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Nurses as advocates

Watson, Jeffery DNP, RN, NEA-BC

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Nursing Made Incredibly Easy!: May/June 2019 - Volume 17 - Issue 3 - p 42-46
doi: 10.1097/01.NME.0000554601.68360.36
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What motivates you to want to speak up and speak out? Is it that you want to engage in broader discussions of social justice in your community or for the populations with whom you work? Perhaps it comes from your observation that the humanity of healthcare delivery is challenged in some way and needs attention. Maybe it emerges from a desire to improve conditions or protections in your work environment. It could be that you want to work to improve health by building green spaces and community gardens. Whatever your motivation, it's clear that advocacy is driven by the universal desire to make a situation better.

According to the American Nurses Association (ANA) Code of Ethics for Nurses, advocacy is “the act or process of pleading for, supporting, or recommending a cause or course of action.” It also includes the identification and promotion of action on social issues impacting marginalized or vulnerable individuals and populations. Advocacy emerges from a need to lend support to those who are in vulnerable positions. It exists as a bridging mechanism whereby an individual or group extends strength or voice to an individual or group until they can advocate for themselves. We've all had a feeling of vulnerability at different points in our lives. It may show up for us in times of illness, stress, or social isolation. In periods of weakness, when we may feel more susceptible than others, we need an advocate.

This article presents a review of the policy process and highlights of nursing advocacy, challenging you to think about your advocacy journey for the benefit of our profession and those we serve.

Why should we advocate?

Nursing is the single largest healthcare profession, with almost 4 million RNs in the US. There's no denying that we possess the numbers to demonstrate significant influence on policy. We also know about the complexity of human life from the study of the life sciences and humanities. We have a keen insight into the social determinants of health. Through practice, we have exposure to the density of forces that converge to shape how we perceive ourselves, how we live our lives, how we manage our health, and what we believe about others. Inherent in the practice of nursing is advocacy.

Nursing's advocacy is most commonly visible when nurses champion causes of individual patients, yet our voices need not stop there. Nurses also speak up on behalf of the profession itself. One such advocacy effort that continues is the recommendation to improve access to primary care by removing barriers to practice for advanced practice RNs (APRNs), first endorsed in 2010 by the National Academy of Medicine (formerly the Institute of Medicine). The advocacy efforts of nurses, nursing associations, and other partners are yielding progress, yet 16 states and 3 US territories continue with reduced APRN practice and still another 13 states restrict APRN practice.

Policy making

Policy is a measured approach to how a group chooses to manage, resolve, or otherwise address a known issue. It often results in changes in or the development of new laws, rules, or regulations. Governments—from our local communities to international bodies—are intimately involved in policy development, especially as leaders contend with the just allocation of human, natural, and capital resources (see International issues).

The US government creates policies that have an impact on the general population; these are called public policies. Historically, nurses and other healthcare providers have focused on a specific subset of public policies, known as health policies. Nursing research helps inform health policies, as well as information gleaned from individual and collective experiences in work and life. Social policies, which address social problems at the neighborhood, community, state, and national level, have been identified through the research of Williams, Phillips, and Koyama as having the potential for a more significant impact on health. Consequently, we must engage beyond our traditional focus on health policy to influence social policy and the needed shift of crucial resources to health promotion and disease prevention.

Agenda setting

Nurses are uniquely positioned to influence the policy process because of our educational background, communication skills, and diverse practice experience. However, according to Buresch and Gordon, nurses haven't held a national presence in the media to consistently influence public policy agenda setting. The 1998 Woodhull Study on Nursing and the Media alerted nurses to their absence in national media sources. This absence caused the profession to be invisible in the national discourse on healthcare. Recently, the Woodhull study was revisited by Mason et al. to determine the progress made in the past 20 years. Surprisingly, the findings regarding the presence of nurses in the media haven't changed. Without a visible presence in the media, the public can't reap the benefits of our valuable insight. Do you think there's a nursing advocacy solution to this problem?

Too often, we delay our engagement on an issue of interest until it becomes a local, state, or federal legislative agenda item. When an issue rises to the point of legislative action, if nurses aren't involved early in the process, the profession will have missed the window of opportunity to exert influence. To get issues noticed by the broader public, we usually need the assistance that comes from partnerships or coalitions.

Nursing organizations that focus on policy contribute to agenda setting by drawing on the expertise and practice experience of their members. For example, the ANA is a dynamic organization through which nurses participate in issues associated with workplace, scope of practice, and other professional issues as identified through member advocacy efforts. Recently, the ANA has worked on behalf of and with nurses from all practice environments to participate in raising awareness about healthcare reform, gun safety, safe staffing, and the ongoing development of the nursing workforce. The ANA facilitates agenda-setting discussions that are reflective of real-time issues relevant to RNs across the country.

The ANA supports nurses in gaining advocacy skills through the American Nurses Advocacy Institute (ANAI), a program started in 2009 for training on how to influence health policy. The objectives of the ANAI are to help nurses identify connections across the policy development process, learn how to perform a political environmental scan, determine how to create and sustain policy change, and learn how to build coalitions. The ANAI is a program in grassroots activism for nurses wishing to enhance their policy leadership skills.

Associations may use lobbyists to augment advocacy efforts. In the realm of government action, lobbyists are often paid individuals with experience in politics who sometimes possess practical expertise in the area of interest. Some nursing organizations engage lobbyists to work with congressional members or state legislators to advance the legislative agenda. Lobbyists can be present with lawmakers on a more consistent basis; however, they rely on the abilities of the nurses they serve to humanize the relevance of abstract issues. Stories, when told by nurses from their practice experience, are compelling and beneficial when attempting to move an agenda item through the legislative process.

Telling your story

One of the most powerful and frequently recommended methods of influencing change is storytelling. When a nurse tells a story, it wakes policy makers to a need. Rooted in nursing theory, storytelling is a potent action that we have in our advocacy toolkit.

In 1999, Smith and Liehr posited a middle-range nursing theory called Story Theory. In this theory, the primary concept is the unfolding human story. It's the human story and your participation in that story that may become the trigger for advocacy efforts. There's no doubt that you've already found yourself immersed in a storyline from one or more of the individuals for whom you've provided nursing care. Human stories are persuasive and necessary to personify issues.

Consider the story of Karen Daley, PhD, MPH, RN, FAAN, past president of the ANA. Dr. Daley's advocacy journey emerged from her perspective as a clinical nurse working in an emergency center in the late 1990s. While placing a syringe in a sharps box, she was stuck by a protruding hypodermic needle. Because of her personal experience and belief that needlestick injuries were preventable, she began a crusade for change. It's through Karen Daley's storytelling, advocacy, and lobbying efforts, including providing testimony before a US House of Representatives subcommittee, that the Needlestick Safety and Prevention Act was signed into law in 2000. Dr. Daley chose to tell her story and, because of her efforts, we now have safety devices and safe sharps containers to help protect nurses from needlestick injuries.

Our influence is needed

Nurses have the skills to impact vulnerable populations well beyond the confines of traditional healthcare settings. Getting started in advocacy is easy and begins with the identification of your passion. What do you see in your work, community, country, or even the world that could benefit from the expertise you have as an RN? Joining state and national professional nursing organizations that focus on policy is an excellent first step. If you're already a member of these organizations, go further and learn as much about advocacy as you can. In doing so, you connect the power of the nursing profession to your passion.

Consider the role you play in advocating for the nursing profession and those for whom you care. Advocacy is the responsibility of all nurses at all levels of practice and from all practice environments. When you advocate for a person, group, population, or an approach to an issue, no guarantee exists that your personal position will be embraced. Instead, through advocacy you can ensure that the perspective you represent is heard.

Nursing is a diverse profession with individuals serving across the continuum of care. As a result, we know that the spectrum of thought around public, health, and social policies is divergent. We won't all agree, nor should we. It isn't the intent of nursing advocacy to demand a position be taken; instead, advocacy allows us to find a space of cooperative dialogue where vulnerable voices have parity with the more dominant voices.

Nursing's influence is needed outside of the traditional work environment. Get up, get out, get involved, and advocate. The future of healthcare depends on it.

International issues

With greater emphasis on the social determinants of health, nurses are using their advocacy skills to speak to the broader social context from which health issues emerge. Current research by Williams, Phillips, and Koyama has identified health improvement opportunities by addressing poverty, increasing educational opportunities for youth, securing living wages for all workers, guaranteeing safe housing, and promoting food security. However, these issues aren't unique to the US; they're global. To improve health, nurse advocates can engage in glocal advocacy efforts—local efforts that have a global impact.

One initiative is the United Nations Sustainable Development Agenda (SDA) for 2030. In September 2015, leaders from nations across the world agreed to the SDA, which became effective on January 1, 2016. The SDA is comprised of 17 sustainable development goals (SDGs), which are divided into three separate categories: economic development, social inclusion, and environmental sustainability.

Glocal advocacy efforts to support the SDGs are seated in local thought and actions. At times, advocacy for an issue is as simple as changing behavior. To support the SDGs, consider using less water when you brush your teeth. Work to decrease or eliminate your use of disposable plastic bottles and recycle at every opportunity. Participate in community discussions to facilitate understanding across sociopolitical divides. Every single effort creates a ripple of hope for someone, somewhere.

cheat sheet

Working with elected leaders


One of the best ways to prepare and stay abreast of legislative issues impacting nursing is to join your state nursing association. Most state nursing associations hold an annual Nurses Day at the Capitol event at which you may have the opportunity to meet face-to-face with your elected leaders. It may be intimidating to think about speaking with a local government official, state legislator, or even a congressional leader. However, remember that advocacy is a conversation.

Here are a few key things to remember when you have an opportunity to advocate with an elected leader.

Well ahead of the meeting

  • Discuss the nursing legislative agenda/topic of interest with your state nursing association leaders first.
  • Identify key talking points around the issue and connect them to your story.

On the day of the meeting

  • Dress professionally.
  • Be punctual.
  • Bring contact and follow-up information with you to leave behind.
  • Demonstrate patience—sometimes meetings get delayed.

At the meeting

  • Be engaging.
  • Avoid the use of healthcare-related jargon.
  • Tell your story.
  • Don't attempt to answer a question for which you don't know the answer. It's better to follow up with a correct answer than provide an inaccurate response.
  • Ask to take a picture and share on social media if it's okay with the legislator.
  • Say thank you.
  • Follow up with your state nursing association.

After the meeting

  • Write and send a thank-you note to the official's office.
  • Continue your advocacy locally and with your state nursing association.

on the web


American Nurses

National Council of State Boards of

Robert Wood Johnson

Texas Nurses

United Nations Sustainable


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                      Wolters Kluwer Health, Inc. All rights reserved.