Joumal of Advanced Nursmg, 1995,21,1180-1185

Politics and nursing: an elective experience

Georgma Taylor MSc BA(Hons) RGN RCNT Cert Ed(FE) Dip NNurse Teacher, North London College of Health Studies, North Middlesex EducationCentre, North Middlesex Hospital, Sterling Way, London N18 lQX, England

Accepted for publication 1 September 1994

TAYLOR G (1995) foumal of Advanced Nursing 21,1180-1185Pohtics and nnrsing: an elective expenenceThe case for enhancing the political awareness of nurses is reviewed, examiningthe need for tbe inclusion of political issues m nurse education programmes Abrief review ofthe available hterature from North America reveals that someschools of nursing have made progress in including aspects of pohtics mnursing cumcula, either as part of a course on health policy or as a separateelective course Topics addressed in these courses, and experiences offered, aimto raise awareness and equip nurses with the knowledge and skills necessary toengage in pohtics at a variety of levels An account is offered of the experienceof running a 4-week theoretical elective course entitled 'Politics and nursing' aspart of the Common Foundation Programme of a Project 2000 course m a collegeof nursing based in North London, England

POLITICAL AWARENESS: THE SITUATIONREVIEWED

That there is a need for aspects of politics to be mcludedm nursing cumcula can no longer he in question In 1984when the World Health Organization set 38 targets for'Health for all' for countries m the European region (WorldHealth Orgamzation 1986), it was clearly stated that'health professionals, with their expert knowledge andinfluence with politicians and the general puhlic can hean important force m mobilising support and initiatingchange'

In a paper delivered at an International Council ofNurses Congress, Tiemey (1990) stressed the need fornurses to be involved m the policy-makmg process, high-lighting that policy affects the daily work of nurses andthat there are two compelhng reasons for nurses to engagemore in policy-making — the requirement for nurses tomaintain control over nursmg practice and the need tohave an impact on access to, and the delivery of, healthcare

Perry & Jolley (1991) described a succession of booksduring the 1980s, all with nursmg and politics m theirtitles, coupled with the appearance at nursmg conferencesof speakers urging nurses to become more political

In 1983, Dean argued that 'all nurses have a role m thedecision-making process through the use of influence

which will result from the development of political aware-ness' Politics was defined m terms of power and the pointmade that nurses have the potential to be powerful, butonly if political awareness develops will they be able toput this power to use It is stated that 'Nurses must recog-nise that m order to improve the lot of those they care forand to maintain their professional freedom and standards,they must ensure a powerful political voice' (Dean 1983)

Power relationships

Gott (1985) again defined politics m terms of powerrelationships and noted nurses' apparent lack of mterestm politics It IS argued that traditionally nurse trammghas limited rather than extended nurses' developmentHowever, m the 1990s, with the development of nursingcourses such as Project 2000 with a broader cumculum,the opportunities are available to address wider issuesWntmg in the wake of the succession of proposalsfor changes m the National Health Service durmg thelate 1980s, Wnght (1989) expressed concem about ade-pohticizmg culture and advocated nurses becommgmore politically aware and more active m organizations

Girot (1990) suggested that as the majonty of nurses areemployed by government in a service funded by govern-ment, whose pnonties are set by the government, therelationship hetween nursing and politics appears to be an

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Politics and nursmg

inseparable one Girot further argued that nurses can nolonger remam isolated but need to develop a closerrelationship with politics to understand the world aroundthem and enable them to influence their own futureHowever, m order to achieve this nurses need to know themechanism of the political system and how decisionsare made

Gott (1985) claimed that teachers of nursing shouldbecome politically aware and that political educationshould secure a place m nursing cumcula

POLITICS AND NURSING: THE NORTHAMERICAN EXPERIENCE

A preliminary review of the available North American lit-erature reveals that the teaching of, and learmng about,politics IS given a high profile m some educational estab-lishments The arguments for inclusion of politics in nurs-ing cumcula are similar to those in the United Kingdom,that IS, essentially, m order to be m a position to influencedecisions concerning the delivery of health care Someaccounts describe how aspects of politics have beenincorporated m the study of health policy

Andreoli et al (1987) wrote against the background ofconcem for high quality nursing services m a changmgsociety and claimed that m order to increase nursing'seffectiveness m competing for scarce resources the pro-fession must increase its complement of politically activenurses Their study took the form of a survey of 210 schoolsof nursing offenng baccalaureate and higher degree pro-grammes, aimed at determmmg how many of these schoolsmcluded, or planned to include, health policy m theircumcula They found that health policy was oftenincluded m the nursmg curriculum, but it was most likelyto be mtegrated mto an existmg course rather than bemgtaught as a smgle course Teaching strategies included par-ticipating m class debate on health policy issues, wntingletters to legislators, attending legislative sessions andinviting politicians as guest speakers to the classes

Andreoli et al (1987) recommended that a separatehealth policy course be offered as an elective course atundergraduate level and that it be a required course atgraduate level m order to enable nurses to becomepolitically adept in effecting changes m health policy

Martm et al (1989) descnhed a course addressing nurs-ing leadership and public pohcy as part of a doctoral pro-gramme, notmg that nurses have mcreasmgly shown anmterest m public policy They called on nurse educatorsto acquaint students with the politics of health care andhealth policy issues and mstil a behef that involvementcan make a difference They acknowledged that, in theUmted States, nursing's mvolvement m policy had beenprimarily focused on the profession of nursmg and arguedthat time has come for a broader vision, for exampleaddressmg structural problems m the health care system

and how nurses can become involved m addressmg theseproblems

Winter (1991) made proposals for educational strategiesand methods appropnate for contmuii^ education pro-grammes, stating that if the profession of nursing is toadvance it is necessary to educate nurses to become keyparticipants m the health pohcy arena The starting pointshould be the recogmtion of the possession of professionalexpertise and therefore 'expert power' Nurses should beconvinced that there are issues that will directly ormdirectly affect nursing practice The programme shouldthen move on to review the legislative structure and theprocess of lobbying

Other accounts descnbe how politics is offered as anelective Acknowledging the potential power of nurses, butalso the need for planned educational experiences to movethat potential power on to become actual power,Schutzenhofer & Spikes (1986) and Schutzenhofer &Cannon (1986) described aa elective course m politicsmcorporated mto a baccalaureate nursing programme

The course was planned to include certain topics, forexample a review of the legislative process, channels forpolitical involvement by nurses, and the process andimportance of lobbymg Supplementary topics werechosen for class discussion by the students once it hadbeen explained that they needed to identify issues mgovernmental politics and the internal politics of nursingStudents were further required to engage in some form ofpolitical activity, for example attending council meetmgsor spending a day lobbying with a nurse's association

Langner & Fetsch (1987) descnbed an elective courseentitled 'Political strategies for health care professionals',aimed at promoting undergraduate nursmg students'understanding of the political process and its effect onnursing practice, as well as developing strategies to influ-ence that process The content of this elective courseincluded the concept of power, the legislative process andthe function of the professional organization Studentsagain attended political activities and made presentationsto their colleagues based on their expenences

McMahon & Westfall (1984) descnbed an elective courseentitled 'Issues in professional practice' which aimed togive registered nurse students on a baccalaureate coursethe opportunity to become fanuliar with the legislativeprocess and with selected ethical and legal issues m nurs-ing practice Students travelled a 'legislative journey'following the passage of an aspect of health care policythrough the legislative process, fi-om 'idea to law'

These authors all claimed some degree of success withthese elective courses, Schutzenhofer & Cannon (1986)stated that based on students' evaluations, they movedfrom political apathy to active involvement in pohticalactivities and became better mformed voters Langnei &Fetsch (1987) found that their students reported a chaiseof attitude about the role of the health care professional

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G Taylor

within the pohtical arena McMahon & Westfall (1984)reported positive feedback from former students mthat continued interest m the political process wasdemonstrated

POLITICS AND NURSING: AN ELECTIVEEXPERIENCE IN THE UNITED KINGDOM

Towards the end of the second semester of their Project2000 course, students at the North London College ofHealth Studies, London, England, are offered a choice froma selection of 4-week theoretical elective courses One ofthe courses on offer was entitled 'Politics and nursmg'

The aims of the course were essentially to consider thescope of the study of politics, to locate nursmg in a politi-cal context and to explore the veinous channels open tonurses to influence the policy-making process

The course content was identified by the course leader,and influenced to some extent by the North Amencanexpenence, but allowance was made to accommodatestudents' requests Flexibility was also required as someissues might appear more pertinent than others, dependingon current issues in politics when the elective is m pro-gress For example, if a major piece of legislation is bemgproposed tune can be allocated to follow the vanous argu-ments surrounding the issue Similarly, if the electivecoincides with an election — general, local or European— it would be worth considenng the processes involved

Some tune was spent examimng defimtions of the word'politics' m order to become aware of the scope of thesubject Such defimtions were taken from two standardpolitics textbooks

No-one is unaffected by politics Speaking very broadly, it is aboutthe way people organize their lives together in a community Theimportant collective decisions which shape the very quality oflife — our wealth, our bealth, our education, our mortality — areall essentially pohtical m their nature

(Kmgdom 1991)

Politics IS an exciting subject It is a subject you digest with yourbreak&st Each mommg its complex canvas unfolds with the dailypapers and broadcast news, by evemng new details bave beenpainted m and the scene subtly, sometimes dramatically, changedPohtics IS unpredictable, d3mamic, it affects us, it is about usPolitics IS arguably tbe most important focus of study on tbehuman condition

(Jones et al 1991)

Relevance of politics for nursing

Time was then mvested in examining the relevance of thestudy of politics for nursing Reference can be made tosemmal works such as those by Salvage (1985), Clay (1987)and White (1985, 1986, 1988) Clay (1989) has furtherdescnbed the 'frightening situation m the United Kingdom

where, more than any other country m the world, poli-ticians have a direct impact on the entire health and nurs-mg service' This view can be exemplified by examimngthe trends in health care that have gathered momentumsmce 1979 Another important issue is that addressed byBassett (1990), namely the disproportionate measure ofinfluence and power enjoyed by the medical profession mrelation to the making of health pohcy

Perhaps the situation can best be summanzed by refer-nng to 'A vision for the future' (NHSME 1993) where it isstated that one of the issues for nurses, midwives andhealth visitors concerns the 'extent to which the pro-fessions mfiuence local health policy'Nursing theory incorporates physical, social, psychologi-cal, cultural, economic, environmental and politicalfactors in an holistic approach, therefore the study ofpolitics has a legitimate place on nursing courses

Concept of power

Havmg defined politics, m its widest sense, and stressedthe relevance for nurses, the discussion then moved on tothe central concept of power, mitially examined in a widecontext It was decided that a startmg pomt, and a curricu-lar thread through the course, should be the concept ofpower The students had already encountered sociologicalissues m the first semester of their course and as mostsociology text books include a chapter on power, it wasfelt that this concept would form a familiar starting pomtfrom which to move forward

Attempts were made to answer the question 'Where doespower lie' ' and thus explanations such as pluredism,elitism, marxism, were considered, as were locations ofpower such as political parties, pressure groups, tradesunions, p£u:liament, the pnme mimster, the cabinet andthe civil service Power m relation to citizenship was alsoconsidered before movmg on to consider power issuesfor nursing

Reference can be made to the work of Dean (1990) wholooked at the distribution of power withm the UnitedKingdom health care system and expressed concem thatnursmg is losing its leadership position at all levelsSimilar issues are depicted by Owens & Glennerster (1990)Perry & Jolley (1991) address the question of power mrelation to the position of women, both as recipients ofcare and as deliverers of health care, and so examine politi-cal issues m nursmg m terms of unequal power relation-ships Schutzenhofer & Spikes (1986) also lmk the lack ofpolitical socialization and education of nurses with thefact that most nurses are women To this end, the issue ofnursmg as a predommantly female workforce was con-sidered and a session was also mcluded entitled 'Womenin politics'

Hemeken & McCloskey (1985) offer exercises to assist mteaching and leaming about power concepts, foUownng

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which It IS possible to move on to the concept ofempowerment as a process of helpmg people to assert con-trol over factors that affect their lives The work of Tiemey(1990) can be dravim on to illustrate the relevance

Professional nurse education must instil in students an awarenessof health and social issues and how these issues afFect practice,a belief that nurses can influence their work environment, andtbe desire and knowledge to shape nursing practice and bealtbcare Tbe acquisition of sucb knowledge is empowermg

(Tiemey 1990)

Labelle (1986) enumerates 10 levers of power availableto nurses, stressmg the numbers of nurses and thus votmgpower, and their contact with the population Shedescnbes individual and organizational approaches toexercising influence and power in promoting health issuesArcher (1987) describes a typology of political mvolve-ment rangmg from 'active long-term political involve-ment', for example seekmg elective office at any level ofgovernment and lobbying policy makers, to 'passivepolitical participation', for exeimple contnbuting money topolitical organizations or voting

Strategies for political mvolvement suggested by Archer(1987) commence with the acquisition of knowledge ofcurrent political issues Networks are presented as a meansof shanng information and offenng support, and workingtogether to achieve common goals Coalitions of interestedindividuals and mterest groups can work collectivelyLobbying, meetmg politicians and trying to influence thepolitical process eire also recommended A useful book bya member of the British parliament, Alf Dubs (1988), pro-vides detailed guidance on how to approach and influencemembers of parliament

Political processes

Knowledge of political processes is essential if nurses areto be able to influence decisions To achieve this,topics such as the structure and function of parliamentand government, and the policy-making process, weremcluded in this course Agam, class discussions can focusaround any particular issues that might be topical Pattemsof voting were included, and some consideration given tothe debate surrounding the issue of electoral reform Therole of local government and the relationship vnth centralgovernment was considered and also European unionPohtical considerations of current issues such as racerelations and homelessness were addressed, also politicalissues m mental health nursmg Another issue whichmight be addressed m the future is that of refugees. Smith(1989), wntmg with concem about the health of refugees,asks 'Can the carmg nurse afford to remain apolitical''

Case studies can be utilized when addressmg the pohticsof health, for example the politics of cancer, raismg ques-tions about government roles m prevention of disease, and

highlighting how health can be affected by governmentpolicies both nationally and internationally Qgarettesmoking smid advertizing is a case in p)oint Further politi-cal links can be drawn through the current concem withthe number of cases of tuberculosis and the homelesspopulation Vehicles for nurses to articulate concerns wereconsidered, such as local community action and tradesunions

THE POLITICS COURSE

Sixteen students completed the 'Politics and nursing' elec-tive course, 10 male and sue female As this was a newventure it was felt it would be of mterest to ask the studentsto complete a short questionnaire pnor to the commence-ment of the course m order to find out why they hadchosen the elective and their expectations Each studentwas given a letter explaimng that it was not compulsoryto complete the questionnaire and that participation, ornon-participation, would not affect the student's progresseither dunng the elective or the course Fifteen studentsreturned their questionnaires and the responses aresummarized

Reasons for choosing the elective included a desire tobecome aware of the pohtical issues surrounding nursmgand an interest in decision-making Five students selectedthe elective as their first choice Twelve of the 15 studentshad not studied politics before, three had studied politicsat A' level and one of these also at degree level Two majorcategones emerged from the responses concerning the rel-evance of the study of politics for nursing students, onewas awareness of the political environment in which nurs-ing takes place and the other, though to a lesser extent,was that of empowerment

Students' expectations of the course reflected the con-tent, as naturally they had had access to this in order toenable them to make a choice

Teaching methods

The course ran over a 4-week period, one day each weekwas a study day Teaching methods mcluded 'mini'lectures, class discussion and much use of televisiondocumentary programmes Visits were not arranged for thestudents, but they were offered the opportunity to arrangetheir ovm visits — the House of Commons, a pressuregroup — or imdertake any other activity they felt wasrelevant Although lmtially interest was expressed, noneof the students took the uutiative to eirrange any suchvisits The major activity dunng the final week of the elec-tive was a debate, planned to demonstrate an enhancedability to articulate opimons in an informed manner Thisactivity was certamly hvely, with all the course partici-pants contnbuting The debate was vanously descnbed bythe students as 'enjoyable, interesting and a useful exercise

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m articulating views' The importance of attending to bothsides of any given issue was also stressed by the students

Evaluation

On completion of the course the students were requestedto complete another questionnaire, the topics coveredduring the elective were listed and the students asked toconsider the relevance of the topics for their fiiture careeras nurses and then to place a tick m one of five columnswith headings ranging from 'strongly agree' to 'stronglydisagree' Although 'strongly disagree' did not feature atall m the responses, and there were only a few ticks m the'disagree' column, there was a definite pattern m theresponses and some topics were deemed more relevantthan others

Politics ofthe National Health Service, politics and nurs-ing, politics of trades unions, trades umons and nursing,were all considered highly relevant Topics such as thestmcture and function of state mstitutions, elections andvoting behaviour were considered less relevant, withtopics addressing political issues surrounding a selectionof client groups appeanng somewhere m-between

Further questions were posed in the wntten evaluation,which was supplemented by a verbal evaluationResponses to a request for suggestions for improving theelective were vaned, but essentially mdicated that the bal-ance between 'information giving' and self-directed studycould shift further towards the latter Interestingly, a desireto consider the politics of nurse education was alsoexpressed Fourteen ofthe 16 respondents said they wouldrecommend the elective to other students (the other twostudents declined to comment)

CONCLUSION

The course was led by a nurse teacher with a degree mpolitics and administration, ably supported by colleagueswith expertise m particular subject areas and activelyengaged m political activities It was apparent dunng theelective that it was being reasonably well received by thestudents and the evaluation supported the belief that itwas a worthwhile exercise Most of the students who par-ticipated felt that the subject of politics was so importantthat It should be a compulsory course for all students,rather than an elective course for a few While such com-ments are encouraging, it must be remembered that mostof these students already had an interest m politics pnorto embarking on the elective Serious thought would needto be given to reaching those students who are not inter-ested before considermg mcludmg politics m the corecumculum

The 'Politics and nursing' elective has run again for thenext group of students and amendments have beenmade as a result of the initial expenence and students'

comments The balance between teacher and student-ledactivities was addressed Students were offered a guidedstudy package to assist them m acquiring factual infor-mation such as the structure and function ofthe legislatureand executive A class discussion followed entitled 'Issuesm democracy' when discussions centred around more con-troversial issues such as accountability A session on 'Menin nursmg' was mcluded and well received

The assignment has since become formative and wasapproached through the medium of class presentationsMore information was made available to students regard-mg educationad visits which might be of mterest to them,and some chose to visit a local pressure group A smallernumber of students attended the second course, but it wasa first choice for all of them and most were there becausethe course had been recommended by students who hadattended the first course

It must be stressed that this elective took place at theend of the first year of the Project 2000 course followmga sociology module in semester 1 and a module entitled'Social policy and health care systems' m semester 2, andessentially auned to raise political aweu-eness by introduc-ing a number of concepts which the students can continueto address, hopefully with heightened awareness, as theyprogress through their course It might be some time, there-fore, before any benefits that might accrue as a result ofparticipating in the 'Politics and nursmg' elective becomeapparent

As the duration of the course is 4 weeks and involves asmall number of students it could be viewed, by some, asan expensive course to run However, it is felt importantto encourage the mterest m politics expressed by smallgroups of students Throughout the elective, whichevertopic was being considered, student discussions centredaround the impact of political decisions on patient careand the future of nursing At this early stage m theirnursmg careers, many course participants have alreadyexpressed increased confidence m engaging in polit-ical discussions surrounding the future of the NationalHealth Service

While the longer term benefits must be viewed as uncer-tam. It IS firmly believed that so long as nurse educational-ists acknowledge the place politics has on the nursingagenda, opportunities will be available for students tofurther their mterests m this area It is just possible that itIS from such students that future nursing leaders mightemerge

Acknowledgements

Gratitude must be extended to colleagues who contnbutedto the elective and to the students who participated m thiselective, for their commitment and support m this ventureand helpful evaluation

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