackground description of the legislation’s

history and its impact on policies andprograms.� Draft formal implementation plans for newlegislation that is specifically directed at the

agency or that impacts its programs oractivities.� Collect and organize up-to-date information

for the preparation of testimony and briefingmaterials to be used by the director and otherofficials at Congressional hearings.

� Draft or review and edit agency comments onproposed agency-related legislation.� Assess the adequacy of existing legislativeauthorities to meet present and planned pro-

gram objectives.� Examine methods of improving relationshipsand communications with Congress and assist

in advising the director and senior staff onthese efforts.

Nurses have been appointed to elevated policypositions within the federal government. Oneadmirable example is Virginia Trotter Betts, JD,

MSN, RN, FAAN, who in 1998 was namedSenior Advisor on Nursing Policy and SeniorHealth Policy Advisor within the DHHS. Ms.Trotter Betts was, at the time, the immediate past

president (1992–1996) of the ANA. Her role asSenior Advisor on Nursing Policy was describedby ANA in a press release as monitoring and

participating in all DHHS policy work involvingthe nursing profession. Issues included nursingeducation, licensure, and scope of practice; nurs-

ing research; nursing workforce concerns; andnursing reimbursement and practice arrange-ments. The assignment also included work ona variety of health policy issues in her role as

Senior Advisor [14]. There are many other exam-ples of positions for consideration at the federallevel, including elected officials or their staff.

Similar to the roles available in federal gov-ernment, nurse policy analysts can work for stateand local government agencies in much the same

roles by advising state and local officials. InMaryland, several nurses have been elected tothe offices of state delegate and state senator.

Senator Paula Hollinger served in the MarylandGeneral Assembly for 28 years as delegate andthen as senator until 2006 when she elected torun for Congress. As Chairman of the Senate

Education, Health, and Environmental Affairs

73HEALTH POLICY ANALYST

Committee from 2003 to 2006, Ms. Hollinger wasa strong voice for policy issues related to thosetopics. She sponsored many health care deliverybills that were passed into law, including the

enactment of a measure to provide state moneyfor embryonic stem cell research and the law thatallows non–health care facilities such as schools,

churches, businesses, and other organizations thatmeet certain requirements to have automatedexternal defibrillator programs. During her time

in office, Ms. Hollinger was presented with manyawards including the Jessie M. Scott Award forLeadership in Health Policy from the University

of Maryland School of Nursing in 2002, thePublic Policy Maker of the Year by the Wash-ington Psychiatric Society, and Public PolicyAdvocate of the Year by the Alzheimer’s Associ-

ation [15].In addition to the opportunities that exist

within government, public and private agencies,

and research foundations, there are numerousopportunities for health policy fellowships thatprovide an excellent opportunity to learn the

policy making and analysis process while gainingexposure to numerous sources for networking andpotential employment. Fellowships may last from

several months to a few years and although someoffer no financial compensation, others offerstipends and salaries. Two examples of fellow-ships currently available include (1) the Robert

Wood Johnson Health Policy Fellowship, a 1-yearfellowship designed to provide a better under-standing of major issues in health policy and

insight into how federal health programs areestablished; and (2) the Barbara Jordan HealthPolicy Scholars Program for college seniors and

new graduates, a 9-week fellowship that placesstudents in congressional offices to learn abouthealth policy and that provides an opportunity togain knowledge about federal legislative policy

procedure and health policy issues while furtherdeveloping critical thinking and leadership skills.

Encouraging advanced practice registered nurses

to choose health policy

Motivating nurses to consider health policy asa career path poses many challenges and obsta-

cles. One study revealed that few of the partici-pants had received formal policy coursework aspart of their nursing education and ‘‘few were

encouraged to seek mentoring or other less formalsources of training.’’ The researchers stated, ‘‘fewnurses have been educated formally or informally

about the political process and the potential forpositive change inherent in the democratic polit-ical and policy making process’’ [6]. In addition tothe impact that this lack of education has on

nurses and on their likelihood to choose healthpolicy as an advanced practice subspecialty, thereis a negative consequence to health policy making

because policy makers do not gain the nursingperspective when forming policy that affects nurs-ing and health care. The nursing perspective and

experience is essential for policy makers to under-stand because policy makers will make decisionsthat affect the nursing profession, with no under-

standing of the potential implications or conse-quences. Because such consequences may benegative and can be lasting and potentially irre-versible, nurses must weigh in with a strong uni-

fied voice in an educated manner to achieve thedesired outcome. Keeping in mind that the publicholds the nursing profession in high regard, policy

makers are very receptive to nurses’ perspectivesand input on health policy issues.

Because many nurses do not understand that

health policy and nursing are so integrally relatedto one another or recognize the value of their inputto policy makers and because health policy is so

often practiced outside the hospital or institutionalsetting, nurses may believe that choosing healthpolicy as an area of specialty is a betrayal to theircolleagues and an abandonment to the nursing

profession. This ‘‘phenomenon based in nursing’sprofessional socialization.frequently leads nursesto perceive policy related or political activity as

inconsistent with the nursing role’’ [5]. The beliefthat a nurse is a caregiver who works at the pa-tient’s bedside often encourages nurses seeking an

advanced practice degree to build on what theyknow when choosing an APRN area of specialty.Consequently, areas of specialty such as the clinicalnurse specialist or the nurse practitioner are com-

mon, whereas a shortage of nurse policy analystsremains.

Nursing educators and APRNs in policy roles

are the primary forces that can drive nurses toconsider a role in health policy. To attract nurses tohealth policy programs, the role of nurse policy

analyst must be identified by graduate- and doc-toral-level nurse educators as a feasible occupation[5,6].According toReutter andDuncan [1], asmore

policy courses are offered in doctoral and master’sprograms, it is more likely that future scholarswill engage in policy-related fields. Nursing facultywho have expertise in health and public policy are

best prepared to teach policy courses [1].

74 MYERS

Using real-life examples of APRNs who arecurrently practicing in health policy roles may bethe most beneficial means of stimulating nurses’

interest in pursuing careers in the health policyarena because meeting ‘‘experts in the field’’ helpsto reinforce that the APRN’s role in health policyis a viable and potentially rewarding option.

Therefore, faculty must be knowledgeable ofcommunity and government leaders to ensurestudent exposure to such individuals [1].

Internships are also an excellent opportunity tostimulate interest in health policy careers. TheNurse in Washington Internship (NIWI) is one

example of an opportunity for nurses to learn howto influence health care through the legislativeprocess. This 4-day internship has been availableto nurses for 23 years and is intended to energize

and prepare participants to become actively in-volved in the health policy process at the local,state, or national levels. Participants learn from

a distinguished faculty of health policy expertsand government officials, of whom many arenurses. NIWI highlights include opportunities to

network with other nurses, an executive branchbriefing, and visits to members of Congress [16].

Summary

For health care’s agenda for the future toinclude nursing and the interest of the profession,

policy makers must be informed by nurses aboutthe key issues facing the nursing profession andhealth care today. For nurses to play a leadershiprole in educating policy makers, nurses must go

beyond a grass roots level of advocating, becomeformally educated about the health care policyprocess, and understand the close relationship

between nursing and health policy. Although grassroots participation is a critical first step to un-derstanding the policy and politics, graduate-level

education in health and public policy, resulting inthe specialization as an APRN in the health policyarena, is by far a more effective and rewardingmeans of attaining recognition and advancing the

goals of the nursing profession. Until nursesbecome actively involved in the health policy arena,policy makers who lack an understanding of the

implications of their decisions will continue tomake decisions that will affect the practice ofnursing and the delivery of health care without

the knowledge and critical input of nurses. Thisinput is invaluable and essential for nursing to berecognized as a powerful professionwith the ability

to influence the formulation of smart health policy.

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