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Influencing Health Care Through AdvocacyBy June Helbig
Essential Questions
· What is advocacy, and what is the nurse’s role in advocacy?
· How can nurses advocate for patients beyond the bedside?
· How does advocacy contribute to professionalism in nursing?
Introduction
The word advocacy is defined as supporting a cause; however, when it comes to patient care, nurses play the role of advocate by supporting the care patients receive as well as their emotional well-being. Nursing care is holistic and provides for all aspects of a patient, including physical and emotional care.
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In addition to standing up for patients, advocacy for nursing practice is needed to ensure working conditions for nurses are safe and represent the values tied to professionalism. This chapter will cover advocacy for nursing practice and the continuously expanding role of the professional nurse. The role of the nurse in the political system will be discussed as well as the role of the American Nurses Association (ANA) in supporting initiatives important to nursing.
Advocating for Nursing Practice
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As the largest group of health care professionals, nurses united in a cause have immense influence on health care policy and health care legislation, which puts nursing in a unique position to impact change (American Nurses Association [ANA], n.d.f). Nurses have always been the patients’ advocate by providing proper care in a safe environment. The ANA has declared 2018 as the year to advocate for people, from individuals to the entire population of the country.
Local advocacy begins at the bedside with the patient and extends to the community. By improving nursing practice and becoming involved in quality improvement projects, nurses can advocate for patients in their communities. Nurses can also actively participate as members of committees that focus on initiatives to improve conditions for patients and nurses in their organizations. Improving care and patient outcomes are at the forefront of advocacy for nursing.
At the national level, “the importance of political involvement by nurses cannot be over-emphasized. Bills for funding nursing education and nursing research come before Congress each year. Communication can have an important impact on legislation” (Society of Gastroenterology Nurses and Associates [SGNA], 2012, p. 2). Nursing can support “legislative efforts to improve the safety of the healthcare environment for health care providers, patients, and volunteers” (SGNA, 2012, p. 3) or to change nursing practice.
Coalitions
Coalitions are groups of people or organizations that share common interests and focus on common issues. Coalitions can be created at the local, state, and federal levels (SGNA, 2012). Because it takes more than one person to get a law passed, it is through the actions and strengths of many people that bills get passed into laws that can help to make improvements. Nursing organizations can build political strength by forming coalitions with other people and other groups. Building coalitions requires the identification of potential collaborators and knowledge about the political environment. Once credibility is built, members gather together to lobby legislators to give support for bills the coalition wants to see passed.
Lobbying
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“ Lobbying is an attempt to persuade or influence the members of a governmental body at the city, county, state or federal level. The purpose of lobbying is to enact, modify or stop the passage of proposals made by a legislative body at any level” (SGNA, 2012, p. 4). Lobbying can take place at all levels of government as well as through voting and becoming active in local politics. Nurses can lobby individually by participating in local committees and organizations. Nurses can form political action committees or run for public office. By participating in local government, nurses can educate their community as well as their local representatives on the issues that affect nurses and local health care organizations. It is important to demonstrate legitimacy, which can be accomplished by obtaining letters of recommendation from community leaders, to establish the nurse advocate as a credible source for information regarding the topic of interest (SGNA, 2012).
Lobbying can also occur on a larger scale within the state and federal government. Political action committees, or PACs, allow associations to raise money for interests that are important for the organization to support. “The core of a PAC can consist of a few members who are highly organized and can raise money in the name of their cause” (SGNA, 2012, p. 5). ANA Political Action Committee (ANA-PAC) actively participates in supporting candidates who support the ANA’s agenda. The ANA-PAC represents all registered nurses and is the voice of nursing on Capitol Hill.
American Nurses Association
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The ANA believes that “advocacy is a pillar of nursing. Nurses instinctively advocate for their patients, in their workplaces, and in their communities; but legislative and political advocacy is no less important to advancing the profession and patient care” (ANA, n.d.a, para. 1). The ANA offers numerous resources to help nurses advocate for patients and the nursing profession.
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The ANA supports nursing on the local and state levels of government as well as federal. At any given time, there may be more than 1,000 nursing and health care-related bills being considered in state legislatures, and ANA’s State Government Affairs program tracks all these nursing-related bills. It covers many different workplace issues such as “safe staffing; mandatory overtime, safe patient handling and movement, and workplace violence” (ANA, n.d.b, para. 1). This committee provides background information and bill summaries for all issues and current legislation. The ANA provides nurses with tools dedicated to several different advocacy topics meant to empower nurses to participate in advocacy at the local, state, and federal levels of government.
ANA Initiatives
The ANA’s RN Action website provides information about important issues the ANA is presently supporting, including safe staffing, nurse education, and nurse abuse. Congress has introduced a bill to overhaul hospital staffing to ensure patient safety. The Safe Staffing for Nurse and Patient Safety Act (S. 2446, H.R. 5052) shows that Congress understands that inadequate staffing policies can lead to life-threatening situations for patients.
The future of health care depends on having highly trained health care workers to provide safe, quality care. Title VIII programs , also known as Nursing Workforce Development Programs, focus on providing money to nurses for continuing education and advanced degrees (ANA, n.d.e). By advocating for such programs, the ANA demonstrates support for nursing at the national level.
Physical and verbal abuse against nurses is a serious problem in the United States. Statistics report that “one in four nurses has been assaulted at work. The likelihood of healthcare workers being exposed to violence is higher than prison guards or police officers” (ANA, n.d.e, para. 1).
· Nearly 75% of all workplace assaults between 2011 and 2013 occurred in the health care industry.
· Between 2000 and 2011, 154 shootings resulted in an injury on the grounds of U.S. hospitals;
· 80% of emergency medical workers experience physical violence during their careers;
· 39% of nurses report verbal assaults each year; and
· 13% of nurses report physical abuse each year. (Advisory Board, 2016, para. 3)
Ensuring a safe environment for the nurse is just as important as ensuring a safe environment for the patient. The ANA encourages nurses to stand together to end nurse abuse and take the pledge to “support zero tolerance policies for violence against nurses; report abuse against nurses …; and share this pledge” (ANA, n.d.g).
Table 4.1
ANA-PAC Initiatives
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Health Care Reform |
Seeks to ensure that everyone has access to essential health care services; optimize primary, community-based and preventive services; support use of innovative, technology-driven, acute, and hospital-based services in cost-effective manner; encourage partnerships to reduce and help to bear the cost of health care; and ensure a sufficient, skilled health care workforce. |
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Nursing Workforce Development |
Ensure that an adequate number of nurses are sufficiently trained to care for the growing aging population. |
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Safe Staffing |
Improve nurse-to-patient ratios to keep patients safe. |
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Home Health |
Advance practice RNs must be able to order home health care services in order to provide appropriate, timely care for their patients. |
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Gun Violence |
Calls on Congress to enact legislation to reduce gun violence. |
Note. Adapted from “Health Care Reform,” “Nursing Workforce Development,” “Safe Staffing,” “Home Health,” and “Gun Violence,” by the American Nurses Association.
ANA Advocacy Tools
The ANA Advocacy webpage provides nurses with resources regarding how to become politically active and engaged in health care legislation. These resources cover writing or meeting with a member of Congress or local government, writing a letter to the editor, staying informed through electronic alerts, and staying connected through social media and blogs. By using some or all of these resources, nurses can actively support policies to impact the nursing practice positively and motivate other nurses to engage in the political process.
Campaign for Action
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In 2010, the Robert Wood Johnson Foundation (RWJF), the country’s largest philanthropic organization devoted to health, joined the American Association for Retired Persons (AARP) Foundation and AARP, the nation’s largest nonprofit, nonpartisan organization dedicated to empowering Americans 50 and older, to create “The Future of Nursing: Campaign for Action” to improve America’s health through nursing. The Campaign for Action has State Action Coalitions in every state and Washington DC that are made up of nurses and business men and women working together to transform health care and bring about change (Campaign for Action, n.d.a). By visiting State Action Coalitions, information can be obtained about the issues with which the action coalition is presently involved.
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America is facing health care reform challenges in the areas of cost and quality of health care that is provided to Americans. It is through the work of the State Action Coalitions that change can occur. The Campaign for Action works with the decision-makers in the local, state, and federal governments as well as health care providers, educators, and business leaders to influence and communicate the need for cost-effective quality health care.
The Campaign for Action works on several interrelated issues, which when achieved, could contribute to healthier Americans. State Action Coalitions are working toward achieving the following:
· Improving access to care,
· Fostering interprofessional collaboration,
· Promoting nursing leadership,
· Transforming nursing education,
· Increasing diversity in nursing, and
· Collecting workforce data (Campaign for Action, n.d.b).
Institute of Medicine Report
In 2010, the Institute of Medicine (IOM) published a report The Future of Nursing: Leading Change, Advancing Health. This landmark report discussed the nurses’ role in the future of health care. It stated that nurses are the largest group of health care providers who are positioned to play a vital role in health care reform. The report made the following recommendations:
· Nurses should practice to the full extent of their education and training.
· Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
· Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States
· Effective workforce planning and policy making require better data collection and information infrastructure. (The National Academies of Sciences, Engineering, and Medicine, 2010, para. 3)
Health care in America has been changing and it is more important than ever that nurses work together to alleviate the need for health care providers. The IOM (2011) report is viewed as a road map to an improved health care system, and it is through elevating the nursing profession that could make it possible. Advanced practice registered nurses (APRN) may now be able to practice independently and to the full extent of their education if restrictions are removed. By doing this, health care consumers may now have increased access to health care at reduced health care costs (Quinn, 2018). Figure 4.1 shows the progress toward this goal.
Figure 4.1
Progress to Date
Note. Adapted from “Removing Barriers to Practice and Care,” by W. Quinn, 2018, Campaign for Action.
Nurses at the Federal Level
Every business day, the U.S. government publishes the Federal Register , a daily journal that contains executive orders and documents as well as current regulations, rulings, and filings, including issues regarding health care, nursing practice, and health care reform. The Federal Register is a great resource to learn about federal-rule making and to research multiple topics for information and new legislation. Nurses who are informed about issues that impact the nursing profession can become involved in their state nurses’ association and start learning how to develop and modify current policy. Nurses can also become politically active. There are several nurses who are currently active in government, including Karen Bass of California, Diane Black of Tennessee, and Eddie Bernice Johnson of Texas who are members of the U.S. House of Representatives (ANA, n.d.d).
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The ANA monitors multiple federal agencies that impact nursing, nursing practice, health care reform, and patient safety. Some of those federal agencies include:
· Agency for Health Research and Quality (AHRQ)—"sponsors and conducts research that provides evidence-based information on healthcare outcomes; quality; and cost, use, and access. The information helps healthcare decision makers improve the quality of healthcare services” (ANA, n.d.c, para. 2).
· Centers for Disease Control and Prevention (CDC)—“responsible for protecting the public from disease and illness” (ANA, n.d.c, para. 3).
· Centers for Medicare and Medicaid Services (CMS)—“responsible for administering the Medicare program and parts of the Medicaid program. CMS is responsible for oversight of HIPAA administrative simplification transaction and code sets, health identifiers, and security standards” (ANA, n.d.c, para. 4).
· The Department of Health and Human Services (HHS)—provides services to protect the American people from illness by providing programs and services. HHS operates more than 300 programs that provide essential services through eight public health agencies and several different service agencies. There are about 11 different operating divisions in total (ANA, n.d.c).
· Drug Enforcement Agency (DEA)—responsible for enforcing the laws and regulations of controlled substances in the United States (ANA, n.d.c).
· Food and Drug Administration (FDA)—responsible for making sure biological products, medical devices, medications, and food consumed by Americans are safe. The FDA also oversees electronic and cosmetic products to ensure that they are safe for use (ANA, n.d.c).
· The Health Resources and Services Administration (HRSA)—"responsible for improving and expanding “access to quality health care for all by eliminating barriers to care, eliminating health disparities, assuring quality of care and improving public health and healthcare systems” (ANA, n.d.c, para 11).
· The National Institute for Occupational Safety and Health (NIOSH)—"responsible for conducting research and making recommendations for the prevention of work-related disease and injury. The Institute is part of the CDC” (ANA, n.d.c, para. 12).
· The National Institute of Nursing Research (NINR)—"supports clinical and basic research to establish a scientific basis for the care of individuals across the life span-from management of patients during illness and recovery to the reduction of risks for disease and disability” (ANA, n.d.c, para. 13).
· Occupational Safety and Health Administration (OSHA)— responsible for regulating, enforcing and interacting with agencies and businesses to establish standards for occupational safety (ANA, n.d.c).
· The Substance Abuse and Mental Health Administration (SAMHSA)—“charged with improving the quality and availability of prevention, treatment, and rehabilitative services in order to reduce illness, death, disability, and cost to society resulting from substance abuse and mental illnesses” (ANA, n.d.c, para. 15).
Proposing Health Care Legislation
The legislative process can be put into motion by any party or person interested in proposing new legislation or proposing to amend existing legislation.
Steps to Introduce Legislation
1. Have an idea for new legislation.
2. Perform research to compile information to support the idea. Substantive evidence-based findings must be presented.
3. Draft legislative proposal.
4. Find support for new legislation.
5. Discuss legislation and gain support.
6. Find those who support the idea for new legislation.
7. Debate and discuss until the proposal for legislation is viable.
The first step in the legislative process is to propose a new idea. All necessary information, supporting data, and statistics must be gathered prior to communication with a legislator. Once all supporting information is ready and available, communication can occur. When initiating communication, proper identification, including one’s name and credentials, is paramount. Communication with a legislator, whether in person or via telephone, email, or social media, is imperative if one wants an idea to become a law.
Once communication occurs, a meeting can be scheduled. When meeting with local, state, and federal legislators, nurses should be prepared to answer questions, discuss the issue in depth, and explain both sides of the proposal. It is important to solicit the legislator’s opinion and acknowledge his or her position on the issue. Those proposing legislation should bring copies of information discussed as well as contact information to leave with the legislator.
The Legislative Process
The legislative process is the cornerstone of the American political process. Article 1 of the U.S. Constitution grants all legislative powers to Congress, which consists of the House of Representatives and the Senate.
Any bill that is introduced must be unchanged and accepted by the House and the Senate before it can be passed onto the president of the United States. If any part of the bill is changed, it must go through both houses again before it can be sent to the president.
There are several ways a bill can be introduced. The idea for a bill can come from anywhere or anyone, but only members of Congress can introduce a bill. Bills can be introduced only when the House is in session. The person who introduces the bill becomes the bill’s sponsor and must gather support for the bill. In the House, bills are introduced by placing them in a box, called the hopper, located on the Speaker’s platform; in the Senate, bills are introduced by placing them on the presiding officer’s desk in the Senate (Lucas, n.d.).
House bills generally begin with the letter H and Senate bills with an S. After the bill is officially introduced to the House or Senate, it is referred to a committee in which debate over the bill will be scheduled, and an electronic copy of the bill is sent to the Library of Congress. Once the bill is debated, it is either accepted or amended. Once changes are made, the committee decides whether to accept or reject the changes. After it is debated it goes to a markup session. If a lot of changes were made, the bill may be introduced to the chamber as a clean bill with a new number. At this point the bill will be either tabled or sent to a subcommittee for intensive research and debate. For the bill to become law, a majority of House and Senate members must vote to pass it and then the president must approve it and sign it into law (Lucas, n.d.).
Figure 4.2
How a Bill Becomes a Law
Nurses as the Patient Advocate
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Every patient is different, with different problems and concerns. The nurse has always been an advocate for the patient. Nurses step in to advocate and be the liaison between the patient and the doctor. Nurses explain the diagnosis and educate patients about the disease process and how to avoid future hospitalizations. Nurses educate patients on the medications taken to remain healthy, prevent readmission, and to prevent complications of the patients’ present disease process. Nurses also help patients find alternate treatments and solutions to health care problems. When patients receive new treatments or change health care providers, information regarding responsibility or accountability is transferred between two or more health care entities. The transitions can be between the members of the health care team or as transitions over time, between episodes of care (Agency for Healthcare Research and Quality [AHRQ], 2014). It is through care coordination that the nurse can truly advocate for the patient. Care coordination is the organization of patient care activities between the participants of patients’ care to ensure that appropriate health care services are provided (AHRQ, 2014). One of the participants must be the RN. All necessary resources required to carry out patient care is managed by communication between the participants among the different aspects of care. The central goal is to meet the patients’ needs with the delivery of safe, quality care. Those involved in care coordination are the patients and their families, health care professionals, system representatives, and health care entities. Figure 4.3 illustrates the different facets of the health care team and how they all work simultaneously to achieve the patient’s individual goal, which is in the center of the triangle. For each patient, this ring will look different depending upon his or her individualized and complex needs and goal. For instance, a patient in a hospital setting may have a goal of being discharged to an acute rehab facility. The surrounding facets may include inpatient care, community resources, and long-term care among others. They all work in conjunction with each other to help the patient achieve the goal of being discharged to the appropriate outpatient facility (AHRQ, 2014).
Figure 4.3
Care Coordination Ring
Note. Adapted from “Care Coordination Measures Atlas Update: Chapter 2. What is Care Coordination?” by the Agency for Healthcare Research and Quality, 2014.
Reflective Summary
No matter the position a nurse holds, he or she is, and always will be, be the patients’ advocate. As an advocate, the nurse is involved with the patient on many levels. The nurse can work with patients in the hospital setting, at home, in clinics, and just about anywhere people can be found. The role of the nurse is continuing to expand to include nurses with advanced practice degrees to be major providers of health care. Nurses are researchers, educators, and teachers, as well as health care providers and patient advocates. The nurse is present from the point of delivery until the end of life. The nurse will continue to be there for patients and to advocate for people from the local to the state to the federal levels of government. Nurses will continue to support programs that support both nurses and patients. Nurses will continue to advocate for safe nursing practice and the delivery of safe quality patient care.
Key Terms
Advocacy: The action of supporting or pleading for a cause or proposal.
Coalitions: Groups of people or organizations that share common interests and focus on common issues.
Federal Register: Daily journal of the U.S. government.
Lobbying: An attempt to persuade or influence the members of a governmental body at the city, county, state, or federal level.
Title VIII Programs: Focus on providing money to nurses for continuing education and advanced degrees; also known as Nursing Workforce Development Programs.
References
Advisory Board. (2016). Nearly 75 percent of all workplace assaults happen in health care, researchers find. Retrieved from https://www.advisory.com/daily-briefing/2016/05/03/nearly-75-percent-of-all-workplace-assaults-happen-in-health-care
Agency for Healthcare Research and Quality. (2014). Care coordination measures atlas update: Chapter 2. What is care coordination. Retrieved from https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/chapter2.html
American Nurses Association. (n.d.a). Advocacy. Retrieved from https://www.nursingworld.org/practice-policy/advocacy/
American Nurses Association. (n.d.b). State. Retrieved from https://www.nursingworld.org/practice-policy/advocacy/state/
American Nurses Association. (n.d.c). Agencies and regulations. Retrieved from https://www.nursingworld.org/practice-policy/advocacy/federal/agencies-regulations/
American Nurses Association. (n.d.d). Nurses serving in Congress. Retrieved from https://www.nursingworld.org/practice-policy/advocacy/federal/nurses-serving-in-congress/
American Nurses Association. (n.d.e). Under threat: America’s education funding for nurses. Retrieved from http://p2a.co/8CFqD6w
American Nurses Association. (n.d.f). ANA-PAC frequently asked questions (FAQS). Retrieved from https://ana.aristotle.com/SitePages/anapac.aspx
American Nurses Association. (n.d.g). Stop nurse abuse: Take the pledge. Retrieved from http://p2a.co/DQPJlDH
Campaign for Action. (n.d.b). Our story. Retrieved from https://campaignforaction.org/about/our-story/
Lucas, F. (n.d.). How a bill becomes a law. Retrieved from https://lucas.house.gov/legislative-work/how-bill-becomes-law
Quinn, W. (2018). Removing barriers to practice and care. Retrieved from https://campaignforaction.org/wp-content/uploads/2018/04/APRN-Practice-two-pager-6-4-18.pdf
Society of Gastroenterology Nurses and Associates. (2012). Understanding and influencing the legislative process. Retrieved from https://www.sgna.org/Portals/0/Education/PDF/Standards-Guidelines/LegislativeStandard_FINAL.pdf
Institute of Medicine. (2011) The future of nursing: Leading change, advancing health. (2011). Retrieved from https://www.nap.edu/read/12956/chapter/1
The National Academies of Sciences, Engineering, and Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://nationalacademies.org/hmd/reports/2010/the-future-of-nursing-leading-change-advancing-health.aspx