Milstead Policy Process: 5 Essential Stages of the in Nursing

This post covers Milstead Policy Process, as detailed below.

What is the Milstead process?

The Milstead process is the name nursing courses often give to the policy process framework presented in Milstead’s Health Policy and Politics: A Nurse’s Guide, originally developed by Jeri A. Milstead and now edited by Nancy M. Short (2026). It describes how a public problem becomes a public policy through a series of stages: identifying a problem and getting it onto the government’s agenda, analyzing and designing policy options, enacting a policy through legislative or executive action, implementing it through rules, programs and funding, and evaluating whether it worked. The stages are presented in order, but in reality they overlap and cycle: evaluation often reveals new problems that start the process again.

The framework gives nurses a practical way to understand where and how they can influence policy. Because nurses see the effects of policy on patients every day and are the most trusted profession in the United States, they have both the knowledge and credibility to shape every stage.

1. The Policy Process: Nurses Shape Health Policy

Policy is a course of action chosen by public authorities to address a problem. Health policy includes laws, regulations, funding decisions and institutional rules that affect health and health care. Politics is the process of influencing those choices. Nurses shape policy at many levels:

• Organizational: serving on hospital committees that set staffing, safety and practice policies.
• Professional: working through organizations such as the American Nurses Association and state nursing associations.
• Government: contacting legislators, testifying at hearings, commenting on proposed regulations, serving on boards and running for office.
• Community: joining coalitions on issues such as tobacco, housing or immunization.

Nurses bring clinical expertise, patient stories and data, which make them persuasive advocates. They are not only implementers of policy decided by others but participants in deciding what policy should be.

2. Problem Identification and Agenda Setting

Many problems exist, but only some receive government attention. Problem identification means defining the problem clearly, with evidence of its size, seriousness and causes. How a problem is framed matters: describing obesity as a matter of personal choice leads to different policies than describing it as a result of food environments.

Agenda setting is the process by which a problem gains the attention of policymakers. John Kingdon’s (2011) multiple streams model explains it: a problem stream (indicators, focusing events and feedback that draw attention), a policy stream (ideas and proposals developed by experts and advocates) and a political stream (public mood, elections and interest groups). When the three streams come together, a policy window opens, and “policy entrepreneurs” push their solutions forward.

Nursing role: nurses identify problems at the bedside, collect data, share patient stories with media and legislators and prepare solutions in advance so they are ready when a window opens. Example: the COVID-19 pandemic was a focusing event that put nurse staffing and workplace violence on many state agendas.

3. Policy Analysis and Design

Policy analysis is the systematic comparison of possible solutions to a problem. A widely used approach, Bardach and Patashnik’s (2020) “eightfold path,” asks analysts to define the problem, gather evidence, construct alternatives, select evaluation criteria, project outcomes, confront trade-offs, decide and tell the story. Common criteria include effectiveness, cost, equity, feasibility (political and administrative) and unintended effects.

Policy design chooses the tools to achieve the goal, such as:

• Regulation: mandates or standards, such as staffing ratios or vaccination requirements.
• Financial incentives or disincentives: grants, payments or taxes, such as tobacco taxes.
• Information and education: public awareness campaigns or labeling.
• Direct provision of services: public programs such as community health centers.

Nursing role: nurses use evidence-based practice skills to evaluate research on alternatives, estimate effects on patients and identify practical implementation problems. Example: in analyzing ways to reduce nurse burnout, a nursing association might compare mandated ratios, staffing committees and loan repayment incentives against cost, evidence and political feasibility.

4. Policy Enactment: Power, Strategy and Enactment of Legislation

Enactment is the formal adoption of a policy through legislation, executive orders, regulations or court decisions. In the legislative path, a bill is introduced, referred to committee, heard and amended, voted on by both chambers, reconciled and signed (or vetoed) by the executive. Most bills die in committee, so early work with sponsors and committee members is essential.

Power and strategy determine which bills pass. Sources of power include expertise, numbers, money, relationships and credibility. Effective strategies include:

• Building coalitions with patient groups, physicians, hospitals and community organizations.
• Lobbying and relationship-building with legislators and their staff.
• Testifying with data and patient stories.
• Grassroots mobilization: calls, emails and lobby days by constituents.
• Compromise and timing: amending bills to gain support and acting when windows open.
• Political action committees and campaign involvement.

Example: Michigan’s Filter First bills passed with bipartisan support after a multi-year coalition of health, education and environmental advocates built relationships with legislators.

5. Implementation: Avoiding Unintended Consequences

Implementation turns law into action. Agencies write rules and regulations (often with public comment), create programs, allocate funding, train staff and monitor compliance. Many good policies fail at this stage because of insufficient funding, unclear rules, resistance or lack of capacity.

Unintended consequences are outcomes not intended by policymakers, which can be positive or negative. Example: the 2016 CDC opioid prescribing guideline was intended for primary care, but some insurers, states and clinicians applied it as rigid limits, leading to abrupt tapering, untreated pain and patient harm. The 2022 updated CDC guideline explicitly warned against misapplying recommendations as inflexible thresholds.

How to avoid unintended consequences: involve frontline clinicians and affected communities in rule-making; pilot programs before full rollout; build in flexibility and exemptions; fund implementation adequately; monitor early data; and create feedback loops to adjust. Nursing role: nurses can comment on proposed rules, serve on implementation committees and report problems early.

6. Evaluation of Policies

Evaluation determines whether a policy was implemented as intended and whether it achieved its goals. It uses two main types of measures:

• Process (formative) evaluation: Did it happen as planned? Examples include number of people served, rules issued, funds spent and compliance rates.
• Outcome (summative) evaluation: Did it work? Examples include changes in health outcomes, costs, quality and equity.

Frameworks such as the CDC’s framework for program evaluation guide evaluators to engage stakeholders, describe the program, focus the design, gather credible evidence, justify conclusions and use and share lessons (Centers for Disease Control and Prevention [CDC], 1999). Evaluation results feed back into the policy process, leading to revision, expansion or termination of policies. Nursing role: nurses collect and interpret data, conduct research on policy effects and present results to decision-makers.

Summary table

References

Bardach, E., & Patashnik, E. M. (2020). A practical guide for policy analysis: The eightfold path to more effective problem solving (6th ed.). CQ Press.

Centers for Disease Control and Prevention. (1999). Framework for program evaluation in public health. MMWR Recommendations and Reports, 48(RR-11), 1–40.

Kingdon, J. W. (2011). Agendas, alternatives, and public policies (2nd ed.). Longman.

Short, N. M. (Ed.). (2026). Milstead’s health policy and politics: A nurse’s guide (8th ed.). Jones & Bartlett Learning.

Related reading: Milstead framework paper on Michigan’s Filter First law, policy analysis and advocacy in social work and workplace safety in nursing.

For further reading, see this external resource.

You can also explore more resources on our website.