Healthy People (HP) 2020 recognizes that health disparity is a specific type of difference in health related to disadvantages in social, economic, or environmental circumstances.1 HP 2020 builds on earlier HP 2000 efforts by establishing a more ambitious overarching goal to achieve health equity, eliminate disparities, and improve the health of all groups.1(p6) Health disparities are associated with health inequalities that are defined by the World Health Organization as differences in “health status or in the distribution of health determinants between different population groups.”2 Nurses are challenged to respond to these equity deficiencies as a matter of social justice and are required by professional mandates and codes to proactively and reactively act on identified disadvantages. These professional commitments to patients and society oblige nurses to evaluate how the nursing education system ensures that nurses actually know how to affect sociopolitical processes in ways that effectively contribute to social change.
Carper's3 work on nursing's fundamental patterns of knowing describes nursing knowledge development as comprised of personal, empirical, ethical, and esthetic knowing. These patterns of knowing have been expanded to include emancipatory knowledge—a type of knowing that originates from an awareness of social injustices entrenched in a social-political system.4 This type of knowledge requires nurses to understand the interplay between social processes and contextual circumstances that create unjust conditions and then alter these influences to correct the wrongs.4 Emancipatory knowing relates to Provision 9 of the Code of Ethics for Nurses calling for “the profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.”5(p151) This emphasis on addressing social justice and advocacy is not unique to the United States; Canadian nurses are similarly challenged by guiding practice documents, including standards of practice, competencies, and codes of ethics.6 Nurses must grasp opportunities to respond to social injustices by contributing as allies, advocates, and activists and also as adversaries of those who support or promote inequities.
Published literature supports that there are inconsistencies or gaps between the call for alliances, advocacy and activism found in nursing literature, discourse, and education standards versus the realities of nursing curricula priorities and practice environment constraints.5–7 Nurses have a social mandate to address injustices, but there is evidence to suggest that agreement is lacking on what constitutes effective and appropriate sociopolitical activism and how to support students' and nurses' knowledge and skills specific to acting on emancipatory knowledge. Nurses are not the only health care professionals called to serve as ally, activist, and advocate. Psychologists and others are also charged to promote social justice and fairness by working against all forms of oppression informed by stereotyping and discrimination.8
Melton8 observes that, for some psychologists, working for prosocial change is daunting and seemingly outside the scope of professional practice. Melton's description of allyship, activism, and advocacy provides examples of these contrasting and complementary roles that are useful when considering potentially similar nursing-specific concerns and possibilities. Melton poses a query specific to the obligation of psychologists to address the effects that oppressive and marginalizing social policies and practices have on society's members and asks, “The question is no longer whether psychology should be explicitly involved but how can one be an ethical, multiculturally competent psychologist without considering allyship, advocacy, and activism?”8(p 84) This query has relevance to all health care professionals, including nurses, and absolutely to those with a commitment to holistic care.
The defined terms ally, advocate, and activist similarly include a supportive relationship to a person, group, or entity of interest, but published and lay literature as well as web-based searches suggests differences in the degree of action and the intensity of the commitment to challenge the injustice or inequity of concern. An ally is often described as a member of a dominant group that supports members of the oppressed group. This support varies in its degree of manifested activity and its direct impact on dismantling structures and processes that contribute to inequities; however, the ally is supportive of the disadvantaged person or group and speaks up in support with varying levels of activity. Melton8 suggests that allies' effectiveness lies in using the power associated with their identity to serve those without this privilege.
Advocates are sometimes portrayed as unique from activists. They support causes, individuals, or groups to ensure that their needs are being met and that their issues are being heard and understood. Nurses need to take care to avoid a paternalistic approach to advocacy. Marginalized or at-risk individuals or groups should be actively involved in determining preferred priorities and action.9 An activist is energetically engaged in action that is intended to right the wrongs that have led to or perpetuate injustice, inequity, and sociopolitical disparity. Some argue that there is a critical need for advocates to embrace the responsibilities of activism to agitate and fight.10
The roles of ally, advocate, and activist overlap and likely are part of a continuum of activity, agitation, and power struggles. These roles recognize and respond to individual and group adversaries. It is also the case that publicly recognized allies, advocates, and activists will be viewed as adversaries by those in power positions supporting the status quo. The challenge lies in creating opportunities for nurses to develop the skills needed to effectively navigate adversarial relationships while agitating processes, systems and people to change unjust circumstances, particularly given the distinct possibility that nurses may lack the power, drive, or skill set necessary to effectively assume these roles and destabilize the status quo.6,7,9
Many nurses likely feel unprepared to lead or participate as militant agents rocking the status quo. Nurses need to take stock of whether rewarded and affirmed behaviors of colleagues, subordinates, teams, and systems serve to reinforce the status quo and encourage only covert activism that may do little to affect social and political injustices.7 How does the context of nursing care delivery systems suppress or encourage advocacy and activism? Educators should evaluate whether students and faculty are truly encouraged to step up and speak out about injustices. Administrators need to reflect on whether dynamic, rational push-back against unfair structures and processes is supported and nurtured. Unless nurses across all types of health settings embrace dynamic change and role model advocacy and activism, there is a risk that the profession's call for sociopolitical action from its membership will be a symbolic gesture at best.
There are many chances to engage in much needed and occasionally risky work of participatory action and advocacy. Nurses might want to explore opportunities readily available in practice and employment settings. Some examples might include workplace equity issues. Unjust policies, rules, and laws abound specific to sexual orientation, gender identity, race, body size, disability, ethnicity, religion, economic status, and other characteristics that have tremendous influence on health determinants. Environmental issues are well-suited to nurses' expertise and there are needs across all levels and types of systems. Some nurses may be particularly interested in interprofessional endeavors or might be intrigued by passions related to community resource inequities.
There are comparatively fewer allies, advocates, and activists than there are injustices and adversaries. The profession calls for nurses to respond to sociopolitical injustices. Answering this call requires role models for nurses and nursing students who will offer encouragement and coaching, as novice allies, advocates, and activists begin their efforts to right wrongs in small and large ways. This action agenda needs to be planned, measured, and improved in meaningful ways that include needs assessments and program evaluations to assure society and stakeholders that the nursing profession is walking the walk. The nursing profession, beginning with nurse educators, must ensure that nurses know how to serve as allies, advocated, activists and worthy adversaries to create a more just and inclusive society that realizes health equity, eliminates disparities, and improves the health of all groups.
1. US Department of Health and Human Services. The Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020 [Internet]. Section IV: Advisory Committee findings and recommendations. http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf
. Accessed February 12, 2020.
2. World Health Organization. Health Impact Assessment (HIA). Glossary of terms used. https://www.who.int/hia/about/glos/en/index1.html
. Accessed February 14, 2020.
3. Carper BA. Fundamental patterns of knowing in nursing. ANS Adv Nurs Sci. 1978;1:13–24. doi:10.1097/00012272-197810000-00004.
4. Chinn PL, Kramer MK. Knowledge Development in Nursing. Theory and Process. St Louis, MO: Elsevier; 2018.
5. Fowler MDM. Guide to the Code of Ethics for Nurses With Interpretive Statements. Development, Interpretation, and Application. 2nd ed. Silver Spring, MD: Nursesbooks.org (The Publishing program of ANA); 2015.
6. Buck-McFadyen E, MacDonnell J. Contested practice: political activism in nursing and implications for nursing education. Int J Nurs Educ Scholarsh. 2017:14(1). doi:10.1515/ijnes-2016-0026.
7. Hewitt J. A critical review of the arguments debating the role of the nurse advocate. J Adv Nurs. 2002;37(5):439–445.
8. Melton ML. Ally, activist, advocate: addressing role complexities for the multiculturally competent psychologist. Prof Psychol Res Pract. 2018;49(1):83–89. doi:10.1037/pro0000175.
9. Harrison E, Falco SM. Health disparity and the nurse advocate: reaching out to alleviate suffering. ANS Adv Nurs Sci. 2005;28(3):252–264.
10. El-Mekki S. Educational justice. Which are you—an advocate, ally or activist? https://edtrust.org/the-equity-line/educational-justice-which-are-you-an-advocate-ally-or-activist/
. Published September 24, 2018. Accessed February 14, 2020.