This article describes a new teaching pedagogy in which faculty use a phased approach to teach undergraduate senior nursing students critical analysis of health care policy, including refinement of existing policy or the foundation for the creation of new policy. An original model developed by the authors is introduced to provide a conceptual design for this authentic learning experience.
The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008) provides a set of standards for nursing education. These standards are designed to establish the foundation for baccalaureate nurses to provide safe, effective, high-quality patient care. Building on the liberal education for baccalaureate nursing practice, these essentials provide a framework and curricular elements to support graduates in assuming the roles of care provider and care manager, as well as being a member of the nursing profession.
As members of the nursing profession, development of the role of advocate, for both patients and the profession, is paramount for baccalaureate nurses. The term advocacy implies safeguarding autonomy, defending social justice, informing, and empowering (Bu & Jezewski, 2007; Hanks, 2007). The social responsibility of advocacy requires special knowledge and skills as well as a commitment to the role of advocate.
Early in the curriculum, students are introduced to the role of the nurse as advocate. This foundation establishes the culture and expectation of professional nursing practice to include a broad view of the professional’s responsibility to society to safeguard and defend social justice, particularly as related to health care. Students must be challenged to examine health care issues as they practice in the roles of the nurse. Essential to assuming these roles is a means by which they can be prepared to influence change grounded in best practice.
The faculty of Grand View University Division of Nursing supports the development of advocacy and social responsibility skills in our nursing program through experiential learning strategies. Establishing a culture of best practice and empowering students with development of leadership skills is woven throughout our caring curriculum, culminating in the senior capstone course Professionalism II. In this course, students formalize the knowledge and skills for critical analysis of health care policy and design.
The current state of health care calls for nurses with the advocacy skills to navigate the political system and inform the public and policy makers of nursing’s role and value. The Pew Health Professions Commission (1995) identified the need for nurses to include a broad skill set, which allows nurses to influence health care policy. Cohen et al. (1996) discussed the importance of development of political skills. According to these authors, the integration of health policy into nursing curricula is essential.
Husted and Husted (2005) acknowledged that public policy content and advocacy skill in nursing education are central to the welfare of patients and nurses. Buresh and Gordon (2006) noted that nursing will become a full partner in shaping policy when nurses assume responsibility for the state of health care. Hahn (2009) further advised that the foundation of political advocacy is a basic understanding of the three “P’s” (power, policy, and politics).
Critical learning strategies are key to providing nursing students with the clear ability to navigate the political system. There is precedent in the literature for experiential strategies that promote student education (Bowles, 2006). Several articles advocate for the development of political advocacy savvy at the undergraduate level (Byrd, Costello, Shelton, Thomas, & Petrarca, 2004; Cohen & Milone-Nuzzo, 2001; Gatzke & Ransom, 2001; Houck & Bongiorno, 2006; Magnussen, Itano, & McGuckin, 2005).
In the first comprehensive study of nursing education in more than 30 years, experiential learning was touted as one of the strengths of nursing education (Benner, Sutphen, Leonard, & Day, 2010). However, the study also revealed that experiential learning in the clinical arena was rarely connected to classroom learning. The authors recommended that educators must change their approach to student learning, away from taxonomies and abstract information, toward helping students learn within the context of situations.
Although the literature identifies teaching-learning opportunities that lead to health care policy advocacy, no evidence was found that baccalaureate nursing students are being prepared to analyze and develop health care policy. The teaching methods presented in this article support student empowerment and an ongoing commitment to advocacy.
The Grand View Critical Analysis Model
The Grand View Critical Analysis Model conveys the skills of involvement needed in the complex arena of health care delivery. Few frameworks in the nursing literature provide guidance on how to help undergraduate students understand and use health care policy. This model is designed for students to view a health care issue initially as a whole. Students then pull the pieces apart into salient features so that they can better understand the critical analysis process and appraisal of evidence as it relates to the issue. Ultimately, the model allows students to maneuver the policy development process as they reassemble the pieces and synthesize the pieces back into a new whole.
Students come to understand the interconnectedness and importance of the Grand View Critical Analysis Model, which consists of a health care issue and the four phases of policy focus, colleagueship analysis, evidence-based practice analysis, and policy development and analysis (Figure). The model requires a clear working definition of health care policy, “a consciously chosen course of action (or inaction) directed toward some end” (Kalisch, Kalisch, & Clinton, 1982, p. 361).
Figure. Grand View Critical Analysis Model.
Assumptions of the model include:
- Undergraduate nursing students have the skills, knowledge, and experience to be active participants in the formulation, implementation, and evaluation of health care policy (Russell & Fawcett, 2005).
- Society and the profession of nursing benefits from nursing student involvement in writing health care policy (American Nurses Association, 2008).
- The sources of policy are distinguished as public, organizational, and professional (Fawcett & Russell, 2001).
- The stages and phases of writing health policy are, similar to decision making, nonlinear (Lindeman, 1999).
- Evidence-based practice, essential to health care policy development, is defined as “the integration of best research evidence with clinical expertise and patient values” (DiCenso, Guyatt, & Ciliska, 2005, p. 4).
Model Base: Selection of Health Care Issue
As students begin critical analysis, they are asked to select a health care issue for study. The issue must have societal implications and be influenced by the nursing profession. Students are asked to think about their clinical experiences throughout their education, brainstorm possibilities, and then identify a trigger or catalyst for an issue or problem (Stetler, 2001; Titler et al., 2001).
After selecting an issue, students move through several overlapping phases throughout the course. Working in teams, students discover the multiple facets of the issue and explore its breadth and depth. Examples of issues selected by students include new graduate bullying, lack of blood glucose monitoring during hospitalization for patients with diabetes, and misuse or overuse of Pitocin® (oxytocin) for women in labor.
Phase One: Policy Focus
The faculty member assigns a policy focus (professional, public, or organizational) to each health care issue. A professional focus results in a resolution, defined as a position statement on a topic, usually introduced for debate in a professional organization (National Student Nurses Association, 2009). The public focus takes the form of a white paper, which is a formal persuasive document that describes a problem and how to solve it (Stelzner, 2008). An organizational focus leads to a step-by-step policy used within an organization related to health care and gives personnel specific direction on a topic (Collins & Patel, 2009). Students keep their selected health care issue with its assigned focus at the forefront as they move into the other three phases of study.
Phase Two: Colleagueship and Coalition Analysis
In this phase, students examine the breadth of an issue through both inter- and intraprofessional lenses. To discover solutions to issues, the team must talk to people who have an interest in or who are involved in the topic. These stakeholders may be found in the form of colleagues and coalitions (Mason, Leavitt, & Chaffee, 2007). Colleagues are identified as individuals who have a common interest in or information that can help address a problem. A coalition consists of a group with a common interest that works toward a goal (Berkowitz & Wolff, 2000). Coalition members have ideas and direct experience related to the issue, which will ultimately help students narrow the direction of the policy.
Students are directed to initially identify stakeholders and then prioritize them in terms of relevance to the issue. Examples of stakeholders include patients and consumers, physicians, insurance companies, legislators, nurses in multiple health care settings, and professional organizations.
After the stakeholders are identified, students gather a range of information and opinions on their selected issue. After talking with the stakeholders, students compare and contrast information received. A formal colleagueship analysis paper culminates in discoveries about the issue and helps the team narrow direction for policy revision or development.
Phase Three: Evidence-Based Practice Analysis
Phase three involves analyzing evidence that will support policy development. Students examine published literature on the health care issue, including nursing research studies. They then synthesize the literature to create a clear understanding of current knowledge of the problem.
The faculty guide students in creating appraisals of the quality of the collected nursing research. Students then determine whether each study is rigorous enough to support policy development. After completing the appraisals, the team chooses one of three research utilization models to determine if the collective findings of the nursing research studies are recommended for change in practice. These models are: the Iowa Model of Research in Practice (Titler et al., 1994, 2001), the Stetler Model of Research Utilization (Stetler, 1994, 2001), or the Ottawa Model of Research Use (Logan & Graham, 1998).
In the evidence-based practice phase, students consider several nursing theories and apply the theories to their issue. Students are then asked to reconsider the colleagueship analysis and together with the written evidence and theory application, further refine the policy direction.
Phase Four: Policy Development and Analysis
A policy proposal and an action plan comprise phase four. This proposal takes the form of a resolution, a white paper, or an organizational policy. Examples of policy proposals include:
- Resolution: “In Support of Organ, Tissue, and Eye Donation Education.”
- White paper: “Polypharmacy in the Geriatric Population.”
- Organizational policy: “Use of Topical Analgesics Prior to Venipuncture in Pediatric Populations.”
Revision or creation of the health care policy itself is the first step in the completion of an action plan for implementation, which consists of a proposal to actualize the policy. The action plan consists of policy (what), rationale for the policy (why), those involved (who), time line for implementation (when), location of policy (where), and an evaluation plan with measurable outcomes (how).
After the policy and action plan are completed, students reflect in their policy development and analysis paper on how their policy represents them as caring professional nurses connected to societal responsibility. The course culminates with a policy presentation gala event designed by the faculty to showcase the work of the seniors. Faculty, staff, and beginning nursing students are invited to the event. Seniors are seen as role models advocating for new or revised health care policy.
Testimonials from Students, Faculty, and Colleagues
Testimonials from students, faculty, and professional colleagues affirm the importance and usefulness of the Grand View Critical Analysis Model. Students are proud of their abilities to analyze and design health care policy. One student reflected:
I enjoy knowing about the “mysterious” process of how policy should be created. Now it makes sense to me that some policies are well done and evidence-based, but some really are not. I know how I can help change or update policy. That is very empowering.
Another student noted:
I didn’t like hearing at the beginning of the semester to trust the process (of policy analysis and development) and see where it takes me, but now that we are nearing the end, I can really see how I am at a very different place with my health care issue than I would have been had I not followed the process.
Faculty teaching the Professionalism II course for the first time found the Grand View Critical Analysis Model to be an effective teaching pedagogy that assisted students in understanding policy development. One faculty member commented, “Students gain a sense of salience as professionals regarding health care policy, and I gain salience as a teacher.” Another faculty member stated:
I have enjoyed watching the students bloom during each part of the process. To allow students to pick a health care issue, defined by their own trigger and passion, and guide them as they run with it, is very rewarding. This class has been educational for me as well. When students pick such diverse topics to study, I broaden my own knowledge.
Professional colleagues support the pedagogy of policy development, particularly in the area of public policy. Resolutions are often sent to the Iowa Nurses Association (INA). In response, the INA sent a letter (INA, personal communication, March 10, 2010) with the following comments:
The INA resolutions committee met and the topic was bringing in the student resolutions. Would students continue to work on the resolutions? If these resolutions then pass the INA House of Delegates, they may become included in the INA legislative agenda, wind up as draft legislation, and become public policy.
The testimonials illustrate the value of the Grand View Critical Analysis Model for teaching baccalaureate nursing students. The model facilitates the nurse’s role in policy advocacy and provides a structure for analyzing policy. It also delivers a method for creating a policy proposal along with a means for communicating a proposal.
There are four recommendations for use of the model in teaching health policy: adoption in baccalaureate nursing programs; examination and expansion of the model in graduate nursing education; utilization as a clear, organizing guide for novice teachers; and application for seasoned faculty as a new educational method. Ultimately, the model is a framework to guide and engage students in the complexities of policy, and it is also a tool to support faculty development.
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