Lessons in Media Advocacy: A Look Back at Saskatchewan's Nursing Education Debate

Agenda Setting

In the agenda setting stage, governments decide which issues require their attention. Often an array of issues are recognized and, based on the interplay of current social, economic, and political forces, governments choose which issues are a priority requiring the choice of a policy option. Policy options include inaction (deliberate choice to maintain the status quo), incremental alternatives (marginal change from the status quo) or fundamental alternatives (significant change) (Fischer Miller & Sidney, 2007; Wu, Ramesh, Howlett & Fritzen, 2010). Various governmental and societal actors attempt to shape the government's agenda in order to have certain issues addressed and particular policy options implemented. Governmental actors include elected officials, governmental bureaucrats, and appointees while societal actors include interest groups (such as business, labor unions, associations, and policy research organizations), researchers and the media (Wu, Ramesh, Howlett & Fritzen, 2010).

Nursing organizations had forecast a nursing shortage and attempted to have this issue placed on the Saskatchewan government's agenda for several years prior to 2000 (Scott, 2000). In March 1999, the government sought additional independent information to determine the scope of the problem when it commissioned a labor analysis report mandated to examine supply and demand trends for nurses in Saskatchewan and forecast potential imbalances between the two (Elliott, 1999). Just 2 months later, influenced by the interim findings from this research, the government announced an increase in the number of nursing seats in the NEPS (Elliott, 1999). Clearly, the nursing shortage was now viewed by the government as an issue that could adversely impact the province's health care system.

The release of the finalized Labour Market Analysis: Saskatchewan Nursing report to the government in October, 1999 confirmed warnings of an impending nursing shortage. The report predicted a shortfall between the supply of, and demand for, RNs and Registered Psychiatric Nurses (RPNs) in Saskatchewan from between 105 to 331 per year (dependent upon best vs. worst case scenario estimates) for each of the next 5 years. (Elliott, 1999). The report found there were increasing numbers of RNs currently employed in the health care system who were near or past retirement eligibility while the number of new RN/RPN graduates in the province had declined from 450 in 1992 to 1993 to an estimated graduating class size of 138 in 1999 to 2000 (Elliott, 1999). The issue was firmly on the government's agenda with an incremental policy option (increased nursing education seats) enacted to mitigate the nursing shortage. The Elliott report was released to the public on January 29, setting the stage for Atkinson's announcement of a return to the 3-year diploma option for nursing education 2 days later.

Policy Formulation

During the policy formulation stage, governments seek to identify an array of plausible policy solutions that might address a defined issue. This may be a discrete process primarily involving government officials, or may involve a variety of societal stakeholders as part of a broader, consultative process (Fafard, 2008). Policy studies have shown government officials do not generally act in isolation during policy formulation, but rather are interacting with a variety of social actors within stable patterns of relationships characterized as policy networks (Jann & Wegrich, 2007). Wu, Ramesh, Howlett and Fritzen (2010) described policy formulation as a nonlinear process that may occur throughout the policy process:

The search for new policy options thus may precede the initiation of a policy problem in agenda setting and may extend beyond the point where a decision is made and implemented, to the evaluation of existing and future potential means to resolve public problems. (p.1/12)

It is not readily apparent from the print media coverage what particular policy options were explored or who was consulted prior to the Minister of Health Atkinson's surprise announcement to reduce RN licensure requirements as a policy solution to address the nursing shortage on January 21. It is possible the government was communicating with government officials in the neighboring province of Manitoba, since within a week of the Atkinson's announcement, the Manitoba Health Minister confirmed he would be making a similar announcement in mid-February regarding the reinstatement of a diploma nursing education program in that province (Pacholik, 2000). It is evident from the print media reports that key nursing stakeholders in Saskatchewan were surprised by the Atkinson announcement and did not feel they had been consulted. The newspaper coverage reported that the announcement “provoked reactions of disappointment and confusion from senior officials with the SRNA” with the SRNA executive director quoted as saying “we're not sure what she's (Atkinson) saying” (Scott, 2000, p. A3). The Leader-Post political columnist Murray Mandryk (2000) wrote 4 days after the announcement “The government is again choosing not to listen to the nurses before acting, the nurses argue. And by acting without consulting, the government is again missing the root of the problem” (p. A7).

Decision Making

At the decision-making stage of the policy process, the government chooses a particular course of action from among the policy alternatives to address the issue on the agenda. Policy studies have pointed to a common pattern whereby, although the final decision is made by those with the elected power in a democratic system, this decision is usually preceded by a process of negotiated policy formation which includes other stakeholders such as organized interest groups (Jann & Wegrich, 2007). In this instance, following the announcement of a new policy on nursing education and licensure in Saskatchewan, stakeholders including the SRNA, the CNA, nurse educators, and nursing students turned to the media to express their displeasure with the proposed policy and to recommend other solutions to the nursing shortage. The views of these nursing stakeholders received a great deal of media attention over the next few weeks, including coverage of a protest by over 200 nursing students on the steps of the Saskatchewan Legislative buildings. The media advocacy techniques apparent in the media coverage will be discussed in the next section, however the success of nursing stakeholders in delivering their message was evident by the willingness of the Minster of Health to meet with the stakeholders in order to diffuse the situation (Kyle, 2000a).

Following the media debate, government and nursing stakeholders met to try and work out a compromise policy solution. Consistent with cyclical policy models, the process was not linear as the government, faced with vocal nursing opposition, was willing to revisit the proposed policy and therefore reverted back to the policy formulation function as it began consultations with stakeholders to seek a policy solution to the nursing shortage that would be agreeable to all sides. The outcome of these consultations was announced on March 17th by the Minister of Health after meeting with nursing students the previous day to share the government's decision (Kyle, 2000b). The new policy retained the nursing degree as the entry requirement for licensure as an RN in Saskatchewan; however the NEPS program agreed to offer two fast-track options in which the students could take the same courses required for the 4-year degree within a compressed timeframe. Students could choose to study in the spring and/or summer following their 3rd year in order to complete the requirements that September or December. A third option remained for students wishing to spread their studies out for the original 4-year timeframe.

At the press conference Minister of Health Atkinson reported that “working together, we've managed to create options for qualified nursing students so that the degree program can be completed in three, 3 ½ or four years”. Implementation of the new fast track options was set to commence in fall 2001. The government maintained its commitment to 260 NEPS seats annually and to working on other nursing recruitment and retention strategies (Kyle, 2000b). A government press release emphasized that the plan was put together by two government departments (Health and Post- Secondary Education and Skills Training) “in consultation with the SRNA, nursing institutions and educators and students” (Saskatchewan Executive Council, 2000). The press release contained quotes of approval from the key nursing stakeholders and included a statement that the announced policy was “applauded” by the SRNA, nursing students and the teaching institutions (Kyle, 2000b). An editorial in the Regina Leader-Post agreed with Atkinson's description of the new policy as a win-win situation:

On Friday, a deal was announced that gave both sides, more or less, what they wanted. The SRNA got official government approval for its 1996 nursing education program requirement of a four-year nursing degree for entry into the profession. And the province won agreement that students could, if they wished, compress the time required to graduate with a degree in nursing to three years . . . Both sides deserve credit for reaching this agreement, which should benefit not just the government and the association but also Saskatchewan patients. (“Nursing Deal to Benefit All Sides”, 2000, p. A14)

Method

The print media coverage included frequent quotations from nursing stakeholders as the debate evolved, indicating they were making themselves readily available to be interviewed by journalists. Nursing stakeholders who were interviewed in newspaper articles included both the president and executive director of the provincial nursing regulatory body (SRNA), the president of the national body (CNA), the dean of the College of Nursing, University of Saskatchewan (an institutional partner in NEPS), and numerous nursing students.

News releases and letters to the editor were also used as techniques to convey key messages. Both the provincial and the national nursing associations sent out press releases with titles designed to capture media attention including “CNA Baffled by Saskatchewan Government Backtrack on Education” (CNA, 2000) and “Now Is the Time for Action” (SRNA, 2000). In addition, there were numerous letters to the editor published in the newspaper from nurse leaders. These included letters (with titles written by newspaper editorial staff) such as “Health minister is ill-advised” authored by a former president and executive director of the SRNA (Hodgson, 2000), “Gov't (sic) is not listening” authored by a former nursing instructor (Trafananko, 2000), and “Nurses Speak Out on Nursing Education” authored by the current CNA president (Kushnir Pekrul, 2000).

Nursing students from the NEPS used both interviews and a media event to draw attention to their unique perspective on the issue. On January 25th, over 200 nursing students rallied on the steps of the Saskatchewan Legislative Building (Kyle, 2000a). Students carried placards with slogans such as “Thanks for the slap in the face Pat (Atkinson)!” and left suitcases on the steps to drive home the message they would leave the province upon graduation if the new policy were to be implemented (Kyle, 2000a). The rally received wide press coverage on television and radio in addition to provincial newspaper coverage. Student representatives at the protest were allowed into the building to meet with the Minister of Health and emerged with assurances that students currently in the NEPS would be allowed to graduate with a nursing degree (Kyle, 2000a). Atkinson told reporters following the meeting that the government and students were “committed to finding a way to get more trained nurses out in the workplace as quickly as possible”. She also floated a new policy option, to fast-track nursing students through the existing program quicker, and indicated that this new option had received the approval of nursing students at the meeting (Kyle, 2000a).

Framing Media Messages

Based on an analysis of print sources, it appears the government and nursing stakeholders had specific messages that they were trying to convey through the media in order to gain public approval for their positions. Framing of messages is typical of media advocacy campaigns, with some messages designed to gain the attention of the media and policy makers (framing for access) while other messages are sent once that attention is obtained (framing for content) (Dorfman & Gonzalez, 2012). Although the protest by nursing students was successful in gaining media attention by illustrating their level of unhappiness with the government's new policy, the messages they sent through media interviews during and after the protest were part of framing for content. The degree to which the frames evident in this debate were deliberate and strategic cannot be assessed within the context of this article's sole focus on retrospective print sources. However, examples of quotations from the newspaper coverage and press releases (see Appendix) are consistent with framing for content during the second step of the media advocacy process. Such messages are more likely to resonate if they speak to widely held values (Dorfman & Gonzalez, 2012). Values articulated in the print sources during the nursing education debate included fairness (to nursing students), gender equity (nursing as a predominantly female profession), and responsibility to protect the public (government vs. profession). All sides appeared to acknowledge that the impending nursing shortage was an issue that must be addressed in the public interest. The debate centered on the choice of policies to address the nursing shortage and on what role the government, the nursing regulatory body, and other nursing stakeholders should play in determining policy solutions.

Government framing focused on the need to address the nursing shortage as quickly as possible, with a shortened nursing education requirement being held up as the fastest way to achieve this goal. Several submessages were highlighted in support of this policy option. First, the new policy would not only quickly alleviate the nursing shortage but would have the side-effect of improving existing RN working conditions by introducing more nurses to help ease current heavy workloads and presumably improve job satisfaction. Second, the government suggested the current licensure requirements were unfair to nursing students since requirements were shorter in other provinces. Finally, the government emphasized that it had the ultimate power because it could simply pass legislation revoking the SRNA's mandate to determine licensure requirements for the province's nurses.

The SRNA and the CNA both stressed in the media that nursing was a self-regulated profession with nursing organizations in the best position to decide on matters related to the provision of quality nursing care. The SRNA refused to change the entry to practice requirement for a nursing degree beginning in 2000 in the face of the government proposal and instead reaffirmed that a 4-year degree was required to ensure new nurses were adequately prepared to perform competently in an increasingly complex health care system. In a press release, the SRNA reaffirmed its position:

The Saskatchewan Registered Nurses' Association (SRNA) has set the standards for education, entry and practice for RN's in the province since 1917. The SRNA position, since 1984, has been that by the year 2000 nurses entering the profession in Saskatchewan would be required to have a degree. (SRNA, 2000, p. 1)

The CNA reinforced this message and stressed degree preparation was necessary for new nurses to provide the “care patients deserve and expect” (Kushnir Pekrul, 2000). Finally, both nursing organizations emphasized the need for policy solutions that addressed the root causes of the nursing shortage rather than looking for a short-term, “knee-jerk reaction to a long-standing challenge” (Kushnir Pekrul, 2000).

The dean of the College of Nursing, University of Saskatchewan supported the SRNA by stating that the government should not interfere with SRNA decisions. She also countered the government message that a degree requirement in Saskatchewan was unfair to students by suggesting it was the new policy that was unfair to students since it would punish them (potentially not all students desiring a degree would be allowed to attain one) in order to fix a problem they hadn't created. The dean reinforced the message from the SRNA and the CNA that policy solutions should focus instead on improving working conditions and encouraging former nurses to return to the profession. Finally, the dean introduced a new message of gender inequality by suggesting the government would not have suggested reducing educational requirements for other traditionally male-dominated professions such as medicine.

The NEPS students entered the debate with enthusiasm and delivered several messages. First, they predicted the new policy would be ineffective because they were so angry that they would leave the province and practice elsewhere if they were not allowed to graduate with a degree. Second, the students expressed disappointment that they had not been consulted prior to the announcement of a new policy that might directly impact their education. Finally, they echoed the messages of other nursing stakeholders that a degree was required to adequately prepare new nurses for the realities of a modern health care system and that nursing should continue to be self-regulating on matters affecting the profession.

Media Advocacy Tactics

Wallack et al., (1993) described common tactics used when framing for content in the second phase of a media advocacy debate. These tactics include social math, media bites, authentic voices, symbols, shaming, and visuals. Elements of all of these tactics were evident in the media approaches employed by nursing stakeholders during the nursing education debate.

In the first tactic, social math, numbers are used to illustrate a point in terms the public will readily understand. One nursing student emphasized students were so angry that they would practice outside the province if they were not allowed to earn a nursing degree. She reported an informal poll of 100 NEPS students found only 15 of 100 intended to stay in Saskatchewan (Warwick, 2000). This message countered the government's contention that the new education policy was required to get new graduates into the nursing workforce more quickly.

Media bites, the second tactic, involve conveying a position on an issue to the media as a succinct summary of a few sentences, or less than 10 seconds in length if provided orally (Wallack et al., 1993). Some quotes conveyed strong messages in one or two sentences. For example, the SRNA president emphasized that reducing educational requirements was not an appropriate solution for the nursing shortage by stating “that's like mixing apples and bananas to get bapples. It doesn't work.” (Scott, 2000). The SRNA executive director characterized the proposed policy as an attack on nursing: “These past eight days have done more harm to the recruitment of nurses into nursing than the past 80 years of self-regulation of the nursing profession. The message that is being sent by the government of Saskatchewan is that nursing is being devalued” (Pacholik, 2000). A second year NEPS student reinforced the message that nursing was being attacked and that a degree was a necessary educational requirement in three sentences: “The government just doesn't seem to be on our side. We just want to be good, competent nurses. We want the best for the people of the province.” (Pacholik, 2000).

Wallack et al. (1993) described a third tactic, “from the face of the victim to authentic voices”, as the media desire to present the story of the victim when reporting on an issue. The NEPS students, through their vocal opposition to the new policy, had credibility as victims since at first it appeared some would be forced to exit after 3 years with a diploma when they had entered the program expecting to obtain a degree. After meeting with the Minister of Health on the day of the rally, a nursing student leader explained “We hadn't been given a guarantee that we could get that degree until we walked into here today.” (Kyle, 2000a). Another student spoke of wanting to be the best possible nurse and personalized this by saying “I wouldn't feel confident leaving after three years and working in ICU (intensive care unit) . . . the people who suffer are the people of the province” (Pacholik, 2000). This statement conveyed the message that members of society would also be victims since they would be negatively impacted by the proposed policy.

The use of symbols to illustrate a message is a fourth tactic that was employed by the NEPS students. At their rally, the students left suitcases on the steps of the legislature, symbolic of their threat to leave the province if the policy wasn't reversed. This symbol may have resonated with the general public as many new graduate nurses had left the province in the previous decade.

Shaming, the fifth tactic, can be a powerful way to gain support if messaging can convince people that the opposition is acting in a shameful manner. The dean of the College of Nursing, University of Saskatchewan raised the specter of gender inequality and the historic oppression of nurses. She compared the nursing shortage with a current shortage of pathologists and challenged the inequity of the government proposal by suggesting the government wouldn't dare to reduce the educational requirements of the medical profession: “Since 97 per cent of nurses are women, Brown believes it boils down to ‘a gender issue. Nursing has a long history of being seen as a servant to medicine’ ” (Pacholik, 2000).

Visuals, the sixth tactic, represent the classic assertion that a picture is worth a thousand words. The NEPS students were successful in creating an event that provided the media with opportunities to take pictures for both print and television coverage. A picture on the front page of The Leader-Post, showing over 200 nursing student protestors shouting and carrying placards on the steps of the seat of government, was a strong visual illustrating the strength of student opposition to the proposed policy (Kyle, 2000a).