Nursing Advocacy

There have been numerous studies and publications on the necessity of nurses becoming more involved in advocacy and health policy development.^, Nevertheless, a recent study by Rasheed et al. found that “Nurses’ involvement in policy making has not improved over time.”⁽⁴⁴⁶⁾ Nurses are in a unique position to have an impact on policy and need to be at the table to improve the health of our nation. The pandemic and the tragedy of George Floyd highlighted the inequities of health care access and subsequently brought social determinates of health to the forefront of concern in our society. Patton et al.² point to the 2015 ANA Code of Ethics that raises the responsibility to address social injustice to the level of an ethical obligation. To fulfill that obligation, nurses need to develop political competence.

Nurses are naturally skilled politicians; they navigate negotiation and advocacy every day. However, often nurses are required to implement policies that were created by others in leadership that lack the nursing lens. Kennedy pointed to the need for nurses to acquire political skills. Nurses need to learn to apply the strategies they use to advocate for their patients to influence policy at all levels. Kingdon described the policy process in his model of agenda setting, a problem is identified, a proposal is developed, and political negotiations occur to open the window of opportunity to move the proposal forward. Whether the problem involves getting medication for a patient, approval to purchase a piece of equipment for the unit, or negotiation for a pay increase for staff, the process begins by identifying and clarifying the problem and its importance. Most problems have a variety of possible solutions, clarifying these may be key to negotiations and development of a proposal. For nurses, keeping the focus on the impact on patient care is essential to the success of moving a proposal forward.

Understanding the environment around the problem can be a first step in opening that window of opportunity as described by Kingdon. Mary Wakefield, a nurse and health care administrator who served as the deputy director of Health and Human Services during the Obama administration, described the following 9 factors that influence legislation: crisis, constituents, fiscal pressures, market forces, special interest groups, research findings, personal experience, political ideology, and the media. We are all familiar with the massive changes in policy that occurred during the crisis of coronavirus disease 2019. The demand for nursing care was greater than ever and it became evident what was possible. One example is the use of telehealth for nurses and advanced practice registered nurses. Allowing telehealth visits to be eligible for billing and reimbursement increased the ability of patients to maintain their health while staying in a safer environment during the height of the pandemic. In addition, the barriers of state licensure for nurses and advanced practice registered nurses were lifted enabling nurses to go to the areas with the highest demand. The conversation regarding compact licensure continues today along with the ability of advanced practice registered nurses to practice to the full extent of their license. Removing these barriers will have a positive impact on access to health care. Despite these national policies, not all advocacy and health policy happen at the state or federal level. While Dr. Wakefield’s model addressed factors influencing legislation, it is also applicable to policy change at the institutional level.

In an interview regarding her entry into political advocacy, Holly described her experience as a nursing leader on making change at local level and how it has impacted her involvement in her community and thoughts on future advocacy. Holly is a system director for nursing education at a large academic medical center and is currently pursuing her Doctor of Nursing Practice. An assignment in her policy class was to have an Advocacy Immersion Experience. Holly was inspired by the United Nations Sustainable Development Goals, Goal 2: Zero Hunger. Even though she lives in an affluent suburb she became concerned about hunger in her community when she noted how many residents were using the food bank. For her immersion experience, she spent a day at the Food Bank in her community. During that day, she shared her concern with the director that the foods being provided were not all the healthiest options. Holly shared data regarding the impact of diet on overall health including the ability to work and attend school. She emphasized that diet is a cornerstone of other social determinants of health. Subsequently, she worked with the director to decrease the amount of processed food offered and increase healthier options. Because of her advocacy and recognized leadership skill in problem solving, she was asked to apply to be on the board of directors of the Food Bank.

On the board, Holly has been able to network with the board members, who are all leaders in the community. One board member was a woman on the city council. During their discussions, Holly was able to start to expand on her goal to decrease hunger in her community. She was introduced to key community stakeholders. including the mayor, the superintendent of schools, the executive director for economic development, and her Representative to the US Congress. The relationships she developed through this network resulted in her appointment to her community’s planning commission, a 5-year term. The planning commission assesses proposals that offer development ideas for the local community and economy. Holly is the nurse at the table considering proposals that will affect the health of her community.

Holly is a living example of Kingdon’s model in action. She defined a problem and through her personal experience and utilizing data, she presented a proposal that was compelling and opened the window of opportunity to move that proposal forward. The road from her day of immersion at the Food Bank to appointment on a very influential committee in city governance is a great example of the application of political principles that will allow Holly to make an even greater impact on health in the future.

Nurses have an insight into the human experience unlike any other profession. Nurses need to recognize the importance of sharing their knowledge at the table in a variety of venues. What will it take to motivate nurses to become more involved in policy and advocacy? We cannot expect front-line nurses or even our advanced practice nurses to be involved if we as nursing leaders are not. We need to assess the baseline knowledge of nursing leaders regarding advocacy and policy. What is the emphasis on this content in the preparation of nursing? The curriculum for nurses related to policy is variable and, in some programs, lacking entirely.^, Gimbel et al. strongly believe a formal program should be in place in every nursing school to increase the participation of nursing within global health policy. They explored whether schools of nursing that were ranked in the top 10 by U.S. News and World Report offered a course on global health policy and found tremendous variability among those top schools. Benton et al. completed a literature review to assess how involvement in policy work is supported by nurses. They found that there is quite a bit of information regarding what should be formally added to curriculum but very little addressing how this is supported at the institutional level once a nurse is in the workforce. At the baccalaureate level, there is a lack of emphasis on the skills necessary to equip the nurse with the ability to manage small “P” policy. Students are not being taught the important aspects of team dynamics and navigating organizational landscapes. Within the master’s and doctoral programs, there should be more emphasis on national and even global policy and the skills needed to enter that arena. In their review, they noted that all the studies they reviewed included small sample sizes ranging from 10 to 475 participants and the studies did not focus on national samples. The small sample sizes and the specificity of location create a major limitation in the ability to generalize the results to nursing leaders across the country. These studies need to be expanded and we must assess nursing leaders’ knowledge and comfort level before we can look to the bedside nurse.

In summary, there are a few areas that need to be explored and help identify the true knowledge gaps that exist for more nurses to become involved in policy and advocacy. First, we need to identify what the knowledge base and current involvement there is in our nurse leaders. We must ascertain what portion of our leaders understand politics and advocacy and how many are involved at the local, state, or federal level. Secondly, we need to have discussions with the nursing school programs to hardwire the educational content pertaining to health policy and advocacy. This content needs to build on itself from the baccalaureate to the masters to the doctorate level. Lastly, we need to encourage nurses to belong to our professional organizations. We need to explore the reasons why more nurses don’t have membership and determine what are the benefits that would be attractive to nurses. There is power in numbers and with approximately 4 million nurses, we should be having a larger impact on the health policy of our country.