DNP Policy Change Project: Kingdon's Multiple Streams and the Institutional Policy Approval Process

Kingdon's Multiple Streams Model: The Framework for Policy Change Projects

Kingdon's Multiple Streams Model (1984, updated 2011) describes policy change as the convergence of three independent streams: the Problem Stream, the Policy Stream, and the Political Stream. The DNP student's role in a policy change project is to identify where these streams can be made to converge (creating a "policy window") and to move a specific policy proposal through that window before it closes.

Problem Stream: The clinical problem that demands a policy response. For the Problem Stream to be active (open to policy intervention), the problem must be visible to decision-makers, through quality data, sentinel events, regulatory pressure, accreditation findings, or patient outcomes data. A DNP policy change project opens the Problem Stream by documenting the local evidence of the problem: NHSN data, adverse event reports, staff survey findings, or benchmark comparison data that make the gap unmistakable to institutional leadership. This documentation maps directly to Chapter 1 of the capstone manuscript.

Policy Stream: The available solutions, policy proposals, clinical protocols, professional organisation guidelines, or regulatory frameworks that could address the problem. The Policy Stream analysis in a DNP project is the literature review: what does the evidence say are the most effective interventions? What do professional organisations recommend? What policies exist at other institutions that have successfully addressed this problem? The Policy Stream gives decision-makers the "what", the specific policy content that should be adopted. This maps to Chapter 2.

Political Stream: The organisational and institutional forces that determine whether a policy proposal will be adopted. Who has authority to approve the policy? Who supports it? Who opposes it? What competing institutional priorities exist? The Political Stream is operationalised in the DNP project through stakeholder analysis, power-interest mapping, and a deliberate stakeholder engagement strategy. This maps to Chapter 3 (the stakeholder engagement plan within the methodology) and to the Discussion chapter (what political factors enabled or constrained the policy approval process).

Policy Window: The moment when all three streams align, the problem is visible, a solution is available, and the political conditions are favourable. DNP policy change projects are most feasible when a policy window is already open: a recent sentinel event that has heightened institutional attention, a JCAHO or CMS regulatory change that requires a policy response, or a new CNO or hospital administration that has signalled openness to practice change. Identifying an open policy window (and timing the project submission to move through it) is a critical part of the DNP policy project's feasibility assessment.

Institutional Policy vs State/Federal Policy: Which Level Does a DNP Capstone Address?

Institutional/Organisational Policy (most common for DNP capstones): A policy that governs practice within a specific healthcare institution, unit, or health system. Examples: a catheter necessity assessment policy, an opioid stewardship prescribing protocol, a nurse-driven early mobility policy, a zero-tolerance workplace safety policy, a staff float pool assignment policy. Institutional policy change projects are feasible within the DNP capstone timeline because the approval pathway is internal, the student navigates the institution's policy committee, Pharmacy and Therapeutics committee, CNO office, or legal review process and can complete a pilot implementation within 12 to 16 weeks of policy approval.

State Policy (advanced, typically post-DNP): Policies that affect APRN scope of practice, reimbursement, prescriptive authority, or public health regulations at the state level. Advocating for a state legislative change (e.g., full practice authority for NPs in a restricted state) is a multi-year process involving the state legislature, professional associations, and lobbyists. This is not feasible as a single DNP capstone project within one or two academic years. However, a DNP project can contribute to a state policy effort by: analysing current state law and its impact on patient access, developing evidence briefs for legislative testimony, or conducting a needs assessment that documents the scope of the problem requiring state-level action. The policy project in this case produces a policy brief and advocacy materials, not a draft institutional policy with pilot implementation data.

Federal Policy: Similarly not feasible as a DNP capstone project within a standard timeline. Federal policy advocacy efforts (Medicare reimbursement for APRN services, DEA prescriptive authority regulations, federal scope of practice legislation) are long-term professional association efforts. DNP students can contribute to federal policy advocacy by developing position statements, testifying at public comment periods, or producing evidence summaries that support organised advocacy, but these contributions are typically framed as a policy advocacy project rather than a policy change project with measurable pilot implementation outcomes.

Stakeholder Analysis for DNP Policy Change Projects

Stakeholder analysis is the formal identification of every individual or group with interest in or influence over the policy change, mapped by their level of power and their level of interest. The power-interest grid (Eden & Ackermann, 1998) places stakeholders in four quadrants: High Power/High Interest (manage closely (these are the key allies and opponents); High Power/Low Interest (keep satisfied) these individuals can block the policy if they become dissatisfied); Low Power/High Interest (keep informed (these are often the frontline staff most affected by the policy); Low Power/Low Interest (monitor) require minimal engagement).

For an opioid stewardship policy change project at a 300-bed community hospital: High Power/High Interest, Pharmacy and Therapeutics Committee (approval authority), CNO (final nursing policy authority), Chief Medical Officer (physician practice authority). High Power/Low Interest (Hospital Legal Counsel (liability review), Hospital Finance Department (cost implications). Low Power/High Interest) Bedside nurses (primary implementers), pain management patients (most affected by the policy change), the DNP student (project lead). Low Power/Low Interest, Hospital marketing department (communication about the change). The stakeholder engagement plan specifies how each quadrant is engaged: monthly P&T committee briefings for High Power/High Interest, biweekly nursing staff feedback sessions for Low Power/High Interest, legal review package preparation for High Power/Low Interest.

Policy Change Project: What the Deliverables Include

A DNP policy change project produces multiple deliverables beyond the scholarly manuscript: (1) a drafted policy document in the institution's policy format (most health systems have a required policy template with specific sections: purpose, scope, definitions, policy statement, procedures, references, approval signatures); (2) documented evidence of the policy approval process (meeting minutes, email approvals, committee sign-off forms); (3) a staff education plan for the new policy; (4) pilot implementation data showing whether the policy achieved its intended outcome during the initial implementation period; and (5) a sustainability plan specifying how the policy will be reviewed and updated over time. The scholarly manuscript documents all of this, but the policy document itself and the approval evidence are typically included as appendices.