Influencing Health Care in the Legislative Arena

Sheila Abood, PhD, RN


Online J Issues Nurs. 2007;12(1) 

In This Article

Sources of Power for Nurse Advocates

The ability to successfully exert influence in the various arenas where future health care policy decisions are made and to take advantage of opportunities to present nursing's perspective on the health care issues depends on having a power base and knowing where and when to exert that influence. Power is the potential to exert influence. Power is an inevitable part of human interaction, and those persons including nurses who deny this fact will be at a serious disadvantage when trying to make change (Kalisch & Kalisch, 1982). The following section addresses the power which can be found in numbers, along with five categories of interpersonal power originally described by French and Raven (1959; n.d.), namely expertise, one's role, personal respect, and the abilities to reward and/or punish. These are sources of power available to even novice policy advocates when they speak up to alter existing policies, institutional systems, laws, or resource allocations in ways that potentially benefit not just one person but many individuals. Each of these six sources of power will be described in turn.

It's a common mistake to assume nurses lack the power to be effective in the legislative arena. Nurses themselves have contributed to this myth by describing themselves as powerless. Nurses sometimes forget that as the largest group of health care providers, they could generate enough power to successfully reform the health care system based on numbers alone. According to the 2004 National Sample Survey of Registered Nurses, there are 2.9 million registered nurses who are dispersed in every voting district in the nation (U.S. Department of Health and Human Services, n.d.). This reality continues to offer the nursing profession a formidable power base that is largely untapped in the day-to-day world of the politics and legislation.

In spite of a serious and ongoing nursing shortage, wide-spread dissatisfaction among bedside nurses, the aging nursing workforce and teaching faculties, continuing conflicts with physicians, and lack of success to demographically diversify, the nursing profession has not been able to actualize their collective power. Nursing has not developed into a cohesive, increasingly powerful professional force that could be a partial counterweight to the dominance of medicine in the policy arena (Mick, 2004). However, involvement of only a fraction of the nation's 2.9 million registered nurses in even the smallest way could become a force for change for the nursing profession and for the health care system and the patients it serves (Artz, 2006).

Another important source of power available to nurses is referred to as expert power which is related to possessing the knowledge and skill that some one else needs (Cohen, Leavitt, Leonhardt, & Mason, 1998; French & Raven, 1959; Lee, 1997; Rakich, Longest, & Darr, 1992). Expert power is the basis for collaboration and for advocacy in a variety of settings including the legislative arena and it provides nurses with considerable credibility to speak out on health care issues. Nurses have one of the better views of the health care challenges facing providers and patients and the very real impact of problems within the health care system, such as the existing nursing shortage. Nurses are in a unique position to share their expertise and knowledge when meeting with power players to educate them, to urge them to action, and to hold them accountable when their positions and voting records don't match their rhetoric. Nurses, as providers and consumers of health care services, have professional and personal experiences regarding the problems and possible solutions to share with policy decision makers. It is expert power that allows nurses to bring their knowledge of nursing, health care, and patient safety to bear directly on the promotion and achievement of their policy goals.

Legitimate power is that bestowed by the particular status or the role of an individual (Cohen et al., 1998; French & Raven, 1959; Lee, 1997; Rakich et al., 1992). All registered nurses have legitimate power through their license granted by their State Board of Nursing to practice nursing. The rights and responsibilities that come with that license give the licensee standing in the health care community and the authority to speak out on nursing and health care issues. In addition, foundation documents developed by the American Nurses Association (ANA), such as the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) and Nursing's Social Policy Statement, (ANA, 2003); provide additional sources of the profession's legitimate power to address organizational, social, economic, legal, and political factors within the health care system and society (Fawcett & Russell, 2001).

Referent power is also a source of power available to nurse policy advocates. It is gained by having other people's admiration and respect (Cohen et al., 1998; French & Raven, 1959; Lee, 1997; Rakich et al., 1992). Registered nurses are part of a profession that commands a level of credibility and trust that few others in health care or any other field can claim. The Gallup Organization's 2006 annual poll on professional honesty and ethical standards ranked nurses as number one in terms of public respect (Saad, 2006). This trust is valuable and is transferable into action to improve what is failing in today's modern health care delivery system. Americans have entrusted us with their confidence to build a better system. We are in a position to foster change in the direction of public policy and influence the wisdom of the people who make decisions about the lives of the people we serve everyday. Nurses must be stewards in pushing an agenda that calls for quality health care for all. Referent power is an incredible asset to use when advocating on behalf of the nursing profession and patients. It opens the door to the offices of power brokers and decision makers. It is also an important asset when reaching out to other groups to gain support for an issue or when enlisting public support for an issue. A familiar example of the use of nursing's referent power can be seen as part of the media campaign helping to reduce the nursing shortage sponsored by Johnson and Johnson.

Reward power is another available source of power. There are many more forms of reward -- in fact anything we find desirable can be a reward, from a promotion with more money to a pat on the back (Cohen et al., 1998; French & Raven, 1959; Lee, 1997; Rakich et al., 1992). Reward power is the ability to give other people what they want, and hence ask them to do things for you in exchange. Rewards can also be used to punish, such as when they are withheld.

In the give and take of the policy arena, it is the policy makers, the legislators at the state and federal level, who have the power to enact or not enact policy changes related to important nursing issues such as enhanced funding for nursing education, safe workplaces, appropriate staffing levels, and the removal of barriers to practice for advanced practice nurses. Because each elected official needs votes to attain and keep his or her office, the voice of every nurse voter is important to each person running for office. As voters, nurses have the ability to reward their own elected officials by voting them back into office and working for their reelection. Conversely, they have the ability to vote them out of office if they do not make decisions which strengthen the health care system.

Lastly, there is coercive power which is the opposite of reward power. Coercive power is based on the ability to punish and is rooted in fear or perceived fear of one person by another (Cohen et al., 1998; French & Raven, 1959; Rakich et al., 1992). Coercion is the ultimate power of all governments. We are all familiar with this type of government power when we obey the state and federal taxation laws. We may not be eager to pay the taxes, yet we do not want to face the negative consequences of not paying up. Generally, coercive power is seen as a negative in our society and not appropriate in situations where you are trying to persuade someone to see your point of view. Although both rewards and threats of punishment are powerful motivators, advocates are better served by using reward power than coercive power.

These different power bases are not necessarily independent and may be complementary. Any individual can have more than one base of power. In fact more than being simply additive, the sum total of several power bases is usually greater than its individual parts. For example, physicians have effectively exercised coercive, legitimate, and expert power to dominate the health care policy process in both the private and public sectors for many years (Kalisch & Kalisch, 1982).

Power is a potential capacity which can provide opportunities to meet goals. A person may possess both a base of power and the capacity to exercise it. Yet the mere existence of a power base and capability is not the same as actualized power. If there is no interest or willingness to employ the power, it remains only a potential resource. Power is simply what you begin with. Being able to successfully work for safe, quality, patient care depends on being able to translate that potential capacity, i.e., power, into influence and accomplishments (Haass, 2005). Understanding and using the various sources of power available to you is critical to ultimate success in the legislative arena.


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