Influencing Policy to Reduce Motor Vehicle Crashes in a Rural Community:

A Multiple Streams Approach

Judy Gregg

Submitted to the Faculty of the Doctor of Nursing Practice Program of Carlow University in

partial fulfillment of the requirements for the degree of Doctor of Nursing Practice

February 9, 2017




ProQuest Number: 10257349




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Acknowledgements
I would like to thank the faculty and staff of Carlow University for all their assistance on this

DNP journey. I am especially indebted to Dr. Kate Tennant, who as my project chair was more

than a mentor. Her guidance and support was extraordinary and this project would have not been

able to be completed without her visionary wisdom. I would also like to thank my committee

member, Dr. Elisabeth George for her attention to detail and assistance with fine tuning my

project.

I am also grateful to Julie Miller, MSN, RN, who served as another committee member and

community expert for this project. Without her community insight, collaborative effort and

direction, this project would not have been possible. I would like to thank all the participants of

Knox County who willingly collaborated on this project to help improve MVC in the local area.

Your insight and teamwork helped make this project a success.

I also need to thank my family for all their support and encouragement over the last few

years. Thanks for believing in my dream and helping me reach my goal.

My hope is that this work will inspire other nurses to see that they too can impact their

community. As the poet Edward Everett Hale once said, “I am only one, but I am one. I can't do

everything, but I can do something. The something I ought to do, I can do. And by the grace of

God, I will”.
Table of Contents
List of Tables…………………………………………………………………………… iv
List of Figures…………………………………………………………………..………….. v
List of Appendices……………………………………………………………………….. vi
Abstract…………………………………………………………………………………….. vii
Chapter 1. Introduction…………………………………………………………………………..1
Background knowledge
Local problem
Intended improvement
Study question

Chapter 2. Review of the Literature………………………………………………………………3

Introduction
Critique and Synthesis of Previous Research
Rationale for Study

Chapter 3. Methods……………………………………………………………………………...16
Ethical issues
Setting
Planning the intervention
Planning the study of the intervention
Methods of evaluation
Analysis

Chapter 4. Results…………………………………………………………………………….....28
Outcomes
Chapter 5. Discussion and Conclusions………………….……………………………………...45
Summary
Relation to other evidence
Limitations
Interpretation
Conclusions

References………………………………………………………………………........................50
iv

List of Tables

Table 1: Focus County and State General Crash Data 2013-2015…………………….….…..30

Table 2: Focus County Issues compared to State & Healthy People 2020 Target Goals……..33
v

List of Figures
Figure 1: Upended Social Ecology Model………………………………………………………13

Figure 2: Multiple Streams Model ……………………………………………………………...14

Figure 3: Multiple Streams Approach applying Nurse Policy Entrepreneurship……………….23

Figure 4: Project Timeline…………………………………………………………………........28

Figure 5: Percentage of Injury Crashes by Age ……...................................................................31

Figure 6: Percentage of Teen Injury Crashes in Peer Counties……………………………...….36

vi

List of Appendices
Appendix A: Informed Consent……………………………………………………………….58

Appendix B: Advocacy Evaluation Planning Worksheet…………………….………………..60

Appendix C: Letter of Support to Use Advocacy Evaluation Planning Worksheet…………..61

Appendix D: Stakeholder Analysis…………………………………………….………………62

Appendix D: Injury Framing Tool……………………………………………………………..63

Appendix E: Adapted Organizational Change Recipients’ Beliefs’ Scale…………………….65

Appendix G: Letter of Support to Adapt Organizational Change Recipients' Beliefs' Scale…66

Appendix H: Framed Message shared with Stakeholders………………..…………………... 67

Appendix I: Copy of A3 used for Alliance Meeting………………………….……….………68

Appendix J: Modified Organizational Change Recipient’s Belief Scale Results………....…..69

vii

Abstract

The purpose of this project was to implement and examine the role of a Nurse Policy

Entrepreneur in reducing Motor Vehicle Crashes (MVC) in a rural community. Applying the

Multiple Streams Approach, the action research study concentrated on the role of a Nurse Policy

Entrepreneur to gather data to explore specific local contributing factors and issues related to

motor vehicle crashes; review current policies and best practices; and meet with stakeholders/

decision makers to create a window for policy change to reduce injury and fatalities from MVC.

The Nurse Policy Entrepreneur analyzed public MVC data from 2013-2015. Teen injury

crash prevention was selected as the issue to be addressed with a local policy. Policy analysis

included comparison with peer counties and current literature to identify best practice. Results

found top preforming peer counties all utilized a Carteens Program for juvenile traffic offenders.

Briefings to stakeholders by the Nurse Policy Entrepreneur created an open policy

window through sharing a framed message to support the Carteens Program. At the conclusion

of the public stakeholder meeting, in addition to verbal support, a modified Organizational

Change Recipient’s Belief Scale tool was used for assessment. Results revealed the coalition’s

belief that teen injury MVC’s in the county was a problem (discrepancy), Carteens was the

appropriate solution (appropriateness), along with principle support for the project. More neutral

results were found for both efficacy which measured their own power to change the problem and

personal impact from the change.

With support for ongoing program oversight from 4H and law enforcement, the Nurse

Policy Entrepreneur shared the policy proposal with the county juvenile judge. After reviewing

the data, and consulting advisors, the judge approved the policy change for teen traffic offenders,

signifying success of the Nurse Policy Entrepreneur to effect policy.

1

Chapter 1

Introduction

Background Knowledge
Former Surgeon General C. Everett Koop once said that if a disease were affecting young

people at the rate of unintentional injuries, the public would be outraged and demand that this

killer be stopped at any cost (United States Senate Subcommittee on Children, Family, Drugs

and Alcoholism, 1989). Unintentional injuries are the leading cause of death in people under 44

years of age, accounting for more deaths in this age group than non-communicable and

infectious diseases combined, and is the fifth foremost cause of death overall in the United States

(Center for Disease Control and Prevention [CDC], 2015a). Although motor vehicle traffic–

related death rates have decreased over the past decade, MVC continues to be the leading cause

of unintentional injury death among children under the age of 19 (Gilchrist, Ballesteros, &

Parker, 2012).

Local Problem

In Knox County, a non-Appalachian rural area located in north-central Ohio, the motor

vehicle fatality rate was 18.1/100,000 which exceeds the Healthy People 2020 target goal of

12.4/100,000 (Centers for Disease Control and Prevention [CDC], 2016). In addition, 61% of

Knox County driving deaths were related to alcohol impairment, compared to Ohio percentage

rate of 36% and the top national performers of 14% (County Health Rankings & Roadmaps,

2015). Seat belt use was only observed at 83% compliance in a 2011 observational survey (Ohio

Department of Public Safety, 2011). Even though motor vehicle mortality rates were higher than

state and national benchmarks, motor vehicle crashes (MVC) were only considered a minor to

moderate issue in the most recent focus county 2014 Community Health Assessment Report

(Knox County Ohio Health Department [KCHD], 2015). While both the health commissioner
2

and law enforcement expressed concern about the prevalence of motor vehicle crashes, MVC

were not currently on the local policy agenda and were only addressed in Knox County through

limited, isolated initiatives.

Intended Improvement

Deliberate actions were needed to raise problem awareness and help set the policy agenda

related to MVC in Knox County. Although policy making and agenda setting may be a novel

role, nurses are well positioned to become policy entrepreneurs to assist in creating a policy

window of opportunity to discuss this problem. A policy entrepreneur is able to help define a

problem, understand the political climate, build teams, and provide leadership to address

important health issues (Mintrom & Norman, 2009). Traffic fatalities are not unavoidable

tragedies, but rather need to be addressed as a preventable occurrence.

Stronger policies and enforcement of regulations associated with the contributing factors

in motor vehicle crashes are needed to reduce occurrences, injuries and death. There is evidence

that the role of a Nurse Policy Entrepreneur can impact the policy process in areas such as motor

vehicle crashes.

Study Question

The purpose of this project was to implement and examine the role of a Nurse Policy

Entrepreneur in reducing MVC in a rural community. Applying the Multiple Streams Approach,

the study focused on how the Nurse Policy Entrepreneur could gather data to explore specific

contributing factors and issues related to motor vehicle crashes in Knox County; review current

policies and meet with stakeholders in order to develop potential solutions which could create a

window for policy change to reduce MVC in this small community as evidenced by the adoption

of a new policy within 6 months.

3

Chapter 2
Review of the Literature

Introduction

Numerous peer reviewed publications were available related to the topics of Motor

Vehicle Crash (MVC) reduction and the role of policy entrepreneurship in affecting public

policy. Most articles were found in public health journals or political science journals. Limited

studies were found relating specifically to nurses in health policy. Due to the nature of the topics

searched, most were retrospective studies or survey analysis. While outcome research has

demonstrated the success of policy entrepreneurs in several articles, studies with nurses in this

role were limited. Also several health policy studies were performed in other countries which

could affect the generalizability to settings in the United States.

The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline

databases were searched for peer review articles related to policy entrepreneurship and motor

vehicle crashes published from 2010 through 2015. Key words searches included “motor vehicle

crash,” “policy entrepreneurship,” “policy entrepreneur,” “policy window,” “nurse and policy

making,” as well as “nurse and policy making and United States,” and “nurse and politics and

United States.” The search was limited to full text availability in the English language. Inclusion

criteria included original research or systematic reviews related to motor vehicle crash

prevention, nurse policy advocacy, and policy entrepreneurs related to health policy. Exclusion

criteria included studies which were not generalizable to a broader context of motor vehicle

reduction or nurse policy entrepreneurship. The search yielded 172 articles but only 34 added to

the body of evidence related to the topic of reduction of motor vehicle crashes or policy

entrepreneurship. In addition, the reference sections of relevant articles were scanned for

additional resources.
4

Critique and Synthesis of Previous Research

Motor vehicle crash prevention. Although the problems of unintentional injuries from

MVC were well documented in the literature, preventing them from occurring remained a

challenging issue. Prevention strategies should be initiated at the various levels of influence, as

noted in the Social Ecology Model, in order to sustain efforts over time and not rely on a single

intervention (CDC, 2015b). The need for stronger policies and enhanced enforcement of laws

were evident throughout various studies found in the literature review related to child safety

seats, seat belt use, teen, impaired and distracted driving.

Child safety restraints. Properly fitted safety seats reduced a child’s risk of injury or

death by 55% (O’Neil, Rouse, Hackworth, Howard, & Daniels, 2012). While all states have

mandatory child safety legislation enacted, regulations and enforcement varied. A recent

nationwide retrospective study showed that although child deaths have significantly declined

from 2002 to 2011, over one third of the children who died in 2011 were unrestrained (Sauber-

Schatz, West, & Bergen, 2014). Another barrier noted in a randomized nationwide survey of

pediatricians found that while most believed child safety seat counseling was important, many

physicians did not educate parents or know the current recommendations (Yingling, Stombaugh,

Jeffrey, LaPorte, & Oswanski, 2011). Child restraint laws, enhanced enforcement programs,

distribution of safety seats with education, and other educational and incentive programs were

described as best practice (CDC, 2015a).

Seat belts. When lap/shoulder belts were correctly used, the risk of motor vehicle

accident death or serious injury was reduced by half (CDC, 2015a). Mandatory seat belt use has

been proven to be effective for increasing use rates when regularly enforced by law officials.

However, many states, including the focus state, have only secondary laws which allow law
5

enforcement to enforce seat belt use only when a driver is stopped for another offense. A

retrospective time series analysis from 2001-2010 found states with primary seat belt laws,

which allowed enforcement of seat belt use as the only traffic offense, reported fewer MVC

fatalities than those with only secondary laws (Lee et al., 2015). Teens were of special concern

with a seat belt compliance of only 80% and were more likely not to wear a seat belt than any

other age group (National Highway Traffic Safety Administration [NHTSA], 2015). In addition,

according to the Youth Risk Behavior Surveillance System Data, only 55% of teen passengers

reported always wearing seat belts when riding with someone else (CDC, 2015a). Also of

concern was a study that found that while overweight teen drivers showed similar compliance

rate to other teens, overweight passengers were 1.72 times more likely to never or rarely wear

their seat belt (Price, Dake, Balls-Berry, & Wielinski, 2011). The CDC recommended primary

restraint laws, increased penalties for violations, short term and high visibility enforcements, and

combined nighttime enforcement programs (CDC, 2015a).

Teen drivers. Teen drivers were four times more likely to be involved in a crash than

more experienced drivers and the risk was escalated when other passengers were in the car

(CDC, 2015a). The NHTSA National Motor Vehicle Crash Causation Survey from data

collected from 7/2005-12/2007 found teen driver error was responsible 79.3% of the time in

crashes involving teen drivers (Curry, Hafetz, Kallan, Winston, & Durbin, 2011). Inadequate

surveillance, distraction, and driving too fast for conditions resulted in almost half of all crashes

studied, which supported the need to target distracted driving, surveillance and hazard awareness

for young drivers (Curry et al., 2011). Graduated driver licenses which restrict driving privileges

were recommended for young drivers. It is estimated that more than 500 lives could be saved and

more than 9,500 collisions could be prevented each year if states adopted best practices for
6

graduated drivers licenses which would include: the minimum age for a driver’s permit would be

16 years old, required logging of 65 hours of practice driving hours, the minimum age of 17

years old would be required for a provisional driver’s license, and night driving limited to prior

to 10 pm without adult supervision (Insurance Institute of Highway Safety [IIHS], 2012).

Impaired driving. The literature documents the need for no tolerance enforcement for

drinking and driving. A nationwide retrospective prevalence study of alcohol and/or other drugs

using data from the Fatality Analysis Reporting System for 2005-09 found that more than half of

driver fatalities in the United States had been using alcohol and other drugs, with approximately

20% using poly-drugs (Brady & Li, 2013). Two other retrospective studies found an increased

risk of MVC with prescribed sedative and psychoactive medication usage (Hansen, Boudreau,

Ebel, Grossman, & Sullivan, 2015; Meuleners et al., 2011). While the problem was well

documented, solutions have remained problematic. One novel approach described in a 2015

retrospective study found fatal alcohol related MVC in Illinois decreased by 26% following a

2009 alcohol excise tax increase (Wagenaar, Livingston, & Staras, 2015). Best practices included

stricter laws, sobriety checkpoints, ignition interlocks, screenings, mass media campaigns and

driver’s license revocation (CDC, 2015a). Solutions to impaired driving included a need for

stricter enforcement of laws, as well as innovative approaches.

Distracted driving. In 2011, over 3,000 people were killed and 416,387 were injured

nationwide as a result of a distracted driver (Adeola & Gibbons, 2013). A retrospective study,

using a nationwide inpatient sample from 19 states during 2003-2010, examined the impact of

texting bans on MVC related hospitalizations. Using negative binomial regression, results

indicated that texting bans were associated with a 7% reduction of hospitalizations overall,

however, only marginal reductions were noted among teen drivers (Ferdinand et al., 2015). Cell
7

phone use and texting, however, were not the only causes of distracted driving noted in the

literature. A case-control study, using data from emergency rooms in France, found the

combined effect of Attention Deficit Hyperactivity Disorder and external distractions were

strongly associated with responsibility for MVC (El Farouki et al., 2014). This study emphasized

the complex nature of distracted driving and further illustrated the need for influencing

controllable variables. Initiatives to reduce distracted driving have included raising public

awareness, improved public policies, enacting and enforcing strict laws, advocating for primary

laws, and better education for young drivers to the dangers of texting (National Highway Traffic

Safety Administration [NHTSA], 2015).

Summary. Based upon the retrospective research in the literature, stronger policies and

enforcement of regulations were clearly the best practice which resulted in the reduction of

MVC. In order for health policy to move forward to address MVC, communities need to define

the problem and identify best practices, as well as engage in wide-ranging implementation and

enforcement of solid policies.

Nurses as policy makers. As the largest health care profession, nurses were found to be

in a unique position to effect policy decisions. According to Patton, Zalon, & Ludwick (2015),

nurses were not only suitable, but also have a professional obligation to be involved in policy

making. In addition, the International Council of Nurses and the World Health Organization

have called for nurses to be involved in policy making. As more nurses are involved in policy

making, the impact of nurses will be demonstrated through improved care to benefit clients,

families and society (Kunaviktikul, 2014).

Current impact. Nurses historically have been involved with policies related to their own

scope of practice (Brekken & Evans, 2011; Morris, 2014; Owsley, 2013). Documented cases of
8

nurses who have improved care for their clients have also been noted throughout the literature.

Several articles reported policy changes based on best practices in hospital and community

settings (Norton, Micheli, Gedney, & Felkerson, 2012; Zadikoff, Whyte, DeSantiago-Caredenas,

& Gupta, 2014). Impacting patient care has also been seen globally as nurses have made impact,

such as in a participatory action research design, which included nurses from six countries who

expressed the need for even more involvement of nurses in policy development to address gaps

in AIDS education, research and practice (Richter et al., 2013). More can be accomplished in the

political realm as nurses use their patient experiences to advocate in the legislative arena

(Maryland & Gonzalez, 2012).

Expanding scope of practice. In the Institute of Medicine’s (IOM), The Future of

Nursing: Leading Change, Advancing Health, nurses are called to be policy participants for

change and not merely spectators. Yet many barriers have existed which have prevented nurses

from doing so, including regulatory boards, resistance from within nursing, lack of competency

in policy making and not being part of decision making bodies (Institute of Medicine [IOM],

2011). Traditionally, nursing education has trained nurses to work within policies instead of how

to lead policy change (Patton et al., 2015). Nurses can play a key role in problem identification,

moving issues to policy agendas and influencing new policies (Walhart, 2013). Advanced

practice nurses who are clinical experts can use the patient experience to help bring a problem to

the attention of a legislator (Roth Parr, 2015). Nurses need to continue to take action as well in

the continuing healthcare bill debate (Gardner, 2014). Nurse are able to help determine best

policy and program solutions, but must be able to navigate the steps of policy making, assess the

level of interest of the policy maker, and develop skills in policy writing (Nannini & Houde,

2010).
9

Summary. Based upon the literature, nurses need to expand their scope of practice to

include leading policy making. Once nurses understand how policy making works, why they

need to become involved, as well as how they can become part of the decision making process,

nurses can have an increased impact on health policy. It is essential that nurses become more

familiar with policy making in order to lead change which will improve health for communities.

Policy entrepreneurs. While the role of policy entrepreneurship within nursing was

limited in literature, the concept has been generally described related to health care policy

through several studies nationally and internationally. Functions of policy entrepreneurs included

defining and reframing problems, devising possible alternatives and facilitating agenda setting

with decision makers (Kingdon, 2010). Four elements central to policy entrepreneurship

included creating community insight to take advantage of windows of opportunity, effectively

defining problems, working well with others as a team player, and leading by example by

reducing perceived risks for the group (Mintrom & Norman, 2009).

Soderberg and Wikstorm (2015) described the policy process as a policy community

developing a feasible proposal to solve a problem which then needs to be promoted by

politicians. Policy entrepreneurs are needed to connect the problem, policy and political streams

together and search for windows of opportunity through their networks and their knowledge of

the process to create action (Soderberg & Wikstorm, 2015).

Contributions. Policy entrepreneurship has been credited with raising awareness of

issues and proactively creating policy alternatives, as well as recognized for providing a roadmap

for future policy leaders (Craig, Felix, Walker, & Phillips, 2010). Policy entrepreneurs can also

add legitimacy and decrease uncertainty in project implementation (Souderberg & Wikstorm,

2015). It was also documented that policy entrepreneurs who converge during the policy
10

window and had the ability to strengthen collaboration were successful in creating change

(Gwozdek, Tetrick, & Shaefer, 2014). Soderberg & Wikstorm (2015) attributed the success of

the policy entrepreneur to having close access to policymakers, taking action when opportunity

arose, having ability to use networks, and having expertise on the subject. Other studies

involving diverse health policy initiatives including immunization, oral health, health promotion,

and tobacco legislation have also attested to the importance of policy entrepreneurs in

strategically contributing to policy outcomes (Abiola, Colgrove, & Mello, 2013; Mamudu,

Dadkar, Veeranki, He, Barnes, & Glantz, 2014; Milton & Grix, 2015).

Caveats. Although most studies demonstrated the strength of policy entrepreneurship in

policy formation, a policy entrepreneur must be aware of a few possible caveats. Milton and Grix

(2015) described a failed attempt to initiate a health promotion policy which had been previously

supported and warned that prior interest and problem awareness alone may be insufficient to

secure advancing a health promotion policy. In addition, another study reported that policy

entrepreneurs did not fully capitalize on the open window of opportunity in a case study which

could have resulted in stronger policies (Mamudu et al., 2014). The final concern noted in the

literature was an example where policy entrepreneurs did not have a clear understanding of the

problem and political realms which led to detrimental policies (Lenton & Allsop, 2010).

Summary. It has been well documented in numerous retrospective studies that policy

entrepreneurs have influenced policy at all stages of the policy process. Based on the studies

available, nurses must be rigorous as they embrace this role in order to positively improve health

policies.
11

Rationale for Study

The use of theoretical foundations and conceptual frameworks in this literature review

were identified in articles authored by a combination of public health professionals, nurses, and

political scientists. Theoretical frameworks from the domains of public health and political

science were acknowledged in 10 of 34 journal articles in this review. While the Social Ecology

Model was acknowledged in two studies, the Upended Social Ecology Model has not been

utilized or acknowledged in the literature due to its novelty. The authors of the reframed

Upended Social Ecology Model, however, referenced the Multiple Streams Model to

operationalize policy and environmental changes (Golden, McLeroy, Green, Earp, & Lieberman,

2015). Several articles in the literature utilized the Multiple Streams Model (Abiola, et al., 2013;

Craig, et al., 2010; Gwozdek, et al., 2014; Lenton & Allsop, 2010; Mamudu et al., 2014; Milton

& Grix, 2015; Strand & Fosse, 2009; Walhart, 2013). The Upended Social Ecology Model and

the Multiple Stream Framework augment each other to influence health promotion through

policy changes.

Social Ecological Model. Ecological theories have traditionally promoted new insights

which are theoretically important to the topic of health promotion and injury prevention. Based

on the 1979 original work of Urie Bronfenbrenner, the Social Ecology Model is grounded on a

broad paradigm over several fields of research which analyzes multiple physical, social and

cultural conditions affecting health. A core theme of the ecological paradigm includes an

individual surrounded by larger social systems which impact one’s behavior including

intrapersonal factors, interpersonal processes and primary groups, institutional factors,

community factors and public policy (Golden & Earp, 2012). The Intrapersonal level activities

include education and skills to change knowledge, perceptions and behavior, along with targeting
12

self-efficacy (Golden & Earp, 2012). The Interpersonal level targets family, friends, teachers

and coworkers to influence social networks (Golden & Earp, 2012). The Institutional level

focuses on organizational culture where community level interventions concentrate on

community services and capacity (Golden & Earp, 2012). The final level includes policy which

seeks to enhance the general community through advocacy including either creation or

enforcement of policy (Golden & Earp, 2012).

The Social Ecology Model assumes the levels of influence are both interactive and

reinforcing which is illustrated through the nesting of the circles of influence (Golden & Earp,

2012). However, in a systematic review, Golden & Earp (2012) found the majority of health

interventions primarily focused on individual level activities followed by interpersonal activities

with the policy level activities least likely cited (Golden & Earp, 2012). In order to strengthen

this framework, Golden, et al. (2015) have proposed flipping the traditional framework to

promote policy and environments that promote health, by placing policy and environments at the

center of the model instead of the individual (see Figure 1). This circle is then surrounded by

communities, followed by organizations, interpersonal connections and fair and equitable

resources for all individuals (Golden et al., 2015). In this new reframed model, communities

decide policy and environmental changes through the application of the Multiple Streams

Approach as described by Kingdon & Thurber (Golden et al., 2015). Organizations would

monitor and support policies and environmental changes, while interpersonal connection would

foster collective action through formal and informal groups (Golden et al., 2015). Finally,

individuals would receive needed resources to support their lives in a fair and equitable way

(Golden, et al., 2015). The new framework requires health promotion professionals to support
13

the significance of health enhancing policies and environments, construct collaborative networks

for change, and promote fair distribution of resources (Golden, et al., 2015).

Figure 1: Upended Social Ecology Model. Adapted from Golden, S. D., McLeroy, K. R., Green,

L. W., Earp, J. L., & Lieberman, L. D. (2015). Upending the Social Ecology Model to guide health

promotion efforts toward policy and environmental change. Health Education & Behavior, 42(1S), 8S-

14S. http://dx.doi.org/10.1177/1090198115575098

In the Healthy People 2020 Objectives, utilization of ecological theory is encouraged in

the area of injury and violence prevention (Healthy People 2020, 2010). The Centers for Disease

Control and Prevention (CDC) have also adopted the ecological theory as a framework to

understand people at risk for violence, along with understanding those who perpetrate violence,

in order to improve prevention strategies at multiple levels of intervention (CDC, 2015b).

Despite the fact that ecological models have been endorsed by both CDC and Healthy People

2020, only 10% of all health promotion studies in 157 intervention articles reviewed by Golden

& Earp applied the Social Ecology Model (Golden & Earp, 2012). By turning the model inside

out, the authors of the Upended Social Ecology Model hope to create synergy with other theories
14

to produce policy and environmental change which will assist health promotion practitioners and

researchers to create tangible tasks and outcomes (Golden et al. 2015).

Multiple Stream Model. The Multiple Streams Model created by Kingdon provides

clarity and structure to Cohen, March and Olsen’s 1972 policy making model which described

policy making as problems, solutions, and participants mixing together like trash in a garbage

can (Petridou, 2014). Instead, Kingdon framed policy making in terms of problem, policy and

political streams which join together with the help of a policy entrepreneur to create windows of

opportunity for policy change (Kingdon, 2010).

According to the Multiple Streams Approach described by Kingdon, all three steams flow

independently until a window of opportunity is presented through the facilitation of a policy

entrepreneur (see Figure 2). The problem stream refers to all the issues that need to be

considered before action occurs, whereas the policy stream is related to all the alternative and

possible solutions to solve the problem. Finally, the political stream represents the attitude and

ideology of the public and decision makers. When these streams flow together, an opportunity

for policy change can be created which is called a policy window of opportunity (Kingdon,

2010). This policy window could result in agenda setting, decision making and/or actual

implementation of an intervention. The Multiple Streams Approach theorizes when the policy

entrepreneur is able to bring the streams together, a policy window of opportunity is opened for a

time which will result in policy change (Petridou, 2014).

Figure 2: Multiple Streams Model. Adapted from Kingdon, J. W. (2010). Agendas, alternatives

and public policies (2 ed.). Upper Saddle River, NJ: Pearson.

15

The Multiple Streams Approach has been described in several studies involving policy

entrepreneurship. Craig, et al., (2010) provides a historical analysis to explain how

comprehensive, school-based, childhood obesity legislation in Arkansas was passed. Through

applying the Multiple Streams Approach, the problem, policy and political streams combined

with the assistance of policy entrepreneurs to produce a policy window to facilitate the

comprehensive obesity legislation, as well as provide a roadmap for future policy leaders (Craig

et al., 2010). Another study applied the Multiple Streams Approach by using thematic content

analysis of key informant interviews, newspaper articles and archived data to describe formation

of a Human Papilloma Virus (HPV) immunization policy and found policy entrepreneurship

played a vital role in policy outcomes (Abiola et al., 2013). Similar methodology and findings

have been demonstrated in oral health, health promotion, and tobacco legislation (Gwozdek et

al., 2014; Milton & Grix, 2015; Mamudu et al., 2014). In summary, the Multiple Streams

Approach has demonstrated success to influence policy in a variety of health issues and provides

a useful framework for healthcare policy initiatives.

16

Chapter 3

Methods

Ethical Issues

Permission to conduct this study was obtained from Knox County Health Department and

evaluated by the Carlow Institutional Review Board (IRB). This quality improvement action

research project posed minimal to no risk to human subjects. IRB application was submitted with

received expedited IRB approval. Participants were autonomous adult members with the right to

decline or withdraw from participation at any time. Informed consent was provided prior to key

informant, individual stakeholder and public stakeholder meetings (see Appendix A). All data

was secured in a locked desk or locked computer file and was destroyed upon completion of the

project. Participant confidentiality was maintained in reports. Outcomes were shared with the

stakeholder group at the conclusion of the project.

Setting

Knox County was a non-Appalachian rural area located in north central Ohio. The county

has a total area of 525.49 square miles and a population of 60, 921 according to the 2010 census

(US Census Bureau, 2014). Knox County was the 45th most populous county in Ohio and the

residents account for 0.5 % of Ohio’s total population (Ohio Department of Health [ODH],

2008). Knox County was comprised of one small city and seven smaller villages.

Knox County was settled in the early 1800s and traditionally an agrarian area with 58%

of the land used for farming. Although farming was still a major economic provider, Knox

County became more involved in manufacturing during Ohio’s industrial era. The residents of

Knox County were predominately a Caucasian, working middle class population. According to
17

the most recent County Health Rankings, Knox County ranked 39th for health out of 88 Ohio

counties (County Health Rankings & Roadmaps, 2016).

Although the county had limited financial resources, a strong civic involvement

prevailed. Through leadership from the health department, key community stakeholders actively

collaborated on many community efforts within Knox County. While the community had worked

together on many modifiable health concerns effectively, Motor Vehicle Crashes (MVC) had not

been addressed to date on a coordinated county level, even though the fatality rate exceeded state

and national benchmarks. At the time, Knox County had earned the 5th worst rating in all 88

Ohio counties for alcohol impaired driving deaths at 52% (County Health Rankings &

Roadmaps, 2016). The County Health Commissioner requested MVC be studied in order to

facilitate community dialogue to begin to address the issue of MVC in Knox County. As the

lead investigator implemented and examined the novel role of a Nurse Policy Entrepreneur in

reducing MVC in a rural community, the Health Commissioner served as the community expert

for this project.

Planning the Intervention

Since the aim of the study was to both improve a community issue, as well as acquire

knowledge about the role of the nurse as a Policy Entrepreneur, a quality improvement project

applying an action research design was utilized and measured using both a reflective journal and

participant survey. A general proposal for the study was developed through discussions with

County Health Commissioner. Application of tools provided by the Harvard Family Research

Project (HFRP) then assisted to define four basic advocacy evaluation planning steps including

focusing, mapping, prioritizing and designing (Coffman, 2009).

18

Focusing. The Nurse Policy Entrepreneur was the primary evaluator who utilized the data

gathered in the problem, policy and political streams for strategic learning and application in

order to frame the issue of MVC’s in Focus County. For this project, Knox County Health

Commissioner served as the community expert for the project and corroborate all data findings.

The focus of the evaluation of the study included the effectiveness of the nurse entrepreneur to

reframe the issue of MVC in Knox County in order to influence community stakeholders to

develop and strengthen community policies.

Mapping. The Advocacy Evaluation Planning Worksheet by HFRP provided a virtual map

to assist in planning strategies to achieve outcomes (see Appendix B). Creation of positive social

and physical conditions were selected as the intended policy impacts of this intervention. The

policy goal was to begin to strengthen and/or develop policies related to improving MVC within

a 3 month window. Activities/tactics identified to support the goals of the project comprised of

issue and policy analysis, briefings and presentations, along with coalition and network building.

In addition, interim goals included influencing stakeholder awareness, salience, and

attitudes/beliefs resulting in the formation of new advocacy alliances to address MVC in Knox

County.

Prioritizing. Based on this logic model, the nurse entrepreneur aligned the most essential

information required with the Multiple Streams Approach. The issue of MVC in Knox County

was considered in detail by the Nurse Policy Entrepreneur through exploration of the problem,

policy and political streams over a three month timeframe. The efforts of the Nurse Policy

Entrepreneur led to the unification of these three steams to create an open policy window which

will resulted in the formation of an alliance to address MVC in Knox County.

19

Designing. The mixed methods action study took place in three phases: framing of the issue,

dialogue with stakeholders, and the initial formation of an alliance to address MVC as a result of

successful agenda setting by the Nurse Policy Entrepreneur.

Initial framing. The initial framing of the issue of MVC in Knox County was evaluated

through independent explorations of the problem, policy and political streams.

Problem stream. Study of the problem stream began by reviewing online public crash data to

examine contributing factors and trends of MVC in Knox County. Specific MVC data was

evaluated using data audits utilizing all focus county data from the Ohio Department of Public

Safety (ODPS) Crash Data for the years 2013-2015. Data was analyzed by year including:

number/rate MVC, number/rate MVC injury, number/rate MVC fatality, ages and gender of

drivers involved, probable cause of crash, seat belt use reported, driver distraction reported,

alcohol impairment of driver. Statewide ODPS statistics was also be incorporated for

comparison. Graphs were used to visualize trends and display data. In addition, Healthy People

2020 Objectives were compared with Focus County statistics to associate local data with national

benchmarks. This data was then corroborated by the County Health Commissioner to determine

the priority problems related to MVC needing to be addressed.

Policy stream. The policy stream was investigated by reviewing current public

laws/policies/initiatives related to MVC in Knox County. Current local regulations, enforcement

data and community programs were compared with best practices in peer communities and

evidence based literature in order to reveal opportunities for improvement.

20

Political stream. Stakeholders who can affect the political stream to set policy agendas were

identified through brainstorming, informant interviews, stakeholder analysis and validation by

the County Health Commissioner.

Once the problem, policy and political streams were defined and validated by the County

Health Commissioner, priority issues related to MVC in Knox County wee framed utilizing the

CDC Injury Framing Tool (National Center for Injury Prevention and Control, 2008). Special

consideration related to the five key change beliefs of discrepancy, appropriateness, efficacy,

principal support and valence were included in the issue framing (Armenakis, Bernerth, Pitts, &

Walker, 2007). Discrepancy refers to the need for change while appropriateness reflects that the

proposed change is the best for the community. Efficacy relates to the stakeholder belief that the

change can be effectively implemented. In addition, valiance will be provided through

discussing the benefits of change resulting in principal support being sought through

commitment from the stakeholder (Armenakis et al., 2007). After issue framing was completed,

phase two of the project began.

Dialogue with stakeholders. Initial communication with stakeholders took place in

stakeholder meetings to discuss the priority problem/policy issue in order facilitate unification of

the multiple streams and create a policy window. Stakeholder input related to the problem and

possible solutions to MVC in Focus County was requested. These informal meetings lasted

approximately 30 minutes and concluded with an invitation to attend a one hour public meeting

with other stakeholders at the Health Department to continue discussion and planning related the

issue of MVC in Knox County. Stakeholder input was assimilated with best practice related to

MVC prevention to develop and improved policy recommendation in collaboration with the

County Health Commissioner using the A3 Framework. The A3 Framework is a standard

21

quality improvement tool which assisted to review the background of the problem, current

condition, analysis, goals and countermeasures recommended.

Alliance formation. Attendance by stakeholders at the joint meeting to discuss a new policy

proposal indicated an initial opening of a policy window. The meeting included a sign in log,

introductions, and brief overview of the issue including suggestions for solutions from initial

stakeholder meetings using the A3 Framework. Countermeasures included a proposal to improve

policy/initiatives and future planning needs in Knox County based on evidence based practice

and stakeholder recommendations. A copy of the A3 document was given to all attendees.

Sustainability was measured through a verbal commitment of stakeholders to address the MVC

issue in Knox County as evidenced by identifying future planning steps at the conclusion of the

meeting. In addition, stakeholders were asked to complete the Organizational Change

Recipients’ Beliefs Scale (Armenakis, et al., 2007) to further validate the opening of a policy

window for change.

Planning the Study of the Intervention

The project interventions were studied for both process and impact. A summative impact

assessment related the implementation and examination of the role of a Nurse Policy

Entrepreneur in reducing MVC in a rural community was measured through outcome measures

related to alliance formation, issue awareness, salience and favorable attitudes voiced toward the

issue. Attendance of individuals at a community meeting to discuss MVC in Knox County

demonstrated affective change and represented initial alliance formation. In addition, evaluation

of the effort of the Nurse Policy Entrepreneur to influence awareness and importance of the issue

of MVC was evaluated through completion of a slightly modified Organizational Change

22

Recipient’s Beliefs Scale (2007) participant survey at the end of the community stakeholder

meeting. The role of Nurse Policy Entrepreneur was also be chronicled throughout the

intervention through reflective journaling.

Methods of Evaluation

Short term goals. (Framing)

 A priority list of issues related to MVC in Knox County was framed and validated

by the County Health Commissioner within 6 weeks of the project start.

 A list of community stakeholders who can affect MVC in Knox County was

identified through brainstorming, informant interviews, and stakeholder analysis

and validated by the County Health Commissioner within 6 weeks of the project

start.

Intermediate goals. (Dialogue)

 Dialogue and brainstorm with community stakeholders through both a personal

meeting and a joint meeting with other stakeholders discussed the newly framed

MVC issue which will included a draft proposal for a new policy

recommendation. Documentation was recorded through journal entries within 12

weeks of the project start. Stakeholders evaluated the effectiveness of the Nurse

Policy Entrepreneur in framing the issue of MVC in Knox County and influenced

the community stakeholders to develop and strengthen community policies at the

conclusion of the community meeting.

Long term goals. (Future benchmarks)

 Continued sustainability was measured through formation of an ongoing coalition

to address the MVC issue in Knox County as evidenced by identifying future

23

planning steps and adoption of a new policy to reduce MVC within the next six

months.

 By 2020, MVC fatalities in Knox County will be reported below the state and

national average and will meet the Healthy People 2020 goal to reduce motor

vehicle crash-related deaths per 100,000 population to 12.4 deaths per 100,000

population and reduce non-fatal motor vehicle related injuries to 694.3 nonfatal

injuries per 100,000 population.

The mixed methods action research measures chosen for studying the process and

outcomes of the role of a nurse policy entrepreneur to reduce MVC in a rural community,

aligned with the Multiple Streams Approach (see Figure 3). The problem, policy and political

stream was analyzed using quality improvement approaches and validated with triangulation

methods.

Strategy: Problem analysis

Problem
Influence of Policy Entrepreneur

Analyze Knox County MVC Outcomes: Priority problems

data for last 3 years and related to MVC in Knox
Stream compare with Ohio and
Healthy People 2020 data
County identified

Open Policy window:

change awareness,
Strategy: Policy analysis of salience and
Policy current policy/initiatives
related to MVC compared
Outcomes: Best Practice to attitudes/beliefs
Stream with top peer Ohio counties
& available literature
prevent MVC identified
formation of alliance
to address MVC in
Knox County

Political Strategy: Stakeholder

analysis and private briefings
Outcomes: Pivotal support
for improving MVC identied
Stream of framed issue

Figure 3: Multiple Streams Approach applying Nurse Policy Entrepreneurship to MVC in Knox County

Ohio.

Problem stream. The problem stream measures included triangulation of data audits,

trends, Healthy People 2020 target objectives, and validation by the community expert. The
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ODPS collects, analyzes, and publishes valid and reliable statistics related to MVC in order to

improve safety and promote research studies to improve road safety in Ohio. Crash data and

supporting information was submitted from designated reporting agencies official crash report

forms to the ODPS Electronic Crash Submission database (Ohio Department of Public Safety:

Crash Report System, 2016). Healthy People 2020, a publication of the Office of Disease

Prevention and Health Promotion is a nationally recognized valid and reliable source for national

public health objectives. Each objective is measurable with national baseline values provided

from valid and reliable data sources (Healthy People 2020, 2010). The Knox County Health

Commissioner served as the community expert consultant, providing validation of findings and

corroboration of completeness for the data analysis through a conversational meeting after initial

data was collected and analyzed.

Policy stream. The focus of the policy stream measures assessed the local current policies

and initiatives in order to establish baseline data compared with best practices. Information

related to the policy stream was attained using public community data and key informants to

establish a table of current policies and initiatives related to MVC in Knox County. In addition,

peer communities identified by the CDC’s Community Health Status Indicators (2015) as top

performers for MVC injury/fatality rates in Ohio were researched to solicit information about

their local policies/initiatives related to MVC. Best practices related to MVC were also

synthesized from a review of the literature. The Nurse Policy Entrepreneur utilized data mining

with current county policies/initiatives, peer county policies/initiatives and best practices found

in the literature to identify opportunities for improvement. Findings and inferences were

validated and verified for completeness through corroboration with the Knox County Health

Commissioner.
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Political Stream. In order to identify all organizations/people who influenced the political

stream related to MVC in Knox County, multiple measures were employed. Since Knox County

was a small cohesive rural community, the emphasis was on inclusion rather than exclusion and

relied on brainstorming and informal key informant interviews to compile a list of all potential

stakeholders. Stakeholder analysis is a widely accepted strategic tool used to frame key strategic

stakeholders. For the purpose of this study, potential stakeholders were framed using the online

BMGI Stakeholder Analysis Matrix framework (2016) to log and prioritize key political stream

stakeholders (see Appendix C). Stakeholder information was also reviewed for completeness and

validity by community expert input.

After the multiple streams were defined and validated, the issue of MVC in Knox County

were framed using the CDC Injury Framing Tool (see Appendix D). This tool was designed by

the CDC Injury Center through discussions with injury communication professionals and tested

through public focus groups to provide a framework to facilitate effective communication related

specifically to injuries (National Center for Injury Prevention, 2008).

Policy Window. In order to gauge the success of the Nurse Policy Entrepreneur in

influencing prevention policy in a rural community, the attitudes of key stakeholders were

measured using the Organizational Change Recipients’ Beliefs Scale (OCRBS) (Armenakis, et

al., 2007). The 24 item assessment tool assisted to gauge change recipient buy in, assessed areas

of deficiencies that may adversely affect the success of change, and served as the basis for

planning and executing actions to enhance buy in. The tool assessed five key change beliefs

including discrepancy, appropriateness, efficacy, principal support and valence and was

validated in 2007. This tool has been validated by four separate empirical studies with four

different samples to assess content validity, interitem correlations, exploratory factor analysis,
26

and confirmatory factor analysis. Content validity established Kappa to be .86 (p <5) with a

general acceptable value to equal or exceed .70 which indicates agreement with 26 items

defining the constructs (Armenakis et al., 2007). The interitem analysis resulted in elimination

of a personal valence item along removal of one item relate to discrepancy in the exploratory

factor analysis. The remaining 24 item tool has demonstrated both internal reliability and

criterion related validity (Armenakis et al., 2007). The tool was modified slightly by changing

words to adapt to a community instead of organizational setting including the words job to role,

pay to reward, and organization to community. A five point scale for all questions with 1 =

Strongly Disagree, 2 = Slightly Disagree, 3 = Neutral, 4 = Slightly Agree, and 5 = Strongly

Agree was applied to the questionnaire. Although the sample size was small, in order to measure

internal reliability of the modified tool, the confidence interval was measured along with the

mean and standard deviation scores.

Analysis
A detailed record of all data collection and analysis was retained by the nurse policy

entrepreneur throughout the project to ensure auditability. All documents were scanned or saved

electronically. Data for each section of the Multiple Stream Model were organized in a different

electronic file to assist in accurate and logical record keeping.

In addition, a reflective journal based on Kolb’s Experiential Learning Cycle (1984)

chronicle the action research intervention process. The journal entry began with the concrete

experience of what was done, then proceeded to reflective observation by the Nurse Policy

Entrepreneur. This led to abstract conceptualization including recommendations of any

modification of intervention with active experimentation resulting in applying the modification

in the future (Kolb, 1984).

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Participant feedback was sought after the public meeting through a confidential modified

Organizational Change Recipients Beliefs Scale to gauge the influence of the nurse policy

entrepreneur regarding participant affective change and overall success in opening a policy

window regarding MVC in Knox County (see Appendix E). Results were analyzed by the nurse

entrepreneur and validated with community expert in correlation to both the aim and interim

outcomes stated in the project. Due to the limited time frame of the project, long term objectives

were not evaluated at this time.

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Chapter 4

Results

This project implemented and examined the role of a Nurse Policy Entrepreneur using a

Multiple Streams Approach to influence policy to reduce Motor Vehicle Crashes in a rural

community. The project was completed over a 4 month timeframe resulting in approval of a

local policy change (see Figure 4).

Figure 4. Project timeline.

Framing the Issue

The first two months of the project entailed reviewing public data to determine to the

most significant issue related to MVC which could be addressed with a local level policy

decision. In order to properly frame the issue, a systematic analysis of the policy, problem and

political streams was required.

Problem stream.

The project began with a review of online public county crash data from Ohio

Department of Public Safety (ODPS) from 2013-2015. Statistics reviewed included: general,

crash, injury and death, driver, vehicle, alcohol, peer county, and city/village data. Tables with
29

little or no valuable information or redundant information were excluded for this study including

crashes involving: hit skip, school buses, work zones, deer, financial responsibility by gender,

proof of insurance, special function units, truck drivers, heavy truck crashes, bicycles, and trains.

General statistics were recorded by the Nurse Policy Entrepreneur using an Excel

spreadsheet with the following numerical information for each of three years: Crash incidents,

fatal crash incidents, injury crash incidents, fatalities, injuries, alcohol impaired drivers, alcohol

related fatal crashes, alcohol related injuries, alcohol related deaths, crashes by gender, daylight

crashes, and county census. While overall crashes in the county were trending down, fatalities

had increased. Alcohol related crashes accounted for 22.24% of the all crashes during the three

year time frame. Men exceeded women in the number of crashes and impaired crashes. Daytime

crashes accounted for 58% of all crashes. In order to accurately compare local and state crash

statistics, incident rates during the 3 year period/population X 100,000 were calculated for

number of crash incidents, injuries, fatalities, fatal crash incidents, alcohol impaired drivers and

alcohol related fatal crashes (see Table 1 for results). Upon comparison, the county had a lower

incident rate in all areas except crash injuries when compared to the state data which questioned

initial assumptions of Knox County issues regarding alcohol related crashes and fatality rates

based on the County Health Ranking Reports.

30

Table 1

Focus County and State General Crash Data 2013-2015

Note. Data adapted from ODPS Crash Data. Incident rate calculated using 2010 Census Data.

Continuing analysis reviewed county crash statistics including month, days of week,

manner of collision, weather conditions, probable causes, holiday periods, location of crash,

location of first harmful event, and road conditions. No patterns were noted across months, days

of the weeks or with holidays. Most crashes occurred in daylight with dry, clear conditions. The

majority of collisions did not involve two vehicles and did not take place at an intersection. The

top three driving errors which ended in fatalities included, improper lane change (35.7%), failure

to yield (21.4%), and unsafe speed (14.2%).

Death and Injury Tables from ODPS for the County for 2013-15 were then examined.

Age distribution among persons injured and killed were reviewed. In addition, restraint use of

occupant by age was also explored. Results found MVC deaths were equally distributed across
31

age groups, however the 16-20 age group were the largest group affected by injury accounting

for 20% of all injury crashes (see Figure 5).

Figure 5. Percentage of Injury Crashes by Age adapted from ODPS Crash Data.

Restraints were only secured in 28% of all fatality crashes, but 85% of all occupants who

sustained injuries only were belted. Also, despite primary restraint law for early drivers, 15% of

occupants in the 16-20 age group did not wear seat belts. Another concern exposed included

MVC deaths among older adults which were found to be trending upwards over the three year

timeframe.

ODPS Driver Statistic Tables were also considered and analyzed by the Nurse Policy

Entrepreneur for driver error by age, conditions of drivers involved in crashes and reported

driver distraction. During the same three year timeframe, the condition of the driver was

described as “normal” 95.04%, driving under the influence was noted only 2.89% and no
32

distractions were reported 94.51% of the time. The largest group of drivers found in error were

age 16-20 year olds, accounting for 10.57%.

The Nurse Policy Entrepreneur then reviewed ODPS data regarding types of units

(vehicles); deaths and injuries by position in unit; crashes, deaths and injuries involving

motorcycles; helmet use and motorcyclists killed and injured, persons in error in motorcycle

crashes. Data excluded due to limited results involved pedestrians, traffic controls of unit in

error, first harmful event of unit, and most harmful event. Data analyzed found passenger

vehicles were involved 91.74% of time. Drivers of vehicles accounted for 73.33% of all deaths

and 75.33% of all incapacitating injuries. Front seat passengers accounted for 20% of all deaths

and 17.22% of all incapacitating injuries.

While motorcycles were only involved 1.14%, they accounted for 26.27% of all fatalities.

Although helmets were worn in 54% of all motorcycle crashes, helmets were worn only 25 % in

fatal motorcycle crashes. Motorcyclists were found to be in error 60.93% of the time.

Alcohol statistics from the ODPS data were reviewed for alcohol related crashes

regarding time of day, severity and involvement of youthful drivers (ages 15-24). While the

majority of MVC occurred during daylight hours, more alcohol related crashes occurred after

dusk, with the majority (51.49%) of alcohol related crashes occurring between 8pm and 4am.

Over the 2013-2015 year period, 26. 7% of all crash fatalities were alcohol related and impaired

driver in fatal crashes accounted for 21.05% of all fatal crashes. However, 2013 reported only

three fatalities which all were alcohol related, thus resulting an inflated statistical average. The

percentage of alcohol impaired drivers accounted for 4.77% of all crashes. Impaired related

crashes involving youth (15-24 year old) were reported in 3.35% of teen crashes. Overall, both

the number of alcohol related fatality and injury crashes for the three year period revealed a
33

downward trend which did not support the initial assumption that alcohol related crashes were

the primary issue in Knox County.

Once all the ODPS data was evaluated by the Nurse Policy Entrepreneur, the four leading

issues related to MVC in the county were identified including: teen driving injury crash rates,

increased mature driver fatalities, seat belt compliance and motorcycle safety. These four issues

were also compared with State and Healthy People Baseline data (see Table 2).

Table 2

Focus County Issues compared to State & Healthy People 2020 Target Goals

Issue Focus County Data State Data Healthy People 2020

Targets
Seat Belt Use Reported 88% (injury crashes) 87% (injury crashes) 92%
28% (fatal crashes) 40% (fatal crashes)
Motorcycle Helmet Use 54% 41% 74%
Reported
Teen Injury Crashes (2015) 1873.64/100,000 1195.51/100,000 694.3/100,000(All ages)
Mature Driver Fatalities- 16.04/100,000 10.06/100,000 12.4/100,000 (All ages)
55 and older (2015)
Note. Data adapted from ODPS Crash Reports 2013-2014 and 2010 Census data.

Overall findings were then validated with several key informants including the Health

Commissioner who served as the community expert for this project, a county deputy sheriff, a

state trooper, and the county chair for the Safe Communities Coalition. All informants verified

the findings and approved the priority areas identified. Possible countermeasures were discussed.

Law enforcement officers voiced the need for primary laws for seat belts, motorcycle helmets

and electronic device use. A need to address mature driver safety was also expressed but concern

was raised on how to not diminish independence or cause discrimination. Key informants also

conveyed a need for more stringent consequences for teen driving violations. In order to further

validate and mitigate these issues, peer county data was reviewed in order to compare best

practices and possible policy solutions based on similar counties.

34

The Centers for Disease Control and Prevention provided a list of peer counties for

comparing data based on similar population size, population growth, population density,

population mobility, percentage of children and elderly, sex ratio, percentage of foreign born,

percentage of high school graduates, single parent households, median home value, housing

stress, percentage of owner-occupied housing units, median household income, receipt of

government income, household income, overall poverty, elderly poverty, and unemployment

(Centers for Disease Control and Prevention, 2016). Since the focus of this study involved

policy which can vary between states, only peer counties identified in the focus state were used.

In order to account for population variance, all data was converted to an incident rate based on a

population of 100,000 by the Nurse Policy Entrepreneur. A total of 13 counties were identified,

analyzed and compared for crashes, injuries and fatalities; alcohol related crashes, injuries &

deaths; motorcycle crashes, injuries & fatalities; motorcycle alcohol crashes, injuries and

fatalities. In addition mature driver fatalities, and teen driver injury data for all peer counties

were specifically compared.

Most peer counties also struggled with similar MVC issues as evidenced in the data.

However, Huron County exceeded the outcomes of Knox County in incidence of crashes,

injuries, alcohol related injury, motorcycle crashes, motorcycle injuries, and motorcycle deaths.

Upon further investigation the peer county also had a lower injury crash rate for teens. Although

the incident rate for mature drives exceeded Knox County, fatalities were trending down as

opposed to trending higher in Knox County. Unfortunately, even though several attempts were

made by the Nurse Policy Entrepreneur to attain direct information from Huron County through

email and phone messages, information was only able to be obtained through online searches.

No programs related to motorcycle or mature drivers were listed on Huron County public
35

websites, however all teen drivers with moving violation offenders and a parent were mandated

to attend a Carteens Program (Huron County Common Pleas Court, Probate and Juvenile

Divisions, 2016). Carteens is a two to three hour peer led traffic safety program mandated by

local juvenile courts for juvenile traffic offenders which is sponsored by local 4H partners in

conjunction with the State Highway Patrol (Ohio 4H Youth Development, 2016).

After analysis of peer data, it was apparent that of the four problem areas identified, only

the issue related to teen drivers could be realistically addressed through a local level policy. Seat

belt use and motorcycle safety would need to be addressed through continued education and

primary state laws. In addition, mature driver fatalities would best be addressed through local

programs to target mature drivers. Upon validation with the community expert, the project began

to focus primarily on improving local policy to impact teen driver safety. In order to create a

policy window to address this problem, the current local policy stream for teen driving violations

was then analyzed by the Nurse Policy Entrepreneur.

Policy stream.

The State of Ohio has a Graduated Driver’s License (GDL) in place for teen drivers

which includes all drivers under 18 must complete a driver education class at a licensed driver

training school with 24 hours of classroom or online instruction and 8 hours of driving time with

an instructor. In addition, the teen driver must complete 50 hours of driving, with at least 10

hours of night driving and hold the temporary learners permit for at least six months (Ohio

Bureau of Motor Vehicles [OBMV], 2016).

During the first year after a driver’s license is obtained, the teen driver may not drive

from midnight to 6am without a parent or driving to work, school sponsored event or religious

event with documentation. Only one non-family member is permitted as a passenger without a
36

parent or guardian. The driver and passengers must all wear seat belts and the driver may not

use any mobile devices. After the first year, restrictions are reduced and the driver is permitted to

take passengers with non-driving hours are changed to 1am-5am (OBMV, 2016).

Local enforcement of GDL and overall traffic violations are left to county judicial

discretion. While the literature supports these policies, local law enforcement voiced frustration

in regard to application of GDL laws, since age and length of driving time are not easily

distinguished without a for cause traffic stop. If a teen is convicted of a traffic violation within

the first six months of having a license, state law allows for the local judge to require a parent or

guardian to accompany the driver for six months or until the driver reaches age 17. The local

judge is also able suspend a teen drivers license as a result of multiple traffic convictions. For

alcohol-related convictions, however, the state mandates the teen driver’s license will be

suspended for at least six months according to Ohio Revised Code 4511.19 (OBMV, 2016).

Even though penalties were permitted to be more stringent, the current local policy in

Knox County related to first time teen moving violations did not include any fines or loss of

driving privileges. Teen violators were ordered to attend a defensive driving program at a cost of

$205. The course focused on collision avoidance techniques, loss of control recovery skills, bad

weather maneuvers through emergency lane change, wet braking, and skid car drills at a local

racetrack (Knox County Ohio, 2016).

Upon further evaluation of all thirteen peer counties related to teen injury crashes by the

Nurse Policy Entrepreneur, all but three peer counties had Carteens in place. CARTEENS, which

is an abbreviation for Caution and Responsibility/Teenagers which began in Ohio in 1987. The

program is led by teen leaders with oversight from 4H partners in conjunction with the State

Highway Patrol. The goals of the program are to reduce the number of repeat juvenile traffic
37

offenders, decrease the number of teen traffic offenders, and increase teen awareness of

traffic/vehicular safety. Carteens program topics include excessive speed, driving under the

influence, seat belt safety use, consequences of unsafe decisions, dealing with peer pressure,

understanding traffic laws, and recognizing and reacting to traffic signs and signals. Of those

with Carteens, all but one county had a lower percentage of teen MVC injury crashes than

counties who did not participate in Carteens (see Figure 6).

Figure 6. Percentage of Teen Injury Crashes in Peer Counties, adapted from ODPS data 2012-2015.

Although several academic papers have been written about Carteens, limited data on the

effectiveness of the program was available in peer reviewed academic journals. However,

several counties have received recognition from the National Safety Council Youth Division

regarding their program impacts (Ohio 4H Youth Development, 2016).

38

Although several academic papers have been written about Carteens, limited data on the

effectiveness of the program was available in peer reviewed academic journals. However,

several counties have received recognition from the National Safety Council Youth Division

regarding their program impacts (Ohio 4H Youth Development, 2016).

The local Ohio State University (OSU) Extension 4H director confirmed to the Nurse

Policy Entrepreneur that the county had an active Carteen program for about 10 years, then the

juvenile court began mandating a different course which focused on defensive driving about 15

years ago. The local OSU Extension director stated the program could easily be reinstated and

would have the support from the 4H community and the State Troopers. Even though the

juvenile judge has been replaced, the reinstatement of Carteens had not been proposed.

Political Stream.

Identification of stakeholders to influence the adoption of a policy to reinstate Carteens in

the county by the Nurse Policy Entrepreneur involved both input from key informants and

stakeholder analysis with validation from the community expert. Key stakeholders identified

included OSU extension which oversees 4H and State Highway Patrol, since both would be

involved with the actual administration of the program. Other stakeholders included members of

the Safe Community Coalition which included health department members and local law

enforcement. Parents and teen drivers were also identified as impacted by this decision, but were

not included at this juncture due to a lack of influence on the decision process.

Support from identified stakeholders was needed by the Nurse Policy Entrepreneur in

order to build momentum and credibility for the issue and the proposed solution, even though the

ultimate decision would be made by the juvenile judge. Although the current juvenile judge had

been on the bench for 1.5 years, no known precedent of her views on teen motor vehicle crashes
39

was identified. Upon completion of analyzing the multiple streams, a framed message was

formed (see Appendix F). This message was shared with the community expert and the

chairperson of the Safe Communities Coalition with positive verbal feedback received.

Dialogue with Stakeholders

The chairperson of the Safe Communities Coalition invited the Nurse Policy

Entrepreneur to present the framed message related to Carteens as potential solution to the teen

injury crash issue at the next Fatality Review Board meeting which served as the initial meeting

to dialogue with stakeholders in lieu of individual meetings. The purpose of this discussion was

to introduce the issue, seek input and solicit interest to attend a follow up meeting. At this

meeting, the nurse policy entrepreneur met with 12 representatives from law enforcement, EMS,

Health Department, and other community leaders. After being given an opportunity to share

framed message, a call for volunteers to join the coalition was proposed. Eight potential

members signed the coalition interest sheet and provided contact information. Many in

attendance had already been identified as stakeholders but had not been approached individually.

Although this meeting served as the initial contact meeting, an invitation to meet in person prior

to coalition meeting was extended verbally and in a follow up email, however no requests were

received for a private meeting.

Alliance Formation

In preparation for the alliance meeting, an A3 Framework which is a public problem

solving and continuous improvement tool, was used as a template to frame the discussion

through a simplified flow of information (see Appendix G). Data used to discuss background

and current conditions included teen injury crash rate and comparison to state rate presented in a

pie graph comparison. Healthy People 2020 Objective IVP14: Reduce nonfatal MVC related
40

injuries was selected with a goal to see a 10% improvement in teen crash injuries (Healthy

People 2020, 2010). Data from peer counties and Carteen participation was represented by a bar

graph. The current teen traffic violation policy and a description of Carteens was also included.

A proposed recommended timeline was also included along with an area for follow up

comments. The A3 data was then validated with the Key Stakeholder from OSU extension and

the community expert.

The two key stakeholders from OSU Extension and the State Highway Patrol, along with

the community expert, were consulted for possible dates and times for the alliance meeting when

all three were able to attend. An online poll was then sent to other stakeholders who expressed

interest and a date and time was selected based on the five responses received.

A meeting reminder was sent to all who expressed interest in attending. Sign in sheets,

A3 and informed consent available on a table as participants arrived. While only five people

were expected at the meeting based on survey results and invitation responses, eight attended the

coalition meeting and another participated via a conference call due to a medical situation.

Several in attendance were sent as representatives by those invited and were not fully aware of

purpose of the meeting which may have influenced the Organization Change Recipients Belief

Scale (ORCBS) survey results. Introductions were made and informed consents for participants

were obtained. The A3 information was presented through individual handout and a PowerPoint

presentation with frank and open discussion. Near the end of the discussion, a participant

proposed that the policy should focus on pre-license driver’s education instead of after a

violation occurred in order to provide primary prevention of the problem. Although the idea was

briefly discussed, it was agreed by those in attendance that driver’s education credentialing was

not a local policy that could be changed through this project. However, since the Carteens
41

evaluation form did gather driver’s education information, a list of driving schools could be

tracked to determine potential weak areas for future study. The Nurse Policy Entrepreneur also

reiterated that this proposal was only one part of the solution to decrease teen MVC’s locally and

only a beginning intervention into the long term resolutions of MVCs in the county. After

finishing the discussion, all participants verbally supported the program and the proposed

timeline. While only the officer from Ohio State Highway Patrol volunteered to accompany the

nurse policy entrepreneur to discuss proposal with judge, other participants requested to be

informed as the policy progressed. At the conclusion of the meeting the OCRBS Tool was

administered and anonymously placed in manila envelope.

The OCRBS data was then recorded as raw data in an Excel spreadsheet according to an

anonymous participant number per survey. Each question was analyzed for mean, standard

deviation and a confidence level of 95%. All questions were then organized in another Excel

spreadsheet according to the five beliefs measured in the tool: discrepancy, appropriateness,

efficacy, principle support and valence. As overall survey tool was reviewed, one question

regarding “principle support” related to supervisor support was unintentionally omitted from

tool. The question was not listed in final methodology section, IRB proposal or on the tool for

this project. Although the question was similar to another question on the tool, internal validity

for the tool related to principle support was not verified. However, overall mean, standard

deviation and confidence level of all remaining principle support questions related to the

proposed initiative were similar and reported above neutral, indicating a positive result. Mean,

standard deviation, and confidence interval (95%) with range for all items were logged for

comparison (see Appendix H).

42

Results from the OCRBS tool which were rated above neutral were considered positive

outcomes demonstrating the effectiveness of the role of the Nurse Policy Entrepreneur to

promote the policy change. Ratings at or below neutral on the OCRBS tool were considered

negative outcomes demonstrating no impact by the Nurse Policy Entrepreneur. Based on the data

collected on the tool, the coalition agreed that teen injury MVC’s in Knox County was a problem

(discrepancy) and Carteens was the appropriate solution (appropriateness). There also appeared

to be principle support for the project. More neutral results were found for both efficacy which

measured their own power to change the problem and valence which measured how the policy

would impact the stakeholders on a personal level. However, this was not unexpected since the

meeting was open to a number of people who didn’t have significant input or impact directly on

the problem in order to facilitate openness and community backing. With overall support from

the stake holders as evidenced through verbal and survey results, the next step in the progression

of the project was to proceed with the policy proposal to the judge.

Policy Window

An actual policy proposal was then developed by the Nurse Policy Entrepreneur and

emailed to all coalition members. The proposed policy included all first time juvenile traffic

offenders and a parent/guardian would be mandated to attend a Carteens program. However,

certain circumstances could result in juvenile traffic offenders alternatively being ordered to

attend the current defensive driving program. In addition, teen drivers would be given a choice

between a loss of driving privileges for thirty days, or a forty-five day suspension with privileges

to drive to and from school and to and from work, taking the most direct route and with no

passengers. Usually, first time juvenile traffic offenders would not be ordered to pay any fines or
43

costs, however every case would assessed a $25.00 processing fee. Unanimous support for the

proposed policy from the coalition meeting stakeholders was received via email.

In preparation for the meeting with the judge, the Nurse Policy Entrepreneur met with the

State Program Director for Carteens to review actual materials used during a program. A concern

noted by the Nurse Policy Entrepreneur about the intervention was the general lack of published

research regarding the effectiveness of Carteens. While each program collects and analyzes

extensive data from participants, few rigorous studies have been published (J. Villard-Overocker,

personal communication, September 6, 2016). During the discussion, the Nurse Policy

Entrepreneur was able to secure a $600 grant to offset startup costs for the county if Carteens

was reinstated during the current fiscal year. In addition, the Nurse Policy Entrepreneur prepared

a folder with a modified printed PowerPoint presentation based upon the A3 and policy proposal,

sample Carteens participant registration and evaluation forms, and a business card as a resource

for the judge.

A meeting was requested and granted by the judge for the Nurse Policy Entrepreneur and

the State Highway Patrolman. However, the patrolman was unable to attend the meeting at the

last minute, so the Nurse Policy Entrepreneur shared the information with the judge privately.

The judge’s initial response was cautiously positive and committed to seeking the council of a

fellow judge from a peer county with an active Carteens program. She also stated she would like

to visit a program in action before giving decision. A list of Carteen programs in area was

provided and future contact to continue discussion was provided. All material was left as a

resource. In addition, the State Highway Patrolman was able to follow up in person with the

judge later in the day to discuss the policy.

44

Two weeks later, the judge requested a follow-up meeting with the Nurse Policy

Entrepreneur which also included the local OSU Extension director. The judge stated that she

had reviewed the program and the voiced her support to reinstate Carteens. Plans to roll out the

program were discussed and agreed upon. Program details will be worked out by OSU Extension

in collaboration with the State Highway Patrol and the Juvenile Courts. All stakeholders

involved in the coalition meeting were informed of the policy change which will begin at the

start of the New Year. Ongoing evaluation of the program will be provided to the judge by the

Carteens Program on a monthly basis and the rate of teen injury MVC will be monitored over the

next three years to validate the impact of the local program.

45

Chapter 5
Discussion and Conclusions
Summary

This project successfully implemented the role of a Nurse Policy Entrepreneur to

influence a local policy change focused on reducing teen injury crashes in a rural community

using Kingdon’s Multiple Streams Approach (2010). Applying the Kingdon model, the problem,

policy and political streams were studied and included the development of a list of priority issues

based on local data, identification of stakeholders, and deliberate discussions about a needed

policy change. Attainment of these objectives led to development and approval of a stronger

policy related to teen driver violations through the opening of a policy window. In addition, an

ongoing coalition was formed by the local OSU Extension to oversee a new program to improve

teen driving safety for all first time offenders and will continue to be evaluated for effectiveness.

A particular strength of the project was the careful application of the Multiple Streams

Framework which facilitated a careful, focused analysis of the issues related to MVC. Through

thoughtful evaluation of all three streams, the development of the framed issue facilitated the

opening of the policy window. Without the application of this approach, premature conclusions

based upon superficial findings could have led to an unneeded policy change.

Relation to Other Evidence

While the results of this project concur with process findings related to use of the

Multiple Streams Framework of previous studies, a main difference relates to the role of an

independent Nurse Policy Entrepreneur. The Multiple Streams Approach has been used in

retrospect in several previous health policy studies to explain the policy process, however no

single policy entrepreneur served as the facilitator (Mamudu et al., 2014; Greathouse, Hahn,

Okoli, Warnick, & Riker, 2005).

46

Moreover, although few professional nurse leaders have applied of the Multiple Streams

Approach to describe healthcare issues, the role of a Nurse Policy Entrepreneur appears

undeveloped in the literature. One retrospective historical analysis from secondary data explored

the role of public health professionals as policy entrepreneurs to address the issue of childhood

obesity, however a political entity was credited with being the primary policy entrepreneur not a

health professional (Craig, et al., 2010). Walhart used the Multiple Streams Approach to evaluate

the issue of human papillomavirus-related intraepithelial neoplasia but did not seek to merge the

streams to create an actual policy window (2013). Another study applied the Multiple Streams

Framework to chronicle policy related to hospital associated infections but the nurses were not

an active participants (Odom-Forren & Hahn, 2006). Internationally, the Multiple Streams

Approach has also been used to retrospectively chronicle policy making in Ghana from 2000-

2003 (Owuraku, Church, Conteh, & Heinmiller, 2015). While it is helpful to use the Multiple

Streams Approach in understanding the comprehensive issues of a problem, active participation

is needed to expedite change.

Limitations

Although this project was completed in a small rural community in Ohio, the principles

of the Multiple Stream Approach can be applied to any issue at any organizational, local, state,

national or international level. One factor that influenced the success of this project was already

established strong relationships within the county which enabled interdisciplinary collaboration.

Conversely, lack of partnerships among peer counties were also a limitation to the project which

could have added value to the project. Although pre-existing associations are not essential to

successful outcomes, good working relationships mitigate resistance to change when applying

the Multiple Streams Approach and expedite collaboration.

47

Interpretation

A policy entrepreneur is able to effectively define problems, works with others, leads by

example, and is able to discern community perceptions in order to influence policy windows

(Mintrom & Norman, 2009). The successful adoption of the new policy was the direct result of

the deliberate application of the Multiple Streams Framework by the Nurse Policy Entrepreneur

to open the policy window. Even though there was an ambiguous awareness of various issues

related to MVC’s in the county prior to this project, no one in the community was facilitating

discussions and follow through until the Nurse Policy Entrepreneur began to explore the

problem, policy and political stream. Once the data was analyzed and the issue framed, the Nurse

Policy Entrepreneur was able serve as a catalyst to facilitate change in the local policy arena.

The novel role of a nurse policy entrepreneur in this project led to the defining and

reframing of the MVC issues in a rural community. This role was facilitated by prior community

involvement by the Nurse Policy Entrepreneur on numerous other community committees and

projects, expanding established community relationships to improve the issue of MVC's in the

community. In addition, as a well-respected member of the community, the endorsement of the

overall project by the County Health Commissioner as the community expert provided credibility

to the role of the Nurse Policy Entrepreneur. Building on preexisting strong civic engagement,

policy and program alternatives were discussed, leading to an approved local policy change

which will positively affect teen health in the community.

Although the county already had established collaborative efforts on many issues, the

impact of this project has been already enhanced in many ways. A new ongoing coalition

between the OSU Extension, the State Highway Patrol and the Juvenile Court System has been

formed to oversee the Carteen Program. In addition, the Carteen program itself will enable the
48

development of leadership skills through training teen leaders to become Peer Carteen

Instructors. An unexpected partnership also developed as a result of this project through

collaboration with a neighboring county who shares a Highway Patrol Post. In order to share

resources and conserve time for the State Highway Patrol, each county may alternate months

offering the program. Teens would be able to fulfill their obligation to attend the Carteens

program at either location but must still be accompanied by a parent. While the grant from the

State Carteens program will fund startup costs, actual ongoing programing costs will be paid

through attendance fees by the participants.

An unforeseen finding of the project related to results of the OCRBS tool. While overall

support for the project was voiced, and discrepancy of the issue, appropriateness of the

intervention along with principle support in the OCRBS results, efficacy and valence were found

to be neutral. In the OCRBS tool, valence questions evaluated how the change of policy would

impact the stakeholder on a personal level, but since this was a community effort the questions

did not reflect the goals of the project. In the future, the tool should be further adapted to reflect

benefits more towards the community rather than personal gain. Efficacy questions were related

to the stakeholder’s own power to change the problem. While this measurement may have

yielded more positive results with tighter control on participants by only inviting key decision

makers to be part of the initial coalition, careful balance must be preserved in rural communities

to maximize active community support. Ideally, the coalition would be empowered and propose

the new policy to the decision maker. However, since the participants did not report efficacy to

change this issue, the Nurse Policy Entrepreneur needed to continue to advocate for the

community at the stakeholders request. While the tool provided basic overall validation on the

issue and proposed solution, verbal feedback from the alliance was more beneficial to the Nurse
49

Policy Entrepreneur. Future use of the OCRBS tool will require further adaptation for application

to a community setting.

Conclusions

The application of the Multiple Streams Approach is a valuable tool for all nurses

regardless of setting and needs to continue to be explored along with the further development of

the role of a Nurse Policy Entrepreneur. The Multiple Streams Framework can successfully

guide nurses to change policy in healthcare at any level of policy change and in any setting. The

Multiple Streams Framework is easy to use and understand, however nurses need to first be

exposed to the process. Schools of nursing and nursing organizations need to further disseminate

the information on the Multiple Stream Approach and the role of the Nurse Policy Entrepreneur

in order to enculturate nurses to become political partners to influence all levels of healthcare as

part of their professional responsibility. Suggested next steps include further implementation of

the role of the Nurse Policy Entrepreneur and application of the Multiple Streams Approach by

nurses in a variety of healthcare settings.

50

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Children, Family, Drugs, and Alcoholism. C. Everett Koop Papers. Washington, DC.

Wagenaar, A. C., Livingston, M. D., & Staras, S. S. (2015). Effects of a 2009 Illinois alcohol tax

increase on fatal motor vehicle crashes. American Journal of Public Health, 105(9),

1880-1885. http://dx.doi.org/10.2015/AJPH.2014.302428

Walhart, T. (2013). The application of Kingdon’s Multiple Streams Theory for human

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69(11), 2413-2422. http://dx.doi.org/10.1111

Yingling, F., Stombaugh, H., Jeffrey, J., LaPorte, F., & Oswanski, M. (2011). Pediatricians’

knowledge, perceptions, and behaviors regarding car booster seats. Journal of

Community Health, 36(1), 166-173. http://dx.doi.org/10.1007/s10900-010-9294-x

Zadikoff, E. H., Whyte, S. A., DeSantiago-Caredenas, L., & Gupta, R. S. (2014). The

development and implementation of the Chicago Public Schools Emergency EpiPen

Policy. Journal of School Health, 84(5), 342-347. http://dx.doi.org/10.1111/josh.12147

58

Appendix A

Informed Consent

Title of the Research Study: Influencing Policy to Reduce Motor Vehicle Crashes in a Rural
Community: A Multiple Streams Approach
Principal Investigator: Judy Gregg, MS, RN, Carlow University (419)631-0614
Co-Investigator: Kathleen Tennant, PhD, RN, Carlow University, (304)281-3143
Source of Support: Focus County Health Department
Why is this research being done?
Stronger policies and enforcement of regulations associated with the contributing factors in motor vehicle
crashes are needed to reduce occurrences, injuries and death. There is evidence that the role of a policy
entrepreneur can impact the policy process in areas such as motor vehicle crashes. The purpose of this
project is to implement and examine the role of a nurse policy entrepreneur in reducing MVC in a rural
community. Applying the Multiple Streams Approach, the nurse entrepreneur will gather data to explore
specific contributing factors and issues related to motor vehicle crashes in Focus County; review current
policies and meet with stakeholders to brainstorm potential solutions in order to create a window for
policy change to reduce MVC fatalities in this small community. A long range goal is for MVC fatality
rates in Focus County to be reported at or below the state and national rates.
Who is being asked to take part in this research?
You have been asked to participate in this study because you have been identified as a key stakeholder in
Focus County Ohio. The following information is provided in order to help you to make an informed
decision whether or not to participate. If you have any questions, please do not hesitate to ask.
What procedures will be performed for research purposes?
Participation in this study will require approximately 90 minutes of your time. You will be asked to
participate in a 30 minute one to one discussion with the nurse policy entrepreneur and a one hour group
brainstorming session with other key stakeholders to discuss motor vehicle accidents in Focus County
Ohio. At the end of the group session you will be asked to complete an attitudinal questionnaire about
your experience in this study.
What are the possible risks, side effects, and discomforts of this research study?
There are minimal risks or discomforts associated with this research.
What are possible benefits from taking part in this study?
While there are likely no direct benefits from participating in this study, potential improvement in the
community response related to motor vehicle crashes in Focus County may gained.
Who will know about my participation in this research study?
59

All information obtained during this study that could identify you will be kept strictly confidential. The
information obtained in this study may be published in scientific journals or presented at scientific
meetings; however, the data will not contain any identifying information.

Is my participation in this research study voluntary?

Your participation in this research is completely voluntary. You are free to decide not to participate in this
study or to withdraw at any time without adversely affecting your relationship with Knox County Health
Department, the nurse policy entrepreneur/researcher or Carlow University.
Voluntary Consent
The above information has been explained to me and all of my current questions have been answered. I
understand that I am encouraged to ask questions about any aspect of this research study during the
course of study, and that such future questions will be answered by a qualified individual or by the
investigator(s) at the telephone number(s) given.
By signing this form, I agree to participate in this research study. A copy of this consent form will be
given to me.
_____________________ __________________________ ________________
Participant’s Signature Printed Name of Participant Date

Certification of Informed Consent

I certify that I have explained the nature and purpose of this research study to the above-named
individual, and I have discussed the potential benefits and possible risks of study participation. Any
question the individual has about this study have been answered, and we will always be available to
address future questions as they arise.

___________________________________ ___________________
Printed Name of Person Obtaining Consent Role in Research Study

____________________________________ ______________
Signature of Person Obtaining Consent Date
60

Appendix B
Advocacy Evaluation Planning Worksheet

From Advocacy Evaluation Planning Worksheet. Coffman, J. (2009). A user’s guide to advocacy evaluation
planning. Harvard Family Research Project. Retrieved from www.hfrp.org/evaluation/publications-
resources/a-user-s-guide-to-advocacy-evaluationplanning.
61

Appendix C
Letter of Support to Use Advocacy Evaluation Planning Worksheet
Wed 3/9/2016 7:45 PM
.
Dear Judy:

Thank you for your request. You can consider this email as permission to publish the worksheet with the Advocacy
Evaluation Planning Worksheet from A User’s Guide to Advocacy Evaluation Planning by Julia Coffman as long as
you also provide a proper citation to credit the original source, and if possible, link to Harvard Family Research
Project’s home page (http://www.hfrp.org). The citation should be:

Coffman, J. (2009). A User's Guide to Advocacy Evaluation Planning. Retrieved from

http://www.hfrp.org/evaluation/publications-resources/a-user-s-guide-to-advocacy-evaluation-planning

A User's Guide to Advocacy Evaluation Planning was developed for advocates, evaluators, and funders who want
guidance on how to evaluate advocacy and policy change

For any further usage of the material, you must contact us again for permission. Please let us know if you have
questions.

Best regards,
Laura Alves
Harvard Family Research Project
Harvard Graduate School of Education
50 Church St., 4th Floor
Cambridge, MA 02138
www.hfrp.org
62

Appendix D

Stakeholder Analysis

Impact of
Project on Current/Desired Support
Power/
Stakeholder Strongly Strongly
Key Role in Influence Reasons for Resistance
(H, M, L) Opposed Supportive
Stakeholder Organization Category Opposed Neutral Supportive or Support

10

11

12

13

14

15

16

17

18

19

20

© BMGI. You may freely modify, distribute and/or reproduce this only if BMGI's logo is not altered or removed.

From BGMI. (2016). Stakeholder Analysis. Retrieved from http://bmgi,org/tools-templates/stakeholder-analysis.

Permission granted.
63

Appendix E

Injury Framing Tool

Injury Framing Tool

This tool is designed to help you create effective messages that incorporate the message
development strategies in the Framing Guide and link your injury issue to the overarching injury
frame:
We want a society where people can live to their full potential.
Injury Issue: __________________________________________________________________
Intended Audience: _______________________________________________________
Intended Outcome (Communication Goal): _____________________________________

What do you want to say about your injury issue?

• How can you help your audience understand the size and scope of your injury issue?
• How can your translate your statistics and data so they are interesting and meaningful to your
audience? What social math examples can you use? (Refer to the social math section of the
Framing Guide for social math tips.)
• What can you say that will describe your specific programs or activities as a way to address the
injury issue (as a solution to the problem)? What is the science or evidence base for the
programs/activities suggested?
Write your statements and social math facts below.

What action do you want your audience to take?

• What actions do you suggest that your audience take relating to your specific program or
activity?
• If focused on individual behavior change, what do you want your audience to know they can do
to protect themselves?
• What is your call to action?
Write your action-oriented statements below.
64

Pulling It All Together

• Now that you’ve identified the message components above, it’s time to create a message that
will move your audience to action. The message development tools in the Framing Guide can
guide you in creating the most effective message for your audience.
Write your final message below.

From National Center for Injury Prevention and Control. (2008). Adding power to our voices: A framing guide for
communicating about injury. Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/injury. Public Domain.
65

Appendix F

Adapted Organizational Change Recipients' Beliefs’ Scale

Instructions: For each statement, place a circle the number in the column that most represents your
response. The survey will be anonymous. Once you have completed the questionnaire, place your survey
in the blank manila envelope when you leave the room. Thank you

Strongly Slightly Neutral Slightly Strongly

Disagree Disagree Agree Agree
This change will benefit me 1 2 3 4 5
Most of my respected peers embrace the proposed 1 2 3 4 5
community changes
I believe the proposed change will have a favorable 1 2 3 4 5
effect on our community
I have the capability to implement the change that 1 2 3 4 5
is initiated
We need to change the way we do some things in 1 2 3 4 5
this community
With this change in my role, I will experience more 1 2 3 4 5
self-fulfillment
The top leaders in this community are "walking the 1 2 3 4 5
talk"
The change in our operation will improve the 1 2 3 4 5
performance of our community
I can implement this change in my role 1 2 3 4 5
We need to improve the way we operate in this 1 2 3 4 5
community
I will earn higher reward from my role after this 1 2 3 4 5
change
The top leaders support this change 1 2 3 4 5
The change that we are implementing is correct for 1 2 3 4 5
our situation
I am capable of successfully performing my role 1 2 3 4 5
with the proposed community change
We need to improve our effectiveness by changing 1 2 3 4 5
our operations
The change in my role will increase my feelings of 1 2 3 4 5
accomplishment
The majority of my respected peers are dedicated 1 2 3 4 5
to making this change work
When I think about this change, I realize it is 1 2 3 4 5
appropriate for our community
I believe we can successfully implement this change 1 2 3 4 5
A change is needed to improve our community 1 2 3 4 5
The community change will prove to be best for 1 2 3 4 5
our situation
We have the capability to successfully implement 1 2 3 4 5
this change
My immediate manager encourages me to support 1 2 3 4 5
this change
66

Appendix G
Letter of Support to Adapt Organizational Change Recipients' Belief Scale

Achilles Armenakis <[email protected]>

To:
Judy L Gregg;

Thu 3/24/2016 9:54 PM

You replied on 3/24/2016 9:55 PM.

Armenakis & Harris 2009 JCM.pdf231 KB

Hi Ms. Gregg:

You have an interesting project to pursue. Thanks for asking my permission to use the OCRBS. First, you do not
need my permission to use the scale. Simply cite JABS. Second, you may modify it any way you feel is necessary.
Just realize the statistics reported in the article are for the scale as is. Therefore, you might need to test the modified
scale. And, third there is no cost to you. Please feel free to use the scale knowing that you do not have to reimburse
me or anyone else for the use. Best wishes for a successful project.

I have inserted a PDF that may be useful to you. Let me know if you have other questions.

Sincerely,

Achilles

Achilles Armenakis
441 Lowder Hall
415 W. Magnolia Ave.
Auburn University, AL 36849
Tel: 334-844-6506
________________________________________
67

Appendix H

Framed Message shared with Stakeholders

Why do people live here in Knox County? It is a quiet, safe community to raise a family where
children can reach their full potential…or so we believe.
Would you be surprised if I said Knox County is a risky place for teen drivers? One out of 5
injury crashes over the last 3 years involved a teen in Knox County. I don’t believe that this an
acceptable rate for our children, or grandchildren or community.
Former United States Surgeon General, C. Everett Koop once said, “...We cannot accept these
injuries as just accidents that will happen. If a disease were killing our children at the rate that
unintentional injuries are, the public would be unbelievably outraged and demand that this killer
be stopped.”
Aren’t teen motor vehicle crashes a problem everywhere? Yes, teen drivers are at higher risk for
crashes but Knox County appears to have a more pronounced issue.
Out of 13 peer counties identified by the CDC for similar settings, population, economics etc,
Knox County had the highest percentage of teen injury crashes accounting for 20 % of all injury
crashes in Knox County.
So what are the other counties doing that we aren’t? Ten of the 13 peer counties had Carteens in
place. In addition, all but 1 peer county with Carteens had better teen crash injury statistics than
the 4 counties without. Although Carteens was an active program in Knox County in the past,
for many years Knox County teens have been mandated to attend a defensive driving course
instead which lead to the disbanding of the local Carteens.
What is Carteens? Carteens is a national traffic safety program conducted by 4-H teen leaders
and program partners such as the Ohio State Troopers for first time juvenile traffic offenders.
The goals of the program include reducing the number of repeat juvenile traffic offenders,
decreasing the number of teen traffic offenders, and increasing teen awareness of
traffic/vehicular safety. Effectiveness of the program is augmented when teens are accompanied
by a parent. The focus is on motor vehicle safety education to encourage caution and
responsibility.
I propose the formation a coalition to develop a feasible plan to reestablish Carteens and then
advocate the juvenile courts to change policy to reinstate Carteens as the primary program for
teen traffic offenders to attend in Knox County.
68

Appendix I

Copy of A3 used for Alliance Meeting

69

Appendix J

Modified Organizational Change Recipient’s Belief Scale Results

Strongly Slightly Slightly Strongly

agree agree Neutral agree agree CI
(1) (2) (3) (4) (5) Mean SD (95%) Range
Discrepancy
We need to change the way we do some 3.87-
things in this community (D) 0 0 1 4 4 4.33 0.71 0.46 4.70
We need to improve the way we operate 3.87-
in this community (D) 0 0 1 4 4 4.33 0.71 0.46 4.70
We need to improve our effectiveness by 3.78-
changing our operations (D) 0 0 1 5 3 4.22 0.67 0.44 4.66
A change is needed to improve our
community (D) 0 0 1 6 2 4.11 0.6 0.39 3.72-4.5
Appropriateness
I believe the proposed change will have a
favorable effect on our community (A) 0 0 2 4 3 4.11 0.78 0.51 3.6-4.62
The change in our operation will improve 3.35-
the performance of our community (A) 0 1 1 4 3 4 1 0.65 4.65
The change that we are implementing is 3.27-
correct for our situation (A) 0 1 2 2 4 4 1.12 0.73 4.73
When I think about this change, I realize it
is appropriate for our community (A) 0 1 2 4 2 3.77 0.97 0.63 3.14-4.4
The community change will prove to be 3.38-
best for our situation (A) 0 0 2 6 1 3.77 0.6 0.39 4.16
Efficacy
I have the capability to implement the 2.45-
change that is initiated (E.) 1 2 1 2 3 3.44 1.51 0.99 4.43
I can implement this change in my role 2.74-
(E.) 1 1 1 3 3 3.66 1.41 0.92 4.58
I am capable of successfully performing
my role with the proposed community 2.86-
change (E.) 1 0 2 4 2 3.66 1.22 0.8 4.46
I believe we can successfully implement 3.35-
this change (E.) 0 0 4 1 4 4 1 0.65 4.65
We have the capability to successfully 3.78-
implement this change (E.) 0 0 1 5 3 4.22 0.67 0.44 4.66
Principle Support
Most of my respected peers embrace the 3.07-
proposed community changes (PS) 0 1 3 5 0 3.55 0.73 0.48 4.03
The top leaders in this community are 3.06-
"walking the talk" (PS) 0 1 3 2 3 3.77 1.09 0.71 4.48
The top leaders support this change (PS) 0 1 1 6 1 3.77 0.87 0.57 3.2-4.34
The majority of my respected peers are
dedicated to making this change work 2.67-
(PS) 0 1 1 5 1 3.33 1.01 0.66 3.99
My immediate manager encourages me
to support this change (PS) 0 0 4 4 1 3.66 0.71 0.46 3.2-4.12
Valence
This change will benefit me (V) 1 0 6 0 2 3.22 1.41 0.92 2.3-4.14
With this change in my role, I will
experience more self-fulfillment (V) 0 1 6 2 0 3.11 0.6 0.39 2.72-3.5
I will earn higher reward from my role 2.34-
after this change (V) 1 1 6 1 2.88 0.83 0.54 3.42
The change in my role will increase my 2.27-
feelings of accomplishment (V) 1 1 5 1 1 3 1.12 0.73 3.73