The Warner reference is the only required reference for this question. References ?Warner, J. R. (2003). A phenomenological

ARTICLEPOLICY, POLITICS, & NURSING PRACTICE / May 2003

A Phenomenological Approach to Political Competence: Stories

of Nurse Activists

Joanne Rains Warner, PhD, RN, DNS

F rom its historic foundation to its essential core, nursing is political. Inclusion of political participation in the professional role has been evident throughout the

development of the profession, the evolution of the health care system, and the changes in the sociopolitical context over the years (Milstead, 1999). This fact, however, has not always been understood or emphasized to the extent needed for the public’s health or to maximize the profession’s capability.

Politics refers to a process of “influencing the allocation of scarce resources” (Leavitt & Mason, 1998, p. 9). It is a value-laden process intended to be a means to an end, specifically, the preferred decision or use of resources. Throughout history, nursing has advocated for particular choices, sought to influence decisions, and promoted val- ues consistent with health and healing. Historic examples of Florence Nightingale’s influence or Lillian Wald’s activism were followed by more contemporary examples of Nancy Milio’s advo- cacy in Detroit and Sheila Burke’s decades in fed- eral government (Leavitt, 1998; Leavitt & Mason, 1998; Milio, 1970). These individuals are joined by a cadre of nurse activists who daily use persua- sion and influence toward specific ends at work and in their communities.

Nursing’s collective political development in recent years indicates growth from an early “buy- in” stage that emphasized political awareness and a “call to arms,” to self-interest related to nursing

135

Political competence is the skills, perspectives, and values needed for effective political involvement within nursing’s professional role. Political competence is requisite within nursing to (a) intervene in the broad socioeconomic and environmental determinants of health, (b) intervene effectively in a culturally diverse society, (c) partner in development of a humane health care system, and (d) bring nursing’s values to policy discussions. This pheno- menological study used narratives of 6 politically expert nurse activists to enhance our understanding of political competence. Six themes emerged from an analysis of the lived experience of their political involvement. They include nursing expertise as valued currency, opportunities created through networking, powerful persuasion, commitment to collective strength, strategic perspectives, and perseverance. These themes can inform development toward greater political efficacy for individual nurses and for the profession collectively.

Keywords: political activism; political compe- tence; phenomenology

Policy, Politics, & Nursing Practice Vol. 4 No. 2, May 2003, 135-143 DOI: 10.1177/1527154403251855 © 2003 Sage Publications

issues, to political sophistication and active work on health issues beyond nursing. The final stage in this model has involved proactive leadership of interdisciplinary coalitions focusing on broad health concerns (Cohen et al., 1996). This progres- sion has not been strictly linear, nor have the stages been mutually exclusive, but the stage of interdisciplinary leadership positions nursing in a more prominent and influential role. How can the profession continue to advance in political devel- opment? Cohen et al. (1996) suggest it “requires an examination of preconceived notions about ‘appropriate’ political behavior bringing new vision to political action” (p. 265). One step involves clearly understanding the behaviors involved in effective political action. What is polit- ical competence for professional nursing? What are its components or elements? How would political competence manifest itself when demon- strated by faculty members, practicing nurses, or students?

This article describes a qualitative research study aimed at exploring the set of skills called political competence as reflected in the stories of 6 politically expert nurse activists. A summary of the literature that provides the rationale for nurs- ing’s political competence precedes a description of the six common themes that emerged in this study. Implications for the profession are drawn from the data.

WHY POLITICAL COMPETENCE

The call for nursing activism within policy and political work is suggested by several factors. The most compelling rationale for nursing involve- ment in policy is derived from a broad under- standing of the nature of health. Increasingly, evi- dence links health status to psychosocial factors, environmental conditions, gender stratification, and cultural-economic issues—factors outside of the health care arena per se (Amick, Lovine, Tarlov, & Walsh, 1995; Reutter & Williamson, 2000). The Pew Health Professions Commission (1991, 1995) envisions practitioners by the year 2005 incorporating this broad perspective of health into their care and addressing root causes of physical and social environmental hazards that threaten health. Strategies to accomplish these

goals often involve political action and policy development. Reutter and Duncan (2002) describe a shift in perspective on policy advocacy that places greater emphasis on nursing’s involvement in reform of the social and economic factors that influence health. Nurses need to engage in politi- cal work if they are to influence the determinants of and the environments for health.

Another perspective on the linkage among nursing, health, and politics is seen in the cultural context (Leininger, 1995). The power and politics embedded in each culture strongly influence many factors that are importantly related to health, such as family social structure, religious traditions, and accepted norms/behaviors. Nursing professionals need to understand the sources of power and patterns in politics to effec- tively promote health and prevent disease in a cul- turally effective way. This is true within the prac- titioner’s native culture and even more important within a culturally diverse global society.

This cultural dimension of power and politics also strongly affects the nature of nursing practice and caring, which expands the rationale for nurs- ing’s political involvement to shaping the profes- sion and delivery of care. The Pew Health Profes- sions Commission (1991, 1995) charges health practitioners with the improvement of the health care system. To continually improve the quality and accountability of the health care system, prac- titioners need to understand the political, socio- economic, and legal determinants of the system and have the requisite political skills to intervene appropriately. Nurses collaborate in three ways in the creation of new and improved delivery sys- tems: “with individuals in the process of care; with communities in the creation of health; and with their health care colleagues in the develop- ment and implementation of service” (Sigma Theta Tau International, 1996, p. 18). These part- nerships and responsibilities require political competence.

Another important benefit of political activism is to bring nurses’ values to the political discus- sions and decisions. Backer, Costello-Nickitas, Mason, McBride, and Vance (1998) note that nurs- ing brings an emphasis on the values of caring, equality, multiculturalism, connectedness, and power sharing to policy and political discussions. Gebbie, Wakefield, and Kerfoot (2000) note that

136 POLICY, POLITICS, & NURSING PRACTICE / May 2003

nurses bring knowledge of how policy decisions affect real lives and have a grounding in clinical practice.

Nurses’ strong beliefs in the capacity and importance of people to care for themselves distinguish nurses from other health professions that share many of the same skills. This belief becomes an orientation toward policy action to enable people to help themselves. (p. 311)

Without the voice of nurses, this perspective may be missing. Nursing values can expand and enrich the decision-making process.

As the contemporary health care context becomes increasingly politicized, nurses’ political competence will be vital to improving the health of the public at individual and collective levels. Political skills will also be crucial in improving the health care system, maintaining a strong profes- sion, and bringing nursing values convincingly into policy formation.

METHOD

This phenomenological research study used narrative and “rich descriptions” of the activities of politically seasoned professional nurses to enhance understanding of the concept of political competence. This approach involved an in-depth analysis of the “conscious lived experience” of everyday policy work and political involvement. From this analysis emerged the elements that people can consider the common understanding of political activity (Fain, 1999). Benner (1994) describes interpretive phenomenology as a partic- ularly rich method for understanding “nursing science, nursing practice, the lived experience of health and illness, and health care ethics and pol- icy“ (pp. xiii-xiv).

A purposive sample of 6 nurses was chosen to tell their stories of political activity. Each activist had published in national peer-reviewed journals or books on the topic of political or policy involve- ment. This group had had extensive experience, variously including appointed and elected office, organizational leadership, electoral campaigns, congressional internships and staff positions, and federal health care reform activities. Purposive sampling assured that the data would reflect the lived experience of political competence.

Consent was obtained according to the Institu- tional Review Board guidelines. Each nurse was interviewed in person or over the telephone; inter- views were audiotaped and transcribed verbatim to increase reliability. Each nurse was interviewed at least once; three were interviewed twice for fur- ther clarification and elaboration. The resulting data came from over 500 minutes of conversation and narrative.

The interviews involved open-ended state- ments such as “Tell me a story about a time you were in a situation where you were able to make something happen because you had political skills” and “Tell me about a time when something happened wrong in your political work.” They were prompted to “Tell me a story about being political as a nurse as you tried to promote health and well-being.” What resulted were stories or nar- ratives about being politically competent. “Narra- tive accounts of everyday skills comportment allow participants to describe their everyday con- cerns and practical knowledge, thereby giving access to practical worlds” (Benner, 1994, p. 112).

Analysis of the transcribed interviews involved a search for reoccurring themes and meaningful patterns. Six themes emerged from the data as dimensions of political competence. These themes respectively emphasize the importance of nursing expertise, networking, persuasion, collective action, a broad perspective, and perseverance. To enhance validity, a nurse researcher skilled in nar- rative pedagogy and phenomenological research independently reviewed the data and validated the themes identified by the author.

SIX THEMES EMERGING FROM THE NARRATIVE

Six themes drawn from the narratives were rep- resented in almost all of the interviews. These themes richly describe nursing involvement in politics and policy formation and present ways to demonstrate political competence. Each is dis- cussed below along with supportive quotes from the interviewees.

Nursing Expertise as Valued Currency

In political interactions, participants must have something to “bring to the table” and use in the

Warner / STORIES OF NURSE ACTIVISTS 137

process. For all interviewees, the most important currency they brought was their nursing exper- tise, which included clinical experiences with pol- icy implications and connections, as well as the unique values and skills acquired in nursing socialization.

Being a professional nurse, I’ve found that political leaders and government officials were immediately interested in what I had to say. I could speak from personal experience and that put me a notch up in the discussion. It gave me clout on the issue. (Nurse A)

Based on her experience organizing a national network of nurses, one interviewee noted that “nurses are incredibly good at interpreting policy, talking to their members about it, and making the connections” (Nurse A). She further explained that these interactions between nurses and elected officials included clinical stories and data. Another interviewee noted that she knew how to get information and use it effectively (Nurse B), and another said, “You can change people’s minds with facts” (Nurse C). Each expressed a sense of valuing this nursing voice and using it to further political causes.

Besides the knowledge and clinical examples, nursing education and experience had given these individuals certain very useful skills. “Nursing gives you observational skills, lots of information, and experience making quick decisions. . . . Nursing is balancing competing priorities and looking for ways for everyone to win” (Nurse D). Another discussed nursing as excellent prepara- tion for the legislator role: “We are very versatile. We are able to grasp complex issues and keep many things on the plate at one time” (Nurse C). During a federal internship, one participant real- ized that her professional skills, related to leader- ship, communication, and “the ability to tackle problems and make things happen in a wide vari- ety of settings,” equipped her for participation in health policy making (Nurse F). Another recog- nized the importance of “clarity about your val- ues, vision, and yourself—which comes from nursing” (Nurse D).

Nursing’s credibility with legislators was viewed as similar to that with the general public—

very high (Nurse C). One story about being hired for a political campaign demonstrates that confidence:

She said, “You are hired,” and I said, “You don’t even know me.” She said, “It doesn’t matter; ANA was the first group to endorse me. I know that if you are a nurse you can do this job.” (Nurse B)

All of the participants believed that being visi- ble as a nurse was an advantage. One credited her reelections to a partisan committee to the one- word descriptor by her name on the ballot: nurse. Another proudly began one interview by saying, “I am a registered nurse,” as if that was the way she began all of her stories (Nurse D). Their nurs- ing expertise and experience was the valued cur- rency they spent in their political interactions.

Opportunities Created Through Networking

Networking was a second theme mentioned by all study participants. Networking involves estab- lishing and maintaining relationships and was described by one interviewee as the “backbone of success in policy and politics” (Nurse F). Time and again, networking was cited as integral to the suc- cesses of these political activists. It was not net- working for its own sake but to enable change, to assemble the crucial assortment of policy players, or to link ideas and people. Opportunities were created and seized.

“Relationship is primary; all else is derivative,” summarized one participant, noting that “the abil- ity to establish relationships can lead to support for you or for what you are trying to accomplish. People support you . . . because they have a rela- tionship with you, they trust you, and they believe you” (Nurse D).

Networking was seen as including casual and formal interactions: “the right conversations at the right time” (Nurse C).

Going to a reception, walking around, eating shrimp, and making small talk is a political activity, and it is vital networking. You don’t do anything or get a movement along until you meet the right people in the right places. To get business done you have to get out there getting

138 POLICY, POLITICS, & NURSING PRACTICE / May 2003

your name known, meeting people, swapping business cards, getting an e-mail, and nurturing relationships. (Nurse F)

This interviewee described publishing as essen- tial networking for her, one that has created excellent opportunities for new employment and connections.

These nurses understood the essential and uni- versal nature of networking.

Most of the work doesn’t take place in the State Dining Room of the White House or on Capital Hill; it takes place day to day by our network of nurses. [It is] the importance of making a relationship and keeping a relationship with an elected leader and getting nurses involved early in campaigns. Getting us visible in campaigns, get-out-the-vote work, and really integrating nursing into legislative work. I see it as having high profiles, but even the lower profile work is just so critically important for nursing. (Nurse C)

These nurses had made policy gains or reaped professional benefits from networking. One said her involvement in the women’s movement led to a leadership role on a committee, which led to another volunteer role and then a job offer through the network (Nurse A). Through net- works, opportunities opened up: “What hap- pened was a typical serendipitous situation which I am certainly convinced has a lot to do with the opportunities we take” (Nurse B). Another noted that “When you are paying attention, making con- nections, and making an effort to network, the path is huge” (Nurse F). The interdisciplinary nature of networking was emphasized by several, one noting that it has given her a sense of nurs- ing’s worth and contributions beyond the disci- pline (Nurse B).

Maintaining relationships while dealing with contentious and varied political issues was seen as challenging. One story began with the moral “Friends come and go, but enemies accumulate.” She spoke of testifying against one individual month after month on a particular issue and later finding herself working with him on another committee.

If I had alienated him and made an enemy of him based on some issue, I would have lost the

opportunity to work with him. You never know who is going to be your friend and it is just not worth making enemies, ever, ever, ever. (Nurse E)

Networking was not described as second nature to nurses.

It is a skill that so few nurses have, but I would have never had the experiences I have [without it]. Most nurses are not comfortable with networking and don’t understand how people want to be able to help you. It is not an imposition, they really want to do it for the most part. Because they expect that if they need something, you are going to do it for them.

She continued by noting that “the ability to ask for help sometimes is perceived as weakness rather than strength,” a misperception that limits nurs- ing (Nurse B).

Networking created personal opportunities, positioned these activists for action and change, and produced beneficial outcomes. It was seen as a crucial factor in political competence.

Powerful Persuasion The importance of persuasive abilities was a

third theme in the stories of these political activ- ists. The explicit purpose of communication in the political arena was viewed as persuasion and influence. The 6 participants variously told stories involving the need to garner enough votes to pass a resolution in a professional organization, win an election, and support a congressional bill. They spoke of persuading people to collaborate on a task force, to agree to a funding arrangement, or to include a book chapter within a limited number of total pages. Persuasion was the required approach.

Nurses were viewed as particularly equipped with experience in persuasion. “If you can con- vince someone to drink Metamucil, you can con- vince them to vote,” suggested one participant (Nurse E). Another said,

Nurses have to go into the field and be comfortable talking to some people about things that nobody else talks to them about. My varied clinical experiences gave me the power of persuasion and salesmanship—the power to be

Warner / STORIES OF NURSE ACTIVISTS 139

able to persuade a group of people to do something that is helpful. (Nurse A)

Each activist interviewed described the energy and passion needed for persuasive communica- tion. One spoke of a time she addressed a national student meeting and really motivated the group; she noted, “There is not enough passion in the world and so people who are passionate about things can manipulate people in a good way or bad way. It is a skill—the power of persuasion” (Nurse A). This communication was equally important with individuals and groups, as dem- onstrated by this experience in the context of orga- nizational politics: “We did an awful lot of hall- way meetings and education and made some powerful speeches before the House of Delegates explaining our side. We did a lot of one-on-one influencing people” (Nurse F).

Beyond passion, there was an emphasis on thoughtful analysis of the ideas: “What was needed was the clarity of the idea, the ability to communicate that persuasively, and why it would be important to the audience” (Nurse F). Another noted, “You can change people’s minds with facts. You can influence people in a particular direc- tion” (Nurse C). She also described the prepara- tion that preceded the interview of a presidential candidate, recalling the rehearsal of idea presenta- tion so it was clear and convincing.

One referred to the idea in the Tipping Point (Gladwell, 2002) that three types of people are needed to create a social movement or prompt change: connectors, helper persons, and sales peo- ple. “Nurses are all three. I think we are so natu- rally cut out for politics. So take those three essen- tial things that we have naturally and you apply the nursing process to politics or to managing anything.” She also pointed out a limitation: “We just fail to apply [the nursing process] outside of our work life with some regularity” (Nurse E).

So, whereas these nurses recognized and val- ued their nursing expertise, connecting with a variety of individuals and networks, they were made aware of the need for powerful persuasion. One described the essential nature of persuasion: “When it comes down to it, you can have great data in your head, but if you can’t communicate your position individually and in groups and make them comfortable, it won’t work” (Nurse F).

Because “in politics it is who has the most mar- bles” (Nurse E), powerful persuasion is an essential component of political skill.

Commitment to Collective Strength The fourth theme in the stories of these nurses

related to the value of collective action as a source of strength. “Individually we make a difference. Collectively we make a bigger difference,” sum- marized one nurse (Nurse D). The collectives in their stories included professional organizations, interdisciplinary task forces, groups of nurse pol- icy leaders at the state level, coalitions for particu- lar policy issues, political parties, and a “set of trusted political colleagues” assembled within a work setting. Sometimes the groups assembled through statute or interest in the same issue; sometimes the nurses took the initiative to build (through networking and persuasion) a contin- gent of people committed to the same priorities and agendas or a group of people who brought expertise and knowledge that one nurse could not have. Group consensus was seen as a powerful collective strength.

The sample identified the benefits of the collec- tive. “I have felt able to influence that political world in part because of what I have learned through the association—also because I have the association behind me, supporting me, informing me, advising me” (Nurse C). The collective was viewed as refining the individual wisdom that was brought to the policy table.

When these nurses were part of a collective group, they knew their voice was louder and per- suasion was greater. One expressed this best by noting,

We need to be aware that we can defeat our own purpose by having a lack of collectiveness. I really value the collective greatly. I couldn’t do what I’m doing without marshalling the support of the collective. It is because I represent a collective history and collective body that anybody should bother listening to me. It comes from a collective source. I see it, I value it, I understand it, I respect it, and I promote it as a value; we should search for collectiveness. (Nurse C)

These nurses acknowledged the paradoxical role of the individual in collective action. “Policy

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change is collective action. But we don’t get collec- tive action unless individuals do something” (Nurse D). Another noted the challenge of prompting a collective action because it runs counter to American individualism and the ethic of the rugged individual. Her solution was “exploring how to be strong and individual, and then maximizing those individual strengths in the collective“ (Nurse C). The collective was not seen as negating the individual, but as depend- ing on and, in the best cases, strengthening the individual.

Strategic Perspective: A View From Stepping Back

The fifth theme of all the nurses in the sample was that they viewed nursing and health from a broad perspective that incorporated strategic analysis of players, action, agendas, and a multi- tude of other factors within the larger context of any situation. They looked beyond the individual, the local, and the immediate. Being politically competent as a nurse was described by one indi- vidual as a matter of perspective: “If you are to give competent care, is the standard ‘excellent care given to that individual patient’ or is the stan- dard ‘excellent care given to that individual patient along with what the nurse can contribute in altering the conditions that lead to that individ- ual’s needing that particular type of care in the first place’ ” (Nurse D). A perspective beyond the immediate was seen as requisite to awareness of the possibilities that could be accomplished through policy and politics. Without this perspec- tive, the right questions would not be asked.

Another understood this perspective as “ana- lyzing your environment and knowing how to influence it” (Nurse B). Included was the action that results from this perspective. Another nurse shared what was a new insight for her: the link between economic opportunities and long-term health outcomes.

That is what I want nurses to get—that if they want to have an impact on the large health outcome over time, they have to be concerned about the economy—about the people at the bottom of the food chain being able to sustain themselves. (Nurse E)

This statement reflects a perspective that places health in a broad context and thinks strategically about how to effect change.

Several nurses used the term assessment to name the foregoing process but added some other descriptors. “Community assessment. It is not just the patient; the patient is the community. It is really a healthy community approach,” clarified one nurse (Nurse A). While recounting some pro- fessional successes, another noted, “I have had the ability to stand back and assess situations. I think [about] some things very differently from a lot of my peers and fix problems largely because I can step back” (Nurse F). Her perspective involved seeing a large context.

A “chess board” analogy emerged in one inter- view to describe a strategic understanding of issues—seeing the whole chess board past, pres- ent, and possible.

It means having a long-range vision. . . . What are my next three moves, my next three sequences. That is why nurses are so wonderfully suited to play [chess, though] we forget to apply what we do in the hospital and the public health clinic and in the school. We forget to apply our innate ability to look at the person in the context of their whole environment. . . . We have to take that assessment skill, which is the big picture assessment skill, and say, OK, who is this person politically? (Nurse E)

Not only was this perspective seen as equip- ping one for political or policy success but as allowing nurses to see more of their practice and professional work as political activity. One nurse quoted Leavitt and Mason’s (1998) definition of political work as “influencing the allocation of scarce resources” whether in the workplace, gov- ernment, or associations. She mused about novice nurses entering into political work:

Nurses graduating from a baccalaureate program may not feel ready a year after practicing to come to Washington and lobby a senator. But if they see a problem in their community that [needs to be] addressed by the Board of Health, they may be very comfortable in doing something, like offering to teach a class. Is that political? We …