Health Policy is NOT Evidence-Based

Updated: May 30, 2019

Nurses, think about your work day. If you work in a hospital like me, you show up, clock in, get report, and start a long day of performing dozens of types of patient care. And while you're accessing a port or donning PPE, has a patient ever asked you why? Why are you wearing that ugly yellow gown backwards? Why do I have to wear this mask?


Every now and then a patient asks a question that stops me in my tracks. Why am I supposed to do it this way? When I'm stumped, my go-to answer is "It's hospital policy." I add finding the answer to my mental checklist for the day, and 9 times out of 10, I've forgotten by the next ambulance arrival.


It's important that healthcare professionals know the policies that dictate how we do our jobs. But it's also important we know how these policies are made. And if you’re anything like me - a stone cold optimist - this next bit of information may surprise you: Health policy is not evidence-based. 


WHAT? 


I’ll repeat: Hospital-wide, state-wide, nation-wide, health policy is not evidence-based.


I’d like to think we live in a world where the policies surrounding healthcare are firmly rooted in scientific evidence — but that’s not the case. In fact, the World Health Organization uses the term evidence-informed instead of evidence-based to describe health policy. This is not an accident. Though many health policy decisions are made with consideration to scientific evidence, research is not the only determinant of health policy. 



Relevant Knowledge + Political Will --> Social Action 


The above equation is my illustration of a 1999 model developed by two researchers, Feetham and Meister. They say that in order to see a Social Action (as in, drafting a new health policy), a society needs two things: Relevant Knowledge and Political Will.


In the context of health policy, Relevant Knowledge refers to relevant health research. Political Will refers to everything else — the entire context of society (i.e. the people, the political climate, the hot topic of the moment, etc.) And this is where the hope for evidence-based health policy goes to die. 


And because the Truth is more palatable in Listicle form, allow me to introduce…


 The 7 Reasons Health Policy is NOT Evidence-Based 


1. The evidence doesn’t exist. 


So many areas of health policy have yet to be studied. And this could be for multiple reasons. Research and data collection are expensive and time consuming. Even if you get the grant, you’ll still need a few years at least before you can publish results. 


In another case, data may be available, but it isn’t quite the right data. Say you’re drafting policy around chronic disease management, specifically for patients with Type II Diabetes. The most relevant research available is on patients with Type I… You can use that information to draft your policy, but then is your policy really evidence-based? No, it’s not. That’s an educated guess. 


2. The evidence exists, but policymakers don’t know about it. 


You know how much research exists but has not made its way into the public consciousness? Trick question. We can’t.  Without strategic information-sharing through marketing, media attention, or congressional testimony, research sits unbeknownst to policymakers. And if the key players don’t know about it, the data gets left out of the game.  If you are doing health research right now, have a plan for how to get it out there.


3. We’ve seen the evidence, but no one knows what it means. 


This example usually would apply to massive data sets like census data, rather than more focused research data — but not necessarily.  If there is a lack of experts to meaningfully interpret the data, then it cannot be used to develop policy. Or worse, it will be interpreted incorrectly and drive a policy change in the wrong direction. This is especially likely for policies in highly political areas, which brings us to…


4. Policymakers misinterpret the evidence.


Policymakers hold their own ideologies, values, and interests, which can skew their interpretation of evidence presented to them. This is surprising to no one. If you need more convincing, in this book, nurse investigators easily give examples of evidence-based nursing interventions that were not carried into new healthcare programs due to policymaker misinterpretation. 


5. Policymakers don’t care about the evidence. 


Policymakers want to know the WHY. Why should they draft legislation to decrease Catheter-Acquired Urinary Tract Infections (CAUTIs)? Are those bad? Oh, people are dying? Lots of people are dying from lots of stuff! Why should they focus on CAUTIs specifically? 


Here’s a hint:  Want to get policymakers interested in your data? Bring in economic returns. Policymakers want to know how much things will cost - and how much they might save. This is a crucial part of their job. If valuable, information-rich research does not also come with a cost-benefit analysis, policymakers usually aren’t interested. 


6. External influences nudge the policy-making process away from the evidence-supported direction. 


Many powerful groups have skin in the health policy game. Healthcare systems, industries, payers, and even  providers, follow healthcare politics closely - not to mention multinational corporations and special interest groups. When a powerful group believes their power is being threatened, they’re ready for a fight. 


In 2014, Minnesota became the 19th state to grant Advanced Practice Registered Nurses (APRNS) full practice authority as primary care providers. The idea is to increase access to primary care for Minnesotans (especially those in rural areas) by allowing Nurse Practitioners to practice at the top of their scope, independently from a physician (after collaboratively working 2,080 hours with one).  


The road to this policy was not easy, with much opposition from the American Medical Association. The evidence showed that nurse practitioners were just as safe and effective - and less expensive - primary care providers as physicians. However, the AMA argued there were safety concerns, citing two high-profile medical errors made by NPs. 


Nurses involved in the lobbying of this policy expressed surprise at how adamantly the American Medical Association opposed the proposed legislation. Certainly, the AMA - tasked with representing physicians’ interests - must have felt the role of the General Practitioner (GP) physician was being threatened, and thus lobbied accordingly. However, nurses felt they were acting in the best interest for Minnesotans, and were disappointed that the fight became Doctors vs. Nurses. 


7. National and international contexts override the influence of the evidence.


Every kind of geopolitical and economic factor can steer the policymaking process. War, disease, famine, and natural disaster can all shift political priorities away from the path which the evidence highlights. Less attention goes to eliminating CAUTI's when we're at war.


For these 7 reasons, the development of health policy is not black and white. Policymakers must weigh every player’s interests, the political climate, economic factors, and yes, the evidence to make the best possible policy decision. Even though something seems like an obvious win for the public’s health, the appropriate policy changes are not a guarantee. 


Nurses can influence the policymaking process in so many different ways. We can get involved with nursing research, join professional societies, run for office, write emails to our health system presidents about the policies we care about. We can provide congressional testimony, pilot new evidence-based health programs in our local communities, and maybe even read a healthcare blog. 


Share with your nursing pals what you’re doing to influence health policy. Share this blog with them! Let’s make civic activism a given among nurses. If you’d like to read more in-depth about nurse’s role in health policy, check out this book. Many of the articles helped inform this list.


If you’re involved with health policymaking, comment and let us know! We’d love to know more. 

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