Abstract
It is a shame that all our readers were not able to attend the Royal College of Nursing (RCN) International Research Conference in Oxford in April; you missed three thought-provoking and inspiring keynote addresses. They were presented by Trish Greenhalgh, Jane Ball and Sally Kendall, each focusing on their experiences, as a researcher, of influencing policy. The liveliness, breadth and depth of each presentation is shown in the RCN’s conference videos – watch them to glean the detail and prepare to join us in JRN’s forthcoming Twitter chat on influencing (https://www.rcn.org.uk/professional-development/research-and-innovation/research-events/rcn-2017-research-conference). Their presentations when seen together clearly showed how researchers can, and indeed must, influence policy. While each address took a different approach, the overarching message for me was strikingly similar – influencing policy is astoundingly complicated, and if you are going to do this you have to be resilient, tenacious and highly skilled, and you need deliberate and well thought-through tactics to help you to be successful. In this Perspective I hope to capture the main tactical ideas presented in the keynotes so that readers can get a head start on how best to influence policy.
When taken together the keynotes, for me, offered us six tactics that researchers and others could use to influence policy. The first, obviously, is to generate high quality, relevant and timely research that policy makers will find useful. However, if those research monies are to be well spent, it is vital that research changes practice. Achieving that relies on the second tactic, which is to identify a receptive context where these research findings and ideas are likely to make an impact on policy and/or practice. Having found this context, it is critical to create and frame arguments within it that will promote the adoption of these ideas: the arguments must be carefully couched in terms that are tailored to suit what may often be a diverse set of target audiences. Next, it is vital to collaborate and to bring people together to blend research with other sorts of evidence so a collective knowledge can be negotiated and used fittingly in each policy context. Doing this successfully requires researchers to be persuasive through their use of carefully constructed arguments, and the keynotes gave us useful hints on how to do that. Once these negotiations have occurred and policy is constructed, it is critical to identify and use strategically placed people to transform policy into everyday life. These people are not just the policy makers. They must also include those who work at the interface between policy and the public, as because of this unique position they are able to shape the way policy is further implemented and/or developed (or not).
These six tactics were highlighted in different ways in the three keynotes. The first talk, entitled ‘Evidence-based policy? Really?’, was presented by Trish Greenhalgh, Professor of Primary Care Health Sciences at Oxford University. No stranger to the policy–research interface, Trish is the winner of the 2016 BMJ Editor’s Award for Persistence and Courage in Speaking Truth to Power. Using diverse stories ranging from research related to NHS IT systems, diabetes prevention programmes, rationing decisions in clinical commissioning groups to tales of the ponds on Hampstead Heath, Trish set the scene for sharing all-important influencing tactics – hers focused on persuasion, framing and bringing people together. Her message was cogent yet simple: influencing is not just about knowing and telling the research evidence – it is about constructing convincing arguments and tailoring messages to suit those you wish to influence.
Trish addressed persuasion by blending the Aristotelian notion of rhetoric, getting your point across, with an understanding of the target audience’s intellectual, emotional and practical dispositions – or as she called them, ‘their points of departure’. She talked about three of the four key features of rhetoric that may be used to develop such targeted messages and reminded us that the argumentation process is critical in making policy. The first of Aristotle’s rhetorical features is the veracity of the facts underpinning the argument and the logic of that argument (logos); next is the credibility and authority of the speaker (ethos) proposing the argument because this will affect how the facts are received; and finally the way the argument is presented has to appeal to people’s emotions (pathos) if they are to be persuaded to accept it. Trish did not talk about the fourth feature of rhetoric – timeliness (kairos), but you will see in Jane Ball’s keynote how important timeliness is when we are dealing with policy-makers.
Before we can engage an audience, however, we have to select it. When we are thinking about the research–policy interface the audience’s composition is critical to the policy made, so we need to work with the best possible group of people for the job to be done. In some rare instances this might be simply researchers and policy makers, but in most instances the best results are likely to come from involving a wider constituency who can bring broader sources of evidence to the discussion. Trish drew on Carol Weiss’ work (Weiss, 1979) on research utilisation to help us consider this. Weiss’ original paper detailed seven models showing a range of ways through which research might be integrated into policy. These models provide a useful starting point to enable both researchers and policy makers to understand better the complexity of this process. Trish’s preferred example drew on Weiss’ interactive (‘constructive’ in Trish’s slides) model within which policy makers bring together many different people (e.g. researchers, planners, politicians, practitioners, interest groups) and types of evidence (e.g. research, experience, political insight) around a particular concern that needs addressing. Critically, this interactive encounter entails the development of persuasive arguments and constructive negotiation, which results in jointly constituted targeted policy.
Framing or presenting facts/arguments from a perspective that will engage and persuade an audience (or factions within it) was an important thread in Trish’s address. We have all heard politicians, media presenters and members of interest groups use this tactic to their advantage. Researchers also need to form and frame arguments in directed ways to influence different levels of the policy-making community. You can see from the section of Trish’s video about the ponds on Hampstead Heath that there are many ways to frame information (ponds can be nature reserves, public amenities or health hazards, etc.) to help various audiences pay attention to it!
Jane Ball, Principal Research Fellow at the University of Southampton, delivered the second keynote – ‘The research–policy interface: “safe-staffing” as an example’, and as you will see from the video, she reflected on the dilemmas, challenges and opportunities of working at this interface – one that she has plenty of experience of, having spent most of her career as a researcher and/or policy advisor. Jane’s tactics for working successfully at this interface are similar to the advice given by Whitty (2015) and Denham (2016) and focus on three crucial things: first, researchers must do research that is rigorous and addresses the key questions on policy makers’ minds; second, the findings from that research need to be presented in ways that are useful to policy makers; third, the right decision makers and stakeholders need not only to hear these messages at the right time, but to be receptive to them and act on them (even if that means luring prime ministers into conversations at drinks receptions).
You would have thought that the rigorously collected research findings on nurse staffing would slip easily across that interface and into practice; but they did not. Just as Trish found obstacles to influencing policy, so did Jane. First of all, the research findings seemed hard for policy makers to interpret because they mainly tended to tell decisionmakers that nurse staffing mattered but were less able to help them to answer their fundamental question: How many registered nurses are needed? It was also difficult to locate the key people to influence because policy about the provision of nursing, and hence of staffing levels, crosses many decision makers, governmental committees and public bodies as well as those who are involved in day-to-day policy decisions at the local hospital or community level. The message has to be just right for whichever of those many individuals or groups is being targeted at a given time. Also staffing is all too intimately linked to financial resources, which makes it especially difficult to get the right message across to all those involved. Finally, the time has to be right for there to be a receptive environment for the message to take hold.
By 2013, Jane reminded us, a rare confluence of events had occurred in England that placed nurse staffing prominently in key stakeholders’ minds – the time was right, the context was receptive and the research evidence was there. The Mid Staffordshire crisis had shown that a review of nurse numbers and skills was needed, a sound body of research had emerged over the previous two decades showing the link between better outcomes for patients and better staffing, and the National Institute for Health and Care Excellence (NICE) (https://www.nice.org.uk/) was there to bring together evidence and craft guidance. It was not long before a nurse:patient ratio emerged for adult wards in acute hospitals during day shifts with the promise of further work to be undertaken in relation to specialist areas (e.g. emergency departments and the community). However, this promise was never fulfilled as NICE’s remit was altered in 2015 on the instructions of key policy makers – the promising context had changed and the time was no longer right for such policy direction. However, as you will hear in Jane’s keynote, this has not deterred researchers and interest groups from keeping safer staffing at the top of their agendas.
The last, and crucial, piece of our tactical arsenal was presented by Sally Kendall, Professor of Community Nursing and Public Health at the University of Kent, in her address about ‘Influencing policy through primary care and community nursing research’. As you can see from the video, Sally’s keynote touched on all of the important tactics described so far, but for me she made a fundamental connection that Trish and Jane did not by considering how policy is made relevant to the public. The answer lay in Lipsky’s concept of street-level bureaucrats (Lipsky, 1980) – front-line practitioners who can and do legitimately use discretion in their interactions with clients to shape policy to suit their circumstances and needs. This allows them to transform policy into everyday life. Sally reminded us that ‘nurses and health visitors working in the community have numerous opportunities to interact with the public and shape and interpret how policy can be implemented’. Researchers wanting to ensure that their work affects the service should never forget that it is these ‘street-level’ professionals who really have it in their power to shape the way in which research-based policy has its ultimate impact, or not.
The three keynotes showed the sort of tactics that researchers need to become familiar with – and to use – if they are to help knit together the research–policy interface. However, they also showed how important it is to recognise practitioners as the final brokers so that high quality research not only shapes policy, but brings benefit to the public. What matters in the end is not just that research affects policy, but that it also feeds through policy into care.