Academic researchers and clinicians may provide an evidence base through research and clinical experience to inform public policy that improves the lives of older adults. Despite the potential benefits, academics and clinicians often fall short in affecting public policy. Some researchers and clinicians may never engage in the policy making process because they lack awareness of the myriad opportunities for involvement, including many different points of entry and levels of intensity for public policy engagement (Hinrichsen et al., 2010; Malone, 2005). Opportunities to inform public policy range from in-person congressional testimony and legislative briefings to written materials, such as policy briefs, systematic reviews, and advocacy fact sheets (Lavis, Permanand, Oxman, Lewin, & Fretheim, 2009a,b; Murthy et al., 2012). Many academics and health care practitioners do not recognize the opportunities that are an extension of their current research or practice. One avenue for policy engagement that has not been fully exploited is the use of policy narratives, a combination of personal stories and academic research findings.
The centrality of a personal story sets policy narratives apart from other forms of policy engagement. Personal stories demonstrate the implications of specific policies on individuals' lives. Amy Berman (2012), a nurse and cancer survivor, has used personal stories to shift the national dialogue on federal palliative care. Her expertise as a nurse gives her credibility to discuss her decision to choose a less aggressive treatment than the breast cancer standards of care, and her personal story provides a human dimension that allows her to demonstrate to policymakers and the general public the value of palliative care in improving her quality of life. Louise Aronson (2013, 2015), as a geriatrician and family member, has used professional and personal perspectives in stories that highlight gaps in appropriate care for older adults and recommends policy changes within the health care system to incentivize increased care coordination and the assessment of caregiver effectiveness and patient goals.
In the past decade, there has been increasing recognition, guidance, and publication avenues for the application of personal stories to facilitate changes in public health policy and practice (Colby, Quinn, Williams, Bilheimer, & Goodell, 2008; King, 2014; Meisel & Karlawish, 2011). Other avenues include Health Affairs' Narrative Matters (access http://www.healthaffairs.org/narrative-matters/submit) and the Journal of the American Medical Association's Care of the Aging Patient: From Evidence to Practice (access http://jama.jamanetwork.com/collection.aspx?categoryid=6256). Such narratives bring needed attention to the “lived experiences” of health care practitioners and consumers. Many have served as a catalyst for policy discussions that more explicitly recognize the human costs of policies that do not adequately reflect or effectively respond to the needs and preferences of the end user of health care: the patients themselves.
Policymakers seek information from academic researchers and observations from clinicians because inherent in the academic and clinical cultures are medical ethics and the scientific method, which includes a peer review process that increases objectivity and decreases bias. However, academic research findings alone are often inaccessible to policymakers; personal stories alone may appear to be isolated cases that have little relevance to the broader context of public health. One of the most effective ways to influence public policy is through compelling narratives that combine facts (i.e., analytical research) and personal stories (i.e., emotional examples) (Dodson, Geary, & Brownson, 2015; King, 2014; Stamatakis, McBride, & Brownson, 2010). Academic researchers have the analytical skills but often lack the training in narrative development or are inherently bad at telling such stories because individual narratives are seen as biased and not grounded in aggregated data by the academic community (Meisel & Karlawish, 2011). Clinicians, on the other hand, have daily interactions with patients and powerful stories to share but may not know the best way to package these stories to policymakers, setting them in context of the bigger picture and the population-level data that are essential to making the case for policy change.
Nurses in particular are in a position to effectively use policy narratives because they are witnesses to illustrative stories and are seen as trustworthy experts (Fiske & Dupree, 2014; Robert Wood Johnson Foundation [RWJF], 2010). Nurses are being called to play a more active role in informing health policy by health care opinion leaders from health services, insurance, corporate, and government sectors (RWJF, 2010). Furthermore, nurses can advance their influence on the policy process by assuming key leadership roles in a variety of governmental, corporate, and community settings.
Informing policy decisions relies on the development and delivery of accessible information (Innvaer, Vist, Trommald, & Oxman, 2002). Several researchers have examined barriers to the use of research for policy decision making, including the lack of relevant and timely research, translation of research findings, and institutional cultures (Oliver, Innvar, Lorenc, Woodman, & Thomas, 2014; Prewitt, Schwandt, & Straf, 2012). To facilitate the uptake of evidence by policymakers, researchers have developed knowledge exchange models to disseminate information, recommended academic–policy-maker collaborations to identify policy-relevant research questions, and suggested training academics on the policy making process (Kietzman, Troy, Green, & Wallace, 2016; Oliver et al., 2014). Many of the identified barriers and facilitators are grounded in cultural differences between the separate entities involved in the policy making process.
The purpose of the current article is two-fold: (a) to identify cultural differences among academic researchers, clinicians, and two of the main leverage points for federal policy, the U.S. Congress and federal agencies, that may hinder policy decisions; and (b) to bridge cultural gaps and enhance public health policy that meets the needs of older adults through the development and use of policy narratives.
Cultural Differences Among Academics, Clinicians, and Policymakers
Public policy development is an iterative process that involves multiple stakeholders and is influenced by many factors, including political environments, personal beliefs and values, and scientific knowledge (Hinrichsen et al., 2010; Prewitt et al., 2012). The primary role of entities in the policy making process and the cultures in which each operates determines the expectations for the generation and use of information for public policy decisions. Table 1 provides an overview of cultural differences that may hinder public health policy development and implementation for four entities in the federal policy making process: academic researchers and clinicians as information producers and U.S. Congress and federal agencies as information users. Each entity has a different type of authority and sphere of influence, culminating in a range of intellectual, professional, and legislative contributions to the policy process.
Overview of Cultural Differences Among Four Entities in the Federal Policy Making Process
Academics and clinicians operate in environments that are often internally focused. Academic researchers are fundamentally concerned with advancing scientific knowledge and understanding. Academic training and the reward structures of academic institutions, especially research-intensive universities, incentivize researchers to narrowly focus their research agendas and within that focus to identify gaps and problems and give qualified conclusions (Kietzman et al., 2016). Although this approach is effective in promulgating future research and better scientific understanding, it impedes the development of effective policy engagement because policymakers demand unqualified solutions with broader relevance to their constituency. Academic researchers are not trained to translate scientific knowledge into accessible, timely, and policy-relevant information (Innvaer et al., 2002) and usually do not consider the implications (e.g., costs, logistics, political consequences) of implementing a given policy recommendation. Clinicians are committed to improving the health of individual patients and increasing the quality, effectiveness, and efficiency of health service delivery. In recent years, there has been an increased demand for the application of clinical skills to public health, to address population-level health needs, whether in response to the outbreak of infectious diseases, natural disasters, or threats of bioterrorism (Gerberding, Hughes, & Koplan, 2002; Leaning & Guha-Sapir, 2013). Because of their direct interface with health care consumers, whether in an individual encounter or public health response, clinicians are better positioned than most academic researchers to anticipate and observe the implications and actual effects of policies that guide their daily practice and affect patient outcomes. However, clinicians may not link their clinical observations to the broader context, the aggregate-level data on which policymakers often rely to make decisions or use to convince other policymakers to lend their support.
Federal policymakers are public servants, beholden to their constituencies and each other, who operate in environments that are externally focused, and are subject to a political process bounded by a host of procedural rules and regulations by which they must abide. In Congress, U.S. representatives, senators, and congressional staff are decision makers on federal policy development and responsible for a broad range of policy topics (e.g., trade, finance, agriculture, education, health). As a result, policy-makers in Congress must be highly selective about which legislation to champion—some issues may relate to a personal mission, others may be based on the concerns of their constituents and advocacy groups, or the political climate in Washington, DC (Hinrichsen et al., 2010). Congress seeks information to be responsive to the top issues of the day, make informed decisions, and to persuade or respond to other policymakers. Considering the implications of implementing proposed legislation is an integral part of public policy development. Federal agency secretaries, directors, and staff are responsible for development of rules, regulations, and guidance, and oversight of federal and state implementation, of legislation developed in Congress. Both congressional and federal agency staff require information that is accessible and relevant to current policy issues (Colby et al., 2008).
Developing a Policy Narrative
Policy narratives may be developed and used to communicate across the cultures of academic researchers, clinicians, and policymakers by presenting policy-relevant information in an easily accessible format (Table 2). An effective policy narrative relies on the credibility of the narrator, knowing the audience, and telling a compelling story.
Developing Policy Narratives to Inform or Influence Public Health Policy
Credibility of the Narrator
As knowledge generators, academic researchers and clinicians are the writers or narrators of policy narratives. Academic researchers are viewed by policymakers as experts who provide unbiased interpretation of facts because of the integrity of the scientific method (Hinrichsen et al., 2010). Clinicians provide on-the-ground observations of how policies are working for individual patients, health care providers, and institutions.
Fiske and Dupree (2014) found that credibility, necessary for effectively communicating science to non-scientists, was dependent on both intent (i.e., warmth as demonstrated by friendliness and trustworthiness) and capability (e.g., competence, expertise). Among a sample of U.S. adults, nurses ranked highest (high warmth/high competence) and researchers moderately (low warmth/high competence) compared to other common jobs in the United States (Fiske & Dupree, 2014). Not surprisingly, advice on writing a compelling personal story states that the writer must demonstrate reliability, credibility, trustworthiness, and warmth (Lopate, 1995). Nurses, and by extension other clinicians, are well positioned to deliver policy narratives because they are seen by the public as being both trustworthy and competent, are trained in application of research findings for decision making, and have stories from their own lives, their patients, or health care institutions. Academic researchers have the critical elements of competence and expertise and may apply personal stories to increase perceptions of warmth and trustworthiness.
Knowing Your Audience
Another crucial element to effective communication is to “know your audience.” Academic researchers and clinicians create messages most often for peers within their own discipline and in structured formats, such as peer-reviewed journal articles, conference presentations, or medical grand rounds, and therefore, they know the audience.
Primary audiences for policy narratives aimed at federal level health policy development and implementation are the U.S. Congress and federal agencies, such as the U.S. Food and Drug Administration, Department of Health and Human Services, and Centers for Medicare & Medicaid Services. Congress and federal agencies have cultural expectations on the generation, exchange, and use of information that often differ from academic and clinical cultures. The information needs of senators, representatives, and congressional staff are primarily motivated by the concerns of their constituents: they need state- and district-specific information that is presented in a clear, concise, and timely manner. The importance of timely information cannot be overstated as the windows of opportunity for policy change are hard to predict and the time for policy action is often fleeting (Innvaer et al., 2002; Kingdon, 2003). Federal agencies are motivated to ensure that laws passed by Congress are implemented in effective and efficient ways, resulting in positive outcomes for those most directly affected. At this point of the policy process, agency staff are seeking information that supports the translation of policy in the “real world,” assuring that the intent of the law is realized in its application.
Telling a Compelling Story
Compelling policy narratives have many of the same traits as the personal essay. They rely on intimacy and use storytelling techniques such as character development, conflict in terms of identifying a policy issue and the risks or benefits of a current policy or a proposed change in policy, and set into motion dialogue toward resolution of the conflict. The writer sets up a dialogue with the reader that, despite the details being specific to the narrator, there is a shared element of the narrative that draws in a common emotional experience (Lopate, 1995).
Policy narratives are designed to tell a coherent story using the narrative structure of a beginning, middle, and end. The beginning frames the story in accessible language that uses a universal statement linked to the policymakers' interests. Given the number and intensity of competing demands on Congress and the federal agencies, researchers and clinicians are best served to start a policy narrative with a “hook” that gets the attention of the target audience: the policy decision maker. For example, “sitting is the new smoking” works because it is to the point and links a current public health issue (i.e., sitting) to a former public health controversy to be avoided (i.e., smoking). The middle, or “core,” of the policy narrative is the evidence, which pairs the personal story to underscore the policy issue, conflict, and possibly a resolution with analytical facts that support and link the story to a broader context; highlights inherent benefits or risks associated with the current or proposed policy; and uses state- or district-level data to link the story and facts to the policymakers' context. The closing acts as a “catalyst” toward information dissemination or action. The content of the closing is dependent on whether the intent of the communication is education, which informs a policy decision, versus advocacy, which argues for or against a specific solution, a policy recommendation, to address the policy issue. For academic researchers, in particular, two philosophies emerge. One claims that once a researcher advocates for a specific position, he or she loses neutrality and with that some credibility, at least on the surface. The other claims that there is a responsibility to use research to improve public health through taking a policy position (Brownson, Royer, Ewing, & McBride, 2006). Either way, to be effective, policy narrative closings must be simple and unqualified. What sets advocacy apart from education is that education provides an unqualified distillation of facts without a formal request for policy action; advocacy provides one or more policy recommendations. Some academics choose to provide a distillation of findings to another entity, such as a professional society or advocacy group, that then uses the research to ask for specific actions or policy recommendations.
Delivering a Policy Narrative
Delivering the policy narrative is the next step in affecting public health policy. Discussing the policy narrative with appropriate audiences is an effective dissemination method. Similar to personal essays, policy narratives have a prologue or backstory, information that is an integral foundation that precedes the story but is not written into the text. Discussions with policy-makers allow academic researchers and clinicians to keep the policy narrative to one page by drawing upon the backstory to emphasize the importance of a policy decision during conversation, if necessary. Another storytelling technique is use of an epilogue to bring closure to a narrative. Although a well-written policy narrative will be able to stand on its own, there are often implications of policy recommendations. Academic researchers and clinicians will have greater success in affecting policy if they are able to discuss the potential costs, logistics, and political consequences of take away messages or policy recommendations outlined in the policy narrative.
Using Policy Narratives to Collaborate Across Cultures
The key to effectively meeting the needs of an aging population is to understand how stakeholders can collaborate to inform, develop, and implement public health policy. Below are some ways the policy narrative may be applied to facilitate collaboration across cultures.
Collaborations between clinicians and academic researchers may be strengthened by developing together a policy narrative that is both grounded in the real stories of individuals and placed in a broader context that illustrates the scope and depth of the policy issues. Policy narratives' reliance on personal stories may enhance communication between academic researchers and clinicians, and policymakers. Two-way communication facilitates information use by policymakers for policy decisions because information producers have a better understanding of policymakers' research priorities and timelines (Innvaer et al., 2002). Academic researchers and clinicians, either in partnership with agency staff or with their own individual research agendas, may be able to close research gaps in policy-relevant research (Kietzman et al., 2016). Some federal agencies, such as the Agency for Healthcare Research and Quality in the Department of Health and Human Services, collect data to be used by external researchers, provide grant mechanisms to fund data collection and analysis beyond what is collected by the federal government, and offer guidance on the translation of research to facilitate information use to improve public health.
Cultural differences between entities in the policy process have implications for public health policy development and implementation. Academic researchers and clinicians may inform public policy by developing policy narratives based on their current research or practice. An effective policy narrative presents policy-relevant information in an easily accessible format for policymakers. In addition, policy narratives may be useful tools for navigating different cultures and facilitating collaborations among academic researchers, clinicians, and policymakers.
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Overview of Cultural Differences Among Four Entities in the Federal Policy Making Process
|Dimensions of the Policy Making Process||Four Entities in the Federal Policy Making Process|
|Academic Researchers||Clinicians||Congressa||Federal Agenciesb|
|Primary role in public policy||Expert informer based on analytical and aggregated quantitative and qualitative data.||Practitioner informer based on implementation of public policies affecting health services delivery.||Developer of laws.||Developer of rules, regulations, and guidance on implementation of laws; oversight of federal and state implementation of laws.|
|Motivation for acquisition of information||Advance scientific knowledge and understanding.||Improve health of patients; improve institutional effectiveness and efficiency of health service delivery.||Respond to requests of constituents; solve a policy issue.||Improve public health; improve institutional effectiveness and efficiency; solve a policy issue.|
|Application of information||Identify problems, gaps, and inconsistencies; present future research directions.||Identify problems and inconsistencies; identify practical resolution to create most effective practice.||Identify positive solutions; identify practical resolution on policy issue; develop policy arguments to persuade other policy decision stakeholders.||Identify problems and inconsistencies; identify practical resolution to create most effective implementation of policy; develop policy arguments to persuade other policy decision stakeholders.|
|Implications of policy recommendationsc||Not considered or disregarded.||Considered based on clinical experience.||Considered based on legislative experience.||Considered based on policy implementation experience.|
Developing Policy Narratives to Inform or Influence Public Health Policy
|Preparation||What is the policy issue?
Who is the appropriate policymaker audience?
Identify policymakers based on state and district representation, relevant congressional committees and federal agencies, and political interests of specific policymakers.
|Overall||What is the intent of the policy narrative?
The intent (i.e., to educate and inform or to advocate and influence a policy decision) sets the tone of the policy narrative.
|Title||What words best represent the policy issue and intent of the policy narrative?||Question or phrase|
|Opening or “hook”||What is a compelling universal statement that ties to the policymakers' interests?||One or two sentences|
|Middle or “core”||What is an emotional story to underscore the policy issue, conflict, and possibly a resolution?
What analytical facts and research support the emotional story and link to a broader context?
Are there any inherent benefits or risks associated with the current or proposed policy?
What state or district level data place the story and facts into the policy-makers' context?||Two to three paragraphs Visual displays (e.g., tables, figures, graphs)|
|Closing or “catalyst”||What are the unqualified take away messages linked to the intent of the policy narrative?
If the intent is to educate and inform, provide a distillation of the story and facts for neutral unqualified messages; if the intent is to advocate and influence, provide unqualified messages that lead to specific policy recommendation(s).
|One or two sentences Bullet points|
|Resources||What references are relevant for policymakers to gain more information?
How can policymakers contact you?
How can policymakers contact other key stakeholders for this policy issue?||Footnotes|