The healthcare industry and nursing profession are in a dynamic environment characterized by unprecedented ambiguity. Increasing pharmacological and technological advances are increasing the length and quality of life; however, excessive and escalating costs, waste, declining quality of care,1 and uncertainties over accountable care are some of the many contributing issues. The problems are not politically based but are exacerbated by the political process.
Issues facing nurses during recent elections were staffing issues, workplace violence, long work hours, bullying and harassment, and workplace hazards.2,3 Nurses have not united to contribute a solution focusing on improving these aspects of healthcare or their profession. Nurse executives are well positioned in the current political environment to focus the power of the country's 4.9 million RNs and LPNs4 to influence lawmakers to help solve issues affecting their profession.
Nurses Utilizing Political Power
The 2018 elections resulted in a House controlled by Democrats and a Senate with Republican control. This division produced a period of relative stability in healthcare because little will be done in the gridlocked Congress; consequently, interim healthcare legislation is shifting to the states. Other issues that appear to have state-level potential were prescription drug prices, state Medicaid work requirements, insurance exchanges, and short-term health plans. The upcoming election cycle offers an opportunity for nurses to exert influence at both the state and national levels.
Nurses have a unique opportunity to wield power over upcoming healthcare legislation at a state level. Nurses' knowledge and expertise, plus public perception of nursing as the most honest and ethical profession,5 produce a significant, but largely unused political power. Gallup5 reported that 84% of Americans rate nurses as having high or very high honesty and ethical standards, far above the 2nd profession (medical doctors), which scored 67%. With the aid of nurse executives and nurse leaders, this incredibly positive public perception of nursing can be weaponized to influence the political processes to better the profession and patient care.
There is negligible evidence of nurses' political involvement in recent elections, which suggests that nurses may not be politically astute or sufficiently engaged in political processes. Nurse members of the 116th Congress in 2019 decreased to 3 (Supplemental Digital Content 1, http://links.lww.com/NNA/A19) from 7 in 2014, further eroding nurses' political power. Nursing is a consuming profession, leaving little time or energy to devote to learning about the political processes and taking an active role in attempting to shape legislation. If mobilized, nurse leaders could shape a powerful nursing lobby by educating and motivating nurses in their hospitals and organizations as well as politicians.
A 1st step toward an effective political campaign is to assess the present level of participation and astuteness of nurses. Using that knowledge, nurse executives and leaders can make informed decisions to educate and motivate and thereby maximize the impact of nurses' efforts.
After approval by the university institutional review board, the respondents were given informed consent and voluntarily participated. Data were collected in 2 periods: 1st during October 2016 through January 2017. The 2018 data collection period was October through December 2018. All respondents were employed full-time. The 2016 sample comprised 363 clinical nurses from 40 states. Their political affiliation was 26.7% Democrat, 44.2% Republican, and 29.1% independent; the average age was 37.2 (SD, 9.3) years, with an average of 12.1 (SD, 7.9) years in healthcare. The 2018 sample of 129 clinical nurses from 28 states was 23.2% Democrat, 39.4% Republican, and 37.4% independent, with an average age of 35.9 (SD, 8.8) years and an average of 10.1 (SD, 7.1) years in healthcare.
The 40-item Political Astuteness Inventory6 was used to assess the political astuteness and involvement of nurses in the political process. Example astuteness items are as follows: “I was acquainted with the majority of issues on the ballot at the last election,” “I know the names of my state senators in Washington, DC,” and “I know which senators or representatives are supportive of nursing.” Example participation statements are as follows: “I voted in the last election,” “I belong to the state professional or student nurses' organization,” and “I attended the last state or national convention held by my organization.”
The party differences in participation and astuteness were small. Republican nurse voters were marginally more active than Democrats; however, Democrats were slightly more astute. Independent voters trailed Republicans and Democrats in participation and astuteness (Table 1).
The trend in nurses' political participation is down. Fewer nurses voted in 2018 (70.4%) than in 2016 (75.9%), but more than the general population voter turnout of about 49%. A larger percentage of nurses was registered to vote in 2018 than in 2016 (92.6% vs 90.6%); however, except for participation in state nurses' organizations, all metrics of nursing political participation decreased from 2016 to 2018. In 2018, fewer than 5% of nurses reported attending the most recent meeting of their district nurses' association, attending the convention of their organization, supporting their state professional organization's political arm, actively supporting a Congressional candidate, or writing a letter to the editor or lay press outlet on a health-related subject (Supplemental Digital Content 2, http://links.lww.com/NNA/A20, which shows nurses' political participation scores for 2016 and 2018). Although there may be some difference in interest level in a presidential election year (2016) than midterm elections (2018), the study results indicate a serious deficiency of nurses' political participation.
Political astuteness was similarly low: 20 of the 21 measures of astuteness in 2018 were lower than in 2016 (Supplemental Digital Content 3, http://links.lww.com/NNA/A21, which shows nursing astuteness scores, 2016 and 2018). In 2018, fewer than half of nurses reported knowing the names of their state senators and representatives in Washington, or from their local districts. Nurses had little awareness of nursing issues or their Congress and legislative support for those issues: 30% reported knowing 2 issues related to the profession that were under discussion at the state or national level, and 8.4% reported knowing which House and Senate committees usually deal with health-related issues and the committees on which their representatives held membership. Fewer than 10% indicated awareness of “at least 2 issues discussed and stands taken at the convention” of their nursing organization or “2 issues related to the nursing profession that are currently under discussion at the state or national level.” The study results reveal a serious deficiency in knowledge of healthcare and nursing issues, the political processes, and the senators and representatives at both the state and federal levels.
Mobilizing to Impact the Future
Prior to the 2018 midterm elections, the American Nurses Association's Department of Governmental Affairs encouraged nurses to check their candidates' vitals against the policies that affected them and their patients the most and “exercise your ability to elect members to Congress who will fight for the issues most important to your profession” and vote.7 Although nurses vote to a greater extent than the general electorate, this study indicates they are not generally politically astute and do not present a common voice in the US political process, nor are they active participants in the political processes. Only 49.4% of nurse respondents in this study were acquainted with the “majority of the issues on the ballot” in the 2018 elections, 42.2% knew the names of their state's senators, and 3.6% actively supported a candidate for the Senate or House of Representatives.
The American Nurses Association and similar professional organizations provide good information on political processes, nursing issues in Congress, and resources to help nurses get involved; however, these resources require that nurses take the initiative to locate and use them. Nurse leaders are in an excellent position to educate, motivate, and mobilize nurses to use their expertise and very favorable public perception to influence the political process and improve their profession and the care of their patients. Nurse leaders could help educate nurses to become familiar with nursing and healthcare-related issues in upcoming elections, become involved in their nursing associations, learn about their senators and representatives at both the state and national levels, and take an active and focused part in political processes. There are 17 bills presently in the 116th Congress of importance to nursing (Supplemental Digital Content 4, http://links.lww.com/NNA/A22) including The National Nurse Act, which would designate the chief nurse officer of the Public Health Service as the National Nurse for Public Health (HR 1597), who would join the Surgeon General and advocate for nurses. With astute leadership, the nursing profession could become familiar with these bills and those at the state level, decide which ones to support, and mount a concerted effort using our leverage to push for their passage. Although national political issues remain very important, the shift of healthcare policy to the states provides new opportunities. Statewide initiatives such as student loan forgiveness for future nursing faculty who agree to teach after graduation, legislated staffing ratios or nurse-patient assignment ratios, abortion rights, universal at-home care, medical marijuana, immigration, and Medicare expansion are examples of nursing issues and nursing-related issues that are increasingly appearing on state ballots. Participating in state politics may be more amenable to nurses than the national level. Nurse executives may consider initiating programs to increase nurses' political astuteness and encourage them to actively participate in exerting influence in their state's politics so that they may more positively impact the health of their patients and the nursing profession.