Reflection apa format reference less than 5 years

CHAPTER 70

Nursing Education Policy

The Unending Debate over Entry into Practice and the Continuing Debate over Doctoral Degrees

Elaine Tagliareni, Beverly Malone

“Great leaders are almost always great simplifiers, who can cut through argument, debate, and doubt to offer a solution everybody can understand.”

Colin Powell

The educational entry level into nursing practice has been debated for decades. The old debate about entry into professional nursing at the prelicensure level and the latest debate about doctoral education and entry into advanced nursing practice inspire strong opinions from leaders in nursing education and practice. The early debate focused on entry at the prelicensure level, and more specifically, the movement of professional nursing practice into the academic setting. The current debate moves the dialogue to consideration of doctoral education, calling for acceptance of both the traditional research-focused doctorate and the rapidly increasing doctorate of nursing practice (DNP) as the profession's terminal degree. Both debates concern the transformation of nursing practice in the midst of changing health care systems and practice demands.

The belief that a nurse's educational entry point impacts the quality and competence of the nurse's work has fueled both debates. This notion, that entry affects practice, has resulted in numerous position statements from professional organizations describing the nature of education needed for the future. The first of these statements, the American Nurses Association (ANA) 1965, First Position on Education for Nursing (American Nurses Association [ANA], 1965) sought to change the trajectory of nursing education and move education out of the service sector and into academic settings. The paper's authors saw a future with two levels of nursing, technical and professional; two-year colleges would provide “minimum preparation for beginning technical nursing practice” (Committee on Nursing Education, 1965, p. 108) and four-year programs would prepare graduates for beginning professional practice. This document also called for practical nursing programs to eventually be replaced by technical programs. Its publication created controversy and debate in the nursing education and practice communities. Following the 1965 ANA position paper, colleges and university nursing programs created specialized master's programs (MSNs) that became the norm for credentialing and licensing of advanced practice roles. The 2004 position paper of the American Association of Colleges of Nursing (AACN), which called for the establishment of the DNP, proposed that study for the four advanced practice roles (midwives, nurse anesthetists, clinical nurse specialists, and nurse practitioners) should be elevated from the MSN to the DNP level by 2015. The DNP is viewed as the clinical path into specialized advanced practice (Donley & Flaherty, 2002). This was a radical departure from specialized master's programs and represented a new form of entry into advanced practice nursing.

The Entry Into Practice Debate

Historical Perspective

Following World War II, a shortage of nurses occurred because many nurses returning from military service did not re-enter the workforce. Also, changes in health care including hospital-based births, surgical procedures, and anesthesia necessitated more nurses working in hospitals (Haase, 1990). In 1948 the Carnegie Foundation commissioned a sociologist, Dr. Esther Lucille Brown, to study nursing education and to address the critical nursing shortage in the United States caused by a decreased supply of nurses and an increased demand following World War II. Brown's report, Nursing for the Future, called for nurses to be educated in colleges and universities instead of hospital-based programs (Brown, 1948). The ANA and the National League for Nursing (NLN) supported the Brown report and urged the profession to move nursing education into the college environment (Orsolini-Hahn & Waters, 2009). Simultaneously, President Harry Truman convened a National Commission on Higher Education which called for the expansion of community colleges. In response to both documents, the NLN representatives arranged a meeting with the Association of Community Junior Colleges (AAJC) (now known as the American Association of Community Colleges [AACC]), to explore teaching nursing in two-year community college programs (Haase, 1990).

While these events transpired on a national level, faculty at Teachers College, Columbia University, were engaged in the exploration of new models of nursing education. A doctoral student, Mildred Montag, proposed in her dissertation that nurses be educated at community colleges as nursing tech­nicians (Montag & Gotkin, 1959). Based on Dr. Montag's dissertation, entitled Education for Nursing Technicians, she received funding to conduct research on this new model and in 1952, under her leadership, faculty from seven original associate degree programs created the 2-year technical program. Although the course of study was referred to as technical and terminal, a term used at the time to signify that the entire course of study could be accomplished in a set time-frame, faculty in the new programs viewed their mandate as more than the development of a shortened traditional program; they envisioned a program of learning that would revolutionize nursing education. The curriculum was no longer based on a “map of the hospital” (Waters, 2007). By 1980, associate degree programs were educating approximately 20% of new graduate nurses (Orsolini-Hahn & Waters, 2009). At the same time, professional nursing programs developed in baccalaureate programs, although not at the same pace as occurred in community college programs (Haase, 1990). The extraordinary growth of associate degree programs from the midpoint of the last century is compelling: in 2011 associate degree nursing graduates accounted for 60% of new Registered Nurse (RN) graduates from more than 900 associate nursing degree programs nationally (Human Resources Services Administration [HRSA], 2013).

Upheaval Within the Profession

Controversy followed the associate degree programs from their inception. The main reason for this was that the educational model was not consistent with the way associate degree graduates were used in practice. Dr. Montag had proposed this new model based on a two-level system of nursing care delivery. She intended that associate degree graduates would function in teams led by baccalaureate-prepared nurses due to the significant difference in technical and professional education. The practice environments, however, used the associate degree graduate in management and leadership positions where they performed satisfactorily (Orsolini-Hahn & Waters, 2009). For almost 50 years, nursing attempted to define the differences between gra­duates of the two types of nursing programs. Because these debates focused on practice in acute care both at the bedside and in management, where roles of both graduates were blurred and overlapped, they failed to clearly define the differences (Haase, 1990). In both education and practice, no clear distinctions between the two levels emerged and most employers never distinguished ADN and BSN nurses with regard to pay, function, or task.

As early as 1965, organized nursing attempted to bring clarity to the differentiation debate. Due to the increasing complexity of health care and changes in practice, the ANA convened the Committee on Education to study nursing education, practice, and scope of responsibilities. The study group recommended that the minimum preparation for professional nursing practice should be the baccalaureate degree. The Committee on Education's statement became the ANA's position paper and contained a description of three levels of nursing education: baccalaureate education for beginning professional nursing practice, associate degree education for beginning technical nursing practice, and vocational education for assistants in the health service occupations (ANA, 1965). The authors of the position statement also recommended that associate degree programs replace practical nursing programs, further alienating vocational and practical nurses and faculty. That same year, the NLN published a document, Resolution 5, calling for examination of the differentiated functions of the two levels of nursing education (Haase, 1990). Subsequently, the 1965 ANA position paper was later reaffirmed by a 1978 ANA House of Delegates resolution which resulted in the recommendation that, by 1985, the minimum preparation for entry into professional practice would be the baccalaureate degree.

These actions divided the health and nursing community (Donley & Flaherty, 2002). Many associate degree nurse educators became disillusioned with the ANA and NLN, leaving both organizations to start a new organization in 1986, the National Organization for the Advancement of Associate Degree Nursing, which later became the National Organization for Associate Degree Nursing (NOADN). The NLN established separate councils for associate degree and baccalaureate educators; the councils rarely interacted. And strained relationships developed between faculty in both types of programs, resulting in little constructive dialogue on ways to differentiate between programs and build a more educated workforce, which had been the primary intent of the Brown report, the ANA 1965 position statement, and the NLN early documents. The central focus of the early debate had been to improve educational preparation, elevate the status of nurses, and ultimately improve the quality and safety of patient care. Yet nursing had become mired in differentiation debates that served only to sidetrack the discussion. As a result, more than 50 years later, the need for a more educated workforce remained at the core of the entry into practice debate.

Current Climate: Collaboration with Common Goals

The release of the Robert Wood Johnson Foundation (RWJF) and Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health (2011) was a pivotal event in the entry to practice debate. The report's wide dissemination and the positive response from the nursing community changed the national focus from differentiation debates to collaborative calls for an “action-oriented blueprint for the future of nursing” to advance the nation's health. Two of its recommendations related specifically to academic progression within nursing: (1) to support an increase in the proportion of nurses with a baccalaureate degree in nursing by 2020 from 50% to 80% and (2) to double the number of nurses with doctorates to add to the cadre of nurse faculty and researchers, with attention to diversity (Institute of Medicine [IOM], 2011). The report noted that nurses who enter the profession with either an associate or baccalaureate degree on average seek one more degree over the course of their careers and that approximately 60% of new nurses are associate degree graduates. Thus, having sufficient qualified faculty and advanced practice nurses to manage emerging models of care in a variety of settings would be unattainable with current articulation agreements. The report affirmed that in order to respond to increasing demands, nurses must achieve higher levels of education and training through an innovative education system that promotes seamless academic progression.

What factors influenced this change in thinking? What turned the dialogue away from differentiation to how academic progression could be accomplished to benefit the profession and advance the nation's health?

Factors Outside of Nursing.

Numerous trends converged to coalesce around the need for a more educated workforce in the context of multiple entry points into the profession. The complexity of care and the predicted shortage of RNs in the mid-1990s to provide that care drove home the need for those RNs in the workforce to be better prepared to provide new models of care delivery, to manage the care of individuals with complex chronic care needs who require intervention in both institutional and home settings, and to teach future nurses in schools of nursing. Additionally, the calls for health care re­form, which preceded the adoption of the Patient Protection and Affordable Care Act (2012), called for new approaches to delivering care to chronically ill individuals and a greater focus on health pro­mo­tion and disease prevention. These approaches re­quire nurses who are knowledgeable about research, care coordination, outcomes management, risk assessment, and quality improvement, skills that are core to the practices of professional nurses. New methods of care delivery required a systems approach to address the consequences of disparities in access to health care services that preclude quality care for all individuals. They also required that nurses have advanced study and practice experience.

Over time, the nursing community embraced the idea that the need for a highly educated workforce was the key issue, not the nurse's educational entry point. Academic progression would be the critical factor for the nursing profession to fully impact the quality and competence of a nurse's work, and the movement to embrace academic progression as essential to nursing's future gained new energy and momentum.

Factors Inside of Nursing.

In 2011, the National League for Nursing released a statement promoting academic progression in nursing education. The statement made clear the NLN's conviction that transformation of nursing education is vital to the preparation of a nursing workforce prepared to tackle the demands of our ever-changing, dynamic 21st century health care system, with its advanced technologies, culturally diverse and aging patient population, and the shrinking of global borders. The NLN reaffirmed its support of multiple entry points to the nursing profession and advocated for creating new opportunities for life-long learning and academic progression to ad­vance the nation's health. Additionally, The Future of Nursing: Campaign for Action, was launched shortly after the release of the IOM report in 2010. The campaign, a national initiative to guide implementation of the report's recommendations, envisions a health care system where all Americans have access to high-quality care, with nurses practicing to the full extent of their capabilities. It is coordinated through the Center to Champion Nursing in America (CCNA), an initiative of the AARP (formerly the American Association of Retired Persons), the AARP Foundation, and the RWJF. As of 2014, the campaign included 51 state Action Coalitions and a wide range of health care providers, consumer advocates, and other leaders.

Internal Cohesion Comes to Nursing.

In the wake of the IOM report's release, groups and organizations that were once viewed as adversarial developed joint position statements and programs. In 2012, The Joint Statement on Academic Progression for Nursing Students and Graduates brought together the NLN, AACN, American Association of Community Colleges, Association of Community College Trustees, and NOADN to declare that every nursing student and nurse needs to have access to additional nursing education (NLN, 2012).

The momentum generated by this report and the Campaign for Action resulted in dramatic changes in academic progression in nursing. The number of students enrolled in RN to BSN programs increased by 22% from 2011 to 2012 (American Association of Colleges of Nursing [AACN], 2012). By 2014, AACN data revealed a strong enrollment surge in baccalaureate nursing programs designed for practicing nurses looking to expand their education in response to employer demands and patient expectations. The number of students enrolled in RN to Bachelor of Science in Nursing (BSN) programs increased by 12.4% in 2013, the 11th year of enrollment increases in these programs (AACN, 2014a). These data reflect a trend in hospital employment that favors BSN graduates, and 59% of new BSN graduates had job offers at the time of graduation, which is substantially higher than the national average across all professions (29.3%) (AACN, 2013b). As employer demand has increased, more nurses from ADN and diploma programs recognize the need to advance their education to remain competitive in today's workforce.

Additionally, enrollment in master's and doctoral degree nursing programs also increased significantly. Nursing schools with master's programs reported an 8% jump in enrollments. In doctoral nursing programs, the greatest growth was seen in DNP programs where enrollment increased by 20% between 2011 and 2012. Enrollment in research-focused doctoral programs increased slightly by 1% (AACN, 2012).

At this time nursing students from minority backgrounds represented 28.3% of students in entry-level baccalaureate programs, 29.3% of master's students, and 27.7% of students in research-focused doctoral programs (AACN, 2014). RN-to-BSN programs exhibited the largest upturn, with minority enrollment gaining four percentage points to reach 26%. Although community college nursing programs are often the access point for entrance into nursing for individuals from minority backgrounds, there is much work to be done in nursing to have adequate representation reflective of the U.S. population.

The history of nursing progression in education includes years of debates about entry into practice at the prelicensure level, an exercise that proved to be divisive and counterproductive. For more than 50 years, from the time of the 1965 ANA position statement, the nursing community became sidetracked about how to achieve differentiation, and the ensuing debates diverted nursing's productive energy away from its fundamental vision to meet the needs of patients in changing practice environments. With the release of the IOM Future of Nursing report (2011) that energy is now channeled into productive dialogue about academic progression and creation of innovative programs to move new RN graduates more efficiently and effectively into advanced degrees. The next 50 years are poised to witness the transformation of nursing practice in the midst of changing health care systems and practice demands.

The Entry Into Advanced Practice Debate

Historical Perspective

Advanced practice nursing emerged as a response to the physician shortage in the late 1950s (Joelle, 2002). By the mid-1960s, nurse practitioner programs existed throughout the United States as post-baccalaureate certificate programs of varying length (O'Sullivan et al., 2005). In 1990 the National Organization of Nurse Practitioner Faculties (NONPF) published Advanced Nursing Practice: Nurse Practitioner Curriculum Guidelines and called for nurse practitioner education to be grounded in graduate level programs (National Organization of Nurse Practitioner Facilities [NONPF], 1990). Within the next decade, the shift away from certificated nurse practitioner (NP) programs was complete, with less than 1% of all NP programs representing non-master's education tracks (O'Sullivan et al., 2005).

Over time a growing movement evolved within nursing to reconsider nurse practitioner educational preparation in earnest. The practice doctorate was discussed as a means to meet the demand for increased knowledge and skills. The following societal changes and emerging health care trends sparked this movement:

• In the late 1990s, nurse-managed health centers emerged as safety net providers for underserved populations, extending the range of primary care services offered by nurse practitioners in autonomous practice settings (Hansen-Turton & Kinsey, 2001; O'Sullivan et al., 2005).

• The nursing community recognized that the demand for new models of care to manage complex chronic comorbidities, specifically of an aging population, required movement away from illness management to nontraditional approaches to case management involving multiple intersecting systems of care. Nurse faculty teaching in NP programs called for parity with other allied health professions. These disciplines, for example, pharmacy, audiology, and physical therapy, had expanded their master's degree programs and created practice doctorates in response to the need for advanced practice professionals to work within complex systems, advocating for evidence-based quality care in an interdisciplinary environment. Nursing leaders argued that parity for nursing was not simply a matter of status but a necessary credential for credibility in leadership and policy positions (Lenz, 2005).

• The Institute of Medicine (2003) proposed changes in practice to reduce medical errors and increase the competencies needed to deliver quality care, including use of informatics, understanding of quality improvement, a focus on patient-centered care, wide acceptance of evidence-based practice, and movement to inter-disciplinary care models. Changes in practice would require new approaches to the education of advanced practice health care professionals, including courses in health care finance and policy, process and outcomes measurement, and analysis and use of evidence-based methods to plan and implement care (O'Sullivan et al., 2005). These new educational demands resulted in increased clinical and classroom hours in NP programs; however, the credit allotment had not increased commensurately. It became apparent to faculty in NP programs that nursing may be under-credentialing its advanced practice graduates (Lenz, 2005).

Emergence of the DNP: the Early Debate

In 2004, AACN members endorsed a position statement on the Practice Doctorate in Nursing (AACN, 2004). This document was a response to calls for change in master's-level advanced practice nursing programs and advocated for moving entry from the master's to doctorate level by the year 2015. The DNP, as the new entry level would be termed, was viewed as a viable alternative to the research-focused doctorate in nursing for those nurses who desired to pursue excellence in nursing practice.

A collaboration between NONPF and the AACN created the publication of the AACN documents (AACN, 2004, 2006). This generated considerable debate within the nursing community (Donley & Flaherty, 2002; Meleis & Dracup, 2005; NLN, 2007):

• What to do about schools in colleges or universities that are not authorized to offer doctorates or interested in offering a DNP?

• Was the AACN document released too soon, before adequate analysis and support from the nursing community could be garnered?

• Did the apparent separation of practice and research in the DNP program's curriculum lead to greater fragmentation in advanced nursing education?

• With the research-intensive environment of higher education, would the DNP undermine the scholarly productivity and funding advantage that schools of nursing receive from research grants?

• What was the impact on the need for well-qualified nursing faculty?

Exponential Growth of the DNP: Less Debate and More Dialogue

Despite the initial concerns about the DNP, the growth of DNP programs across the United States has been unprecedented. From 2005 to 2011, DNP programs increased by 85%, with a 66% increase between 2009 and 2011 (Udlis & Mancuso, 2012). By 2014, almost 250 DNP programs existed and an additional 59 DNP programs were in the planning stages. From 2012 to 2013, the number of students enrolled in DNP programs increased from 11,575 to 14,699. During that same period, the number of DNP graduates doubled (AACN, 2014c).

Clearly the DNP program has addressed an unmet need for doctoral preparation in nursing as schools nationwide reported sizable and competitive student enrollment (AACN, 2013a). Although all DNP programs must adhere to the Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006), numerous ways in which to organize and deliver programs currently exist (Udlis & Mancuso, 2012). The Essentials document called for moving the level of preparation necessary for advanced nursing practice from the master's degree to doctorate level by the year 2015, a deadline which has proved to be unrealistic. This variability in both intent and implementation of programs has led to a continuing debate about the purpose and value of the DNP. Three of the issues at the heart of the debate are: lack of standardization of the DNP program, uncertainty over nurse practitioner versus DNP practice, and lack of preparation of graduates for the faculty role.

Lack of Standardization.

The DNP was viewed by proponents as a benefit to advanced practice nurses because it leveled the playing field in terms of status and authority between nursing and other health professions who have practice doctorates. Burns-Bolton and Mason (2012) argued that the DNP would distinguish advanced practice nurses as professionals that compare to other clinical doctorate health professionals but “has been undermined by the development, and now domination, of DNP programs that prepare administrators and educators” (p. 248). The DNP degree does not clearly represent the four roles of advanced clinical practice, and role definitions have been imprecise and unclear.

Lack of Preparation of Graduates for the Faculty Role.

As more and more graduates of DNP programs begin or return to faculty roles in schools of nursing, the concern is that graduates will lack the complex and specialized knowledge intrinsic to the role of the nurse educator. In 2013, the NLN called for doctoral programs in nursing, including both research and practice doctorates, to prepare graduates with the knowledge and skills to teach, provide leadership for transforming education and health care systems, and conduct or translate research in nursing education. In practice disciplines such as nursing, it is especially important that educators and practitioners alike be able to evaluate and demonstrate links between educational outcomes and patient care quality, a particularly challenging task in a health system that is undergoing rapid change.

Calling for the doubling of the number of nurses with doctorates by 2020 to add to the number of nurse faculty, the IOM Future of Nursing report (2011) notes that at no time has there been a greater need for research on nursing education. Consideration needs to be given to the urgent need to not only double the number of nurses with doctorates, whether DNP or PhD, but to prepare them to develop and incorporate evidence-based approaches to coordinated care within programs of learning and to expand graduates' views of patient-centered care, population-based care, and team-centered coordination during care transitions.

Lessons Learned From Nursing's Journey

There are at least five major areas of learning from the profession's protracted journey in nursing education: vision, inclusion, diversity, the practice and education bridge, and the politics of connection: allies, partners, and champions (Box 70-1). To achieve transformation of a system, the nurs­ing community must continually prioritize the essential components of the nursing education agenda and be sure they are consistently implemented across the country.

Box 70-1

Lessons Learned from Nursing's Journey

There are at least five major areas of learning from the profession's protracted journey in nursing education: vision, inclusion, diversity, the practice and education bridge, and the politics of connection: allies, partners, and champions. These are not unknown areas of learning for nursing; however, they are frequently the forgotten and discounted priorities as change is pursued. As time moves us forward, to achieve not only change but transformation of a system, these priorities must be acknowledged and consistently implemented as essential components of the nursing education agenda.

Vision. By refusing to become distracted by old and new arguments related to entry, rather than focus on being responsive to a new vision for the nation's health care system, nursing/education today has the opportunity for leadership into a new era of lifelong learning and progression, claiming a stake in the vision without the perception of exclusive professional self-enhancement, sometimes referred to as tribalism. The vision is the overarching umbrella that allows space for dialogue, reflection, and debate that can exceed our individual or professional differences leading to creative pathways of collaboration and transformation. It is a vision that provides space for cocreation in alignment with the NLN definition of excellence: cocreating and implementing transformative strategies with daring ingenuity.

Inclusion. Nursing's history is replete with vivid examples describing the exclusion of nursing as a legitimate profession. It would seem that having been the recipient of a model of exclusion, we would be especially sensitive and proactive to dispel it within our ranks. Even at this time, however, the nursing profession still clearly disallows space for the licensed practical nurse (LPN) and the health care assistant (HCA). For nursing not to claim our relationship to our colleagues and exclude nurses from a variety of entry points for both prelicensure and postlicensure programs is shortsighted of the patient-centered, community-responsive care vision that a reformed health care system can offer.

Diversity. To focus on the vision for nursing, diversity has to be broader than race and ethnicity (NLN, 2012). Yet to be true to the vision for this nation with its multicultural people, race and ethnicity must also be a focus. Although the nursing workforce is still predominantly white, over time the proportion of racial/ethnic minorities has been increasing. Black/African Americans, Asians, and Hispanics/Latinos currently make up 25% of the RN population. Although this growth is notable, the RN workforce has a smaller percentage of Hispanics/Latinos and black/African Americans when compared with the total working-age population in the United States. The percentage difference for Hispanics/Latinos is particularly troubling: they compose 14% of the working-age population but only 5% percent of the RN workforce (HRSA, 2013). The old and new debates infrequently discuss these issues. Strategic efforts are still lacking in terms of making a difference in diversity. For a culture of diversity within the nursing/education workforce and workplace there must be the desire; the will to envision, create, plan, and implement; and to move to a culture of inclusiveness.

The Practice and Education Bridge. It would seem that the more recent debate on the DNP has learned from the earlier debate on entry for education and practice. This new learning involves an ongoing relationship between practice and education, and means a redesigning of both our nursing education and clinical organizations to be more inclusive of one another. The resounding question is “How can one think about a nursing education or clinical issue without practice and education playing primary roles in understanding the question and helping to determine the answer?”

The Politics of Connection: Allies, Partners, and Champions. From these nursing education debates of old and today, there is the message that nursing cannot stand alone or that even sectors of nursing cannot stand alone. Without allies, partners, and champions, we become so internally focused that we repeatedly lose sight of the vision. The vision of a transformed health care system that is patient centered and community responsive is the life line for the nursing profession. Nursing education with all of its twists and turns has consciously and unconsciously worked to create a strong diverse nursing workforce to heal the world.

Conclusion

Donley and Flaherty (2002) have raised the question regarding the long-term achievements of the 1965 ANA position paper. The document called for all nursing education to take place in colleges and universities; today over 90% of prelicensure nursing programs exist in community colleges and bachelor's degree–granting institutions. In that sense, the position paper had a profound effect on changing the trajectory of nursing education. However if you consider the document to be a call for a more educated workforce, then the mandate has not yet been fully achieved. Similarly, if you consider that the major outcome of the DNP is parity for advanced practice nursing with other allied health disciplines, then the nursing profession is well on its way to establishing leadership and greater policy credibility. Moreover, if the intent is to advance excellence in nursing practice and nursing education to address the vision of a transformed health care system that is patient centered and community responsive, the outcome is, at present, unknown.

Discussion Questions

1. Is the current movement to produce a more educated workforce consistent with multiple entry points into the profession? Can these two realities exist in harmony?

2. How will the profession provide leadership to address the vision of a transformed health care system that is patient centered and community responsive? How will nurses with doctorates, whether DNP or PhD, lead the development and use of evidenced-based approaches to nursing education? Will these two challenges be the next debate for the nursing profession?

3. How will the lessons learned from nursing's protracted journey in nursing education influence future debates about nursing's role in health care reform?

References

American Association of Colleges of Nursing [AACN]. Position statement on the practice doctorate in nursing. [Retrieved from]  www.aacn.nche.edu/DNP/DNPPositionStatement.htm; 2004.

American Association of Colleges of Nursing [AACN]. The essentials of doctoral education for advanced nursing practice. [Retrieved from]  www.aacn.nche.edu/DNP/pdf/Essentials.pdf; 2006.

American Association of Colleges of Nursing [AACN]. AACN releases preliminary data from 2012 annual survey. [Retrieved from]  www.aacn.nche.edu/news/articles/2012/enrolldata; 2012.

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Online Resources

AACN Position Paper: The Baccalaureate Degree in Nursing as Minimal Preparation for Professional Practice.

 www.aacn.nche.edu/Publications/positions/baccmin.htm.

Future of Nursing Campaign for Action.

 www.nln.org/aboutnln/livingdocuments/nln_vision.htm.

NLN Vision Series.

 www.nln.org/aboutnln/livingdocuments/nln_vision.htm.

CHAPTER 72

Interest Groups in Health Care Policy and Politics

Joanne R. Warner

“Politics isn't about big money or power games; it's about the improvement of people's lives.”

Paul Wellstone

The ink from President Obama's pen was hardly dry as he signed the Patient Protection and Affordable Care Act (ACA) into law before interest groups were considering how to stall or prevent its implementation. In fact on that very day, March 23, 2010, a suit was filed declaring the law unconstitutional. Included in the suit's supporters were private interest groups such as Citizens United who objected to the law's mandate to buy insurance or pay a penalty. A legal conclusion to their questions came in a June 2012 Supreme Court ruling upholding the individual mandate, but striking down the requirement for states to expand Medicaid ( Clemmitt, 2012 ). The legislative journey for the ACA presents many examples of interest group influence, including the citizen activists' organization Americans for Prosperity, who continue to cast doubts on the ACA's merits, warning that the implementation is “chaotic and frustrating” ( Peters, 2013 , paragraph 4). What promises to unfold for the ACA is the robust involvement of interest groups vociferously defending their preferences in the structure and financing of America's health care system.

Interest groups play a significant role in health care reform. However, they are a paradox within our governing system. We need and value them but at the same time they annoy and distract us. We embrace them as empowered citizen involvement, and we resent the perception of buying elections and votes. The love-hate ambivalence is born, in part, from the way a 1787 notion has translated into today's Washington-centric political era. Democracy within our individualistic society presents inherent tensions that are both our genius and our burden.

An interest group is a collection of people who pursue their common interests by influencing political processes. They are also known as factions, special interests, pressure groups, or organized interests. The original definition depicted them as “united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens, or to the permanent and aggregate interests of the community” ( Madison, 1787 , paragraph 2). The mere act of organizing presupposes “some kind of political bias because organization is itself a mobilization of bias in preparation for action” ( Schattschneider, 1960/2005 , p. 279). Today, federal, state, and local political arenas experience the activity of organized groups who influence elections, votes, societal opinion, and the policy process itself.

This chapter gives context to the duality of distrust and appreciation for interest groups while also portraying them as a significant feature of our governing system. It traces the historical roots of interest groups, describes their functions and methods, and concludes that they embody the good, the bad, and the ugly of governance. It also describes the contemporary terrain of health care interest groups as well as a discernment framework for interest group involvement.

Development of Interest Groups

James  Madison's  The Federalist No. 10  (1787)  forms part of his treatise on the preferred structure of a republic. He proposes that rather than removing the causes of factions, the best wisdom is to control the effects of interest groups. To do otherwise is to undermine liberty. The legitimate roots of interest group organizing are therefore traced to the framers of the Constitution and the birth of the American version of democracy. Later, the French philosopher Alexis de Tocqueville observed the country from an outsider's view. His Democracy in America (1835) endures as a classic description of our inclination to form associations for common purpose and to create a vibrant political structure independent of the state ( de Tocqueville, 1835/2010 ).

The impetus to organize exists not only within the American people but also within the political structure. Groups can influence policy through elections, lobbying the legislature, and pressuring the executive branch of any level of government.This diffusion of power presents many opportunities for persuasion. It also allows interest groups to shop for a different level of government if they are unhappy with policy; for example, federal versus state government ( Anderson, 2011 ).

Historically, groups formed around interests such as slavery and alcohol prohibition. At the turn of the twentieth century, interest groups based in Washington blossomed. The social activism of the 1960s generated more groups focused on civil rights, the environment, and specific economic and humanitarian causes ( Nownes, 2013 ). As the power and money of interest groups grew, Congress acted to restrict their influence and limit direct contributions to candidates. However, the reforms that grew from the Watergate scandal of the 1970s inadvertently enhanced their power by promoting the formation of political action committees (PACs). The Bipartisan Campaign Reform Act of 2002 (the McCain-Feingold Act) revised the Federal Election Campaign Act of 1971 to control soft money contributions, that is, funds funneled through political parties to candidates, and the funding of issues ads ( Federal Election Commission, 2013a ). For good or ill, special interest money continues to grease electoral and political wheels.

From this historical perspective, several kinds of groups are in existence today: the trade unions and business associations that advance their economic interests, and the groups representing newer social movements ( Fiorina et al., 2009 ). Within the latter group, there are interest groups that provide information and are active in the current health care reform debate. Examples include the U.S. Public Interest Research Groups (USPIRG), who “stands up to powerful interest when they threaten our health and safety” or when big money dominates the dialogue ( U.S. Public Interest Research Groups, 2013 ); Essential Action, which wages campaigns on topics not visible in the mass media or on political agendas including access to medicines and the global effort to reduce tobacco use ( Essential Information, 2013 ); and the Center for Science in the Public Interest (CSPI), whose consumer advocacy in health and nutrition involves novel research, providing information, and ensuring that science and technology serve the public good ( Center for Science in the Public Interest [CSPI], 2012 ). These examples demonstrate the enduring nature of interest groups juxtaposed as an evolving list of groups and issues.

When is an interest group not what it appears? Astute citizens and policymakers need to be aware of front groups whose public persona is that of an unbiased group but whose funds and agendas are from an industry or political party. For example, the Center for Consumer Freedom, which has a message of individual choice but is a front group for the restaurant, alcohol, and tobacco industries. This group opposes public health messages of science, health, and environmental groups, calling them a “growing fraternity of food cops, health care enforcers, anti-meat activists, and meddling bureaucrats who ‘know what’s best for you’” ( Source Watch, 2009 ). The popular Get Government Off Our Back (GGOOB) campaign was also exposed as a tobacco industry front group that rallied diverse groups to oppose policy. Analysis of GGOOB suggests that knowing the source of a group's funding can limit harmful misrepresentation and highlight how ideological arguments can diminish the power of solid science and research in policymaking ( Apolionio & Bero, 2007 ). The presence of front groups calls each consumer to vigilance about the bias and intention of groups who advocate and provide information.

Functions and Methods of Influence

How do interest groups function within a complicated governance system? What methods can they use to advance their causes, and how do they determine which to use? Their methods are lobbying, grassroots mobilization, influencing elections, shaping public opinion, and litigation.

Lobbying

Lobbying involves the direct influence of public officials and their decisions.  Wolpe (1990)  presented a concise description of lobbying as “the political management of information” (p. 9) because it involves educating, shaping opinions, and offering data and analyses. Lobbyists also often assist in bill drafting and revision. By hiring full-time Washington- or state-based lobbyists, groups have a more enduring presence; this also allows for ongoing relationships between staff, officials, and lobbyists to be the foundation of influence. Lobbyists become adept at the nuances of the legislative process and can provide nimble responses.

The largest number of registered federal lobbyists recorded to date is 14,842 in 2007 and the largest total lobbying expenditure was recorded at $3.55 billion in 2010. In 2012, 12,407 federal lobbyists were a part of $3.31 billion lobbying spending ( Center for Responsive Politics, 2013a ). Of the top 8 lobbying industries in 2013, four are related to health: insurance, hospitals, pharmaceuticals, and physicians, in order of size ( Center for Responsive Politics, 2013b ). Lobbying is thus a substantial business.

Grassroots Mobilization

Grassroots mobilization involves indirectly influencing officials through constituency contact. More decentralized politics and expanded communication options make grassroots involvement effective. Pseudo-grassroots efforts that mobilize technology more than citizens are mockingly called AstroTurf lobbying; another version is grass-tops lobbying, when a prominent personality champions an issue. Most interest groups employ some version of grassroots mobilization ( Bergan, 2009 ).

Electoral Influence

Electoral influence can be considered the primary prevention of policymaking because it is an important activity that precedes policy work. It determines who is elected to shape future policies ( Warner, 2002 ). Successful electoral campaigns need three resources: time, money, and people. Interest groups can provide the last two. Just as interest groups provide a collective voice, PACs provide the collective financial support. For example, the American Nurses Association (ANA) formed the ANA-PAC in 1974 to support federal candidates who are aligned with the ANA agenda and values, with the ultimate intent of improving the health care system ( ANA ,  2013 ). As a result of campaign reform efforts in 2002 the influence of PACs has been contained. During 2013 to 2014 PACs can only donate $5000 per election (primary, general, or special) and $15,000 annually to a national party, although individuals can give up to $2600 per year to each candidate ( Federal Election Commission, 2013b ).

Shaping Public Opinion

Shaping public opinion overlaps with electoral influence and grassroots mobilization; it involves issue advocacy and public persuasion, similar to campaigning for an issue. It is similar to an infomercial that sells an issue or to direct mail blanketing an area with information promoting a particular perspective. The impression of societal consensus could, in turn, persuade policymakers as they create policy. These initiatives either cost money or are free media in the form of news coverage.

Litigation

Lastly, litigation can shape governance toward the goals of the group. The Brown v. Board of Education of Topeka, Kansas is a classic example of years of strategic effort culminating in a significant judicial ruling changing the landscape of society. The National Association for the Advancement of Colored People (NAACP) was the interest group championing social justice and the elimination of racial discrimination that organized 200 plaintiffs in five states to bring cases of racial segregation and discrimination in schools to the Supreme Court. This ruling affected racial discrimination throughout society and inspired interest groups to pursue their proposed change through the court system ( Brown Foundation for Educational Equity, Excellence and Research, 2012 ).

To create their action plans, each interest group develops a distinct identity that originates in its methods, resources, and purpose. This discussion of function and method illustrates that their influence within the governance process, whether nuanced or bold, can span the entire process and can range from superficial to substantial.

Related to the scope of influence is the question of effectiveness. The critique ranges from the good to the bad and the ugly. Many maintain that they successfully enhance our democratic processes and actualize our early vision of democracy, as argued by James Madison. In doing so, they prevent violence and tyranny by engaging citizens in social change through other means. In theory, groups represent our pluralistic and transparent government. In practice, scholars believe that opposing groups' lobbying, media, or actions often cancel out their cumulative influence ( Fiorina et al., 2009 ).

The bad and the ugly of their influence were termed demosclerosis, or the clogged vessels of our governmental body and subsequent policy gridlock. This acknowledges that the country's well-being cannot be achieved through the collective concerns of special interests and that the policy process grinds into inaction with too many special groups vying for their own advantage ( Rauch, 1994 ).  Quadagno (2005)  presents a bold example of demosclerosis by concluding that health care reform has been thwarted over the years by special interests and that these groups are the “primary impediment to national health insurance” (p. 207). Even as the antireform coalition has changed over the years from primarily physicians to insurers, its goal of inertia and status quo has prevailed over the reformers' efforts. The chronicle of the ACA provides contemporary examples.

Landscape of Contemporary Health Care Interest Groups

A Pittsburgh Post-Gazette editorial warned then President-Elect Obama against health care reform early in his presidency because “the field is a rat's nest of entrenched interests” ( Pittsburgh Post-Gazette , 2008 , p. 2). This unsavory reference underscores the complex nature of health care interests. Who are these players, what money is involved, and what is nursing's place and relative effectiveness in the context of federal lobbying groups?

Funds from interest groups are predominantly spent on lobbying and on campaign contributions, and the health industry is heavily involved in both. The Center for Responsive Politics (a nonpartisan research group that tracks money in politics) ranked the health sector as the sixth largest interest group contributor. During the 2012 election cycle, health professionals contributed a record $260.4 million to federal candidates; although Republicans received a larger proportion of those funds, nurses traditionally favor Democrats. Lobbying expenditures from the health care sector peaked in 2009 at $552 million as the ACA was being created. The pharmaceutical industry dominated the 2012 spending by contributing $235 million of the total $487 million of health spending ( Center for Responsive Politics, 2013c ). Stakeholders concerned with health care reform also include those outside the health industry (e.g., insurance corporations, labor unions, and myriad business and consumer groups). In fact, from an ecological perspective, most topics eventually trace back to health and the human potential it impacts.

Table 72-1  presents campaign contributions made by health professionals from 1996 to 2012, including both health professional PACs and individual contributions. It demonstrates dramatic increases in contributions and variation in the partisan allocations, usually related to whatever party is in power. Clearly, health professionals are engaged in electoral politics.

TABLE 72-1

Health Professionals' PAC and Individual Contributions to Campaigns

Election Cycle	Total Contributions	% to Democrats	% to Republicans
2012	$152,275,788	43	57
2010	$77,614,465	48	52
2008	$101,791.889	53	47
2006	$56,758.918	38	62
2004	$75,280,121	37	63
2002	$42,738,790	38	62
2000	$48,042,286	42	58
1998	$31,587,151	41	59
1996	$37,811,666	36	64

Adapted from Center for Responsive Politics. (2012). Health professionals: Long-term contribution trends. Retrieved from  www.opensecrets.org/industries/totals.php?cycle=2012&ind=H01 .

Nursing has experience and success with collective involvement in campaigns. The American Nurses Association (ANA) has provided a collective voice and presence in Washington from 1974 to the present. Their goal is the “improvement of the health care system in the United States” by contributing to candidates who support the ANA policy agendas ( American Nurses Association [ANA], 2013a , p. 1). Decisions to endorse candidates are made by the Board of Trustees. It is important to realize that endorsement decisions are based on agreement with ANA's policy stands and not on the candidate's party. In the 2012 cycle, 82% of their $542,500 contributions went to Democrats and 16% to Republicans ( Center for Responsive Politics, 2013d ).  Table 72-2  lists contributions of nursing PAC contributions to federal candidates in 2012.

TABLE 72-2

Nursing PAC Contributions to Federal Candidates

Nursing Political Action Committee	Amount Contributed
American Association of Nurse Anesthetists	$683,800
American Nurses Association	$542,500
American College of Nurse Midwives	$70,500
American Academy of Nurse Practitioners	$63,050
American College of Nurse Practitioners	$26,500

Adapted from  Center for Responsive Politics. (2012) . PACS health: PAC contributions to federal candidates. Retrieved from  www.opensecrets.org/pacs/industry.php?txt=H01&cycle=2012 .

Trended data provide interesting information about the choices that nurses make for their collective electoral influence. The ANA PAC raised and spent over $1 million in one election cycle (1994) but has not reached that amount since. Contrast this to trended data about the American Association of Nurse Anesthetists whose PAC has exceeded $1 million in every election cycle since 2000, with a record high of $1.6 million in 2008 ( Center for Responsive Politics, 2013d ,  2013e ). A simplistic assumption is that nurses donate closer to their specialty, yet the fuller explanation is likely more complex and not yet explained.

When the campaign dust settles and policy-making continues, lobbyists base their advocacy on the values and positions of the group. The ANA, for example, has a long history of supporting universal access to quality health care and advocating for a system that serves the interests of both patients and nurses ( ANA, 2013b ). The key elements of the 2008 Health System Reform Agenda continue to be relevant standards and values that infuse into ongoing reform efforts: access, quality, cost, and workforce. The ACA addresses most of these elements except health care as a human right for all and public funding through Medicaid expansion ( ANA, 2010 ).

The landscape for health care reform therefore is populated with many interest groups, some in the health industry and many with vested interests in the cost and structure of the reform efforts. Significant money goes into elections and lobbying and nursing is involved in both. Although it may not be ranked as one of the most powerful groups, its political currency is trust, integrity, and a reputation for championing quality care for all within an equitable and accessible system.

Assessing Value and Considering Involvement

Most choices involve a “what's-in-it-for-me?” appraisal. In addition to that discernment, the robust ambivalence surrounding interest groups heightens the need for evaluation criteria. How can nurses and other health care providers assess the qualities of an interest group? Where should they allocate their finite resources of time, energy, money, and reputation?

Table 72-3  portrays queries that provide a framework for discernment to assess an interest group and determine the extent of involvement. The framework also provides language and justification for decisions. This approach matches the spirit, though not the rigor, of the scientific evidence-based nature of the health care profession. The nine queries are not listed by priority, as the weight of their importance will differ according to the individual. Nurses can engage in the discernment and defend their involvement in terms of the nine guiding principles, which may prove more thoughtful than replicating the behaviors of our parents or simply following the crowd.

TABLE 72-3

Framework for Assessing Interest Groups

Factor	Questions to Assess the Factor in an Interest Group
Efficiency	What portion of the group's budget supports advocacy, education, or the social interest represented, compared with the portion that supports the group's infrastructure, overhead, or administration?
Effectiveness	What is the track record of accomplishments related to education, awareness, legislation, or cultural change? What outcomes can be credited to the group, either individually or in coalition?
Values	Do the values of the group align with your personal, political, and professional values? Do your beliefs match the values that inspire the group's work? Does this work stir some passion in you?
Tactics	Do you support the methods used by the group? Do the tactics match your preferred approach to social change, including options such as violence, protesting, nonviolent resistance, media campaigns, or organized action?
Visibility and responsiveness	Does the group have the level of public visibility that you prefer? Do they employ the level of outreach to their members that you prefer? Do they communicate clearly and consistently with the constituency?
Social norms	Does the group match your local culture and the social norms of the people with whom you associate? Would your involvement in this group change the way people perceive you personally or professionally? Does that perception matter to you?
Perception	What is your perception of the leaders and key stakeholders of the interest group? Does that perception matter to you?
Costs	What would involvement require of you? Are there dues or voluntary financial commitments? Can you contribute the amount of time required? Will they ask to use your name, title, or reputation, and will any unintended implications involve professional cost? Does your employer prohibit or discourage involvement with this group?
Benefits	What's in it for you? Will you obtain any profit, professional advantage, or membership benefits? Do you value the social benefit of association? Are you willing to be involved for altruistic intentions? Are you willing to be involved if the benefits go to others, for example, an underrepresented population, the environment, or a cause beyond your immediate life?

Conclusion

In a democracy, interest groups are integral to the governing process. They are sanctioned by our Constitution and valued as a vehicle for citizen participation, but are also despised as an underhanded wielding of influence through money. Despite societal ambivalence, they are likely here to stay. Perhaps the best approach is to cleverly frame them. As Republican strategist Mary Matalin whimsically noted, “They're stake-holders when they're with you, and they're interest groups when they're against you” ( Espo, 2009 , paragraph 8). Or perhaps the best advice is to intentionally discern our own involvement, know the rules of the game, and use interest group power to further the causes we treasure.

Discussion Questions

1. In what ways is, or is not, the nursing profession a special interest group in American democracy?

2. What strategies would enhance the effective influence of nurses as a collective special interest group in policy advocacy and electoral politics?

3. What role does the nonpartisan stance of nursing PACs play in the broad engagement of nurses in electoral politics and policy advocacy?

References

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Online Resources

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CHAPTER 74

Professional Nursing Associations

Operationalizing Nursing Values

Pamela J. Haylock

“The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.”

Code of Ethics for Nurses with Interpretive Statements, Provision 9 (2001)

The tendency to form associations for common action characterizes American culture, something noted nearly 2 centuries ago by Alexis de Tocqueville during his 10-month stay in America ( de Tocqueville, 1835/2000 ). Nursing associations facilitate and accomplish the work of the profession. Today, there are more than 120 nursing specialty associations in the United States ( American Journal of Nursing, 2012 ). Other associations have international and multidisciplinary membership, and still more represent ethnic groups, specialties, and specific interests of nurses.

This chapter presents an overview of professional nursing associations, their critical roles in leadership development of members, and use of collective professional voices to shape policy, advocating for nursing and consumers of health care.

The Significance of Nursing Organizations

Professional organizations and associations in nursing are critical for generating the energy, flow of ideas, and proactive work needed to maintain a healthy profession that advocates for the needs of its clients and nurses, and the trust of society ( Matthews, 2012 ). Members can engage in discussions and advance solutions for issues of quality, access, and costs of care. In addition to advancing nursing knowledge and clinical competencies, professional organizations build nurses' leadership skills and promote the advocacy component of nurse practice by ( Schroeder, 2013 ):

• Providing networking and collaboration opportunities

• Facilitating discussion forums on issues

• Lending a collective voice to legislative and policy initiatives

• Providing leadership development opportunities

Active, engaged members feel more connected to the profession and tend to have broader perspectives beyond a particular community or practice setting ( Cardillo, 2013 ). Personal and professional development occurs through volunteer activities, mentoring by more experienced members, and holding elected office. An association's publications, e-mail, and social media help members to be informed about clinical, employment, regulatory, and political issues affecting practice. Most importantly, professional associations allow nurses to speak in one voice, finding common ground and developing common messages, visions, and missions, reducing the fragmentation that hampers nurses' efficacy in shaping policy.

In 2010, the Institute of Medicine released the report The Future of Nursing: Leading Change, Advancing Health ( Institute of Medicine [IOM], 2011 ). An underlying principle of the initiative is that “accessible, high-quality care cannot be achieved without exceptional nursing care.” The report notes that realizing full economic value of nurses' contributions across health care settings can enable nurses to help bridge the gap between coverage and access, coordinate complex care, and meet the need for primary care. Four key messages structure the report's 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.

• Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.

• Effective workforce planning and policymaking require better data collection and an improved information infrastructure.

The Future of Nursing Campaign for Action, an initiative of AARP (formerly the American Association of Retired Persons), the AARP Foundation, and the Robert Wood Johnson Foundation (RWJF), is rooted in pillars to drive and measure change ( Campaign for Action, n.d. ):

• Advancing education transformation

• Leveraging nursing leadership

• Removing barriers to practice and care

• Fostering interprofessional collaboration

• Promoting diversity

• Bolstering workforce data

There is uncertainty surrounding the profession's abilities to overcome major obstacles that prevent nurses from optimizing their impact in health policy. A Gallup poll of more than 1500 acknowledged national opinion leaders found that, although nurses were identified as the health professionals who should have greater influence in the areas of patient care quality and safety, major obstacles prevent such influence from becoming reality ( RWJF, 2010 ). A crucial obstacle to maximizing nursing's influence is the fragmentation in the leadership of organized nursing ( IOM, 2011 ). This dismal prophecy begs the question: How can nurses become full partners in America's health care redesign? The Future of Nursing report calls for nurses to assume leadership roles, provide mentorship for the next generations of nurses, and participate in policymaking processes ( IOM, 2011 ). The IOM report has brought about significant unification among national nursing organizations around a policy agenda. Professional organizations offer nurses opportunities to be part of the answer to questions about promotion of health and well-being and providing safe and quality care to the diverse population of the United States.

Evolution of Organizations

Nursing organizations emerged as nursing became a social force. The first nursing organization, the Royal British Nurses' Association, was founded in 1887. In North America, nursing groups initially appeared as alumnae associations focused on nursing schools and alumnae groups. The need for a broader focus became apparent along with the recognition of the importance of nursing influence ( Dolan, Fitzpatrick, & Herrmann, 1983 ). A meeting of superintendents of nurse training schools during the 1893 Chicago World's Fair resulted in the formation of the American Society of Superintendents of Training Schools (ASSTS). The ASSTS became the National League of Nursing Education and, later, the National League for Nursing. In 1896, 10 alumnae associations merged to become the Nurses' Associated Alumnae of the United States and Canada. The group's name changed in 1899 to the Nurses' Associated Alumnae (NAA) of the United States. The American Nurses Association (ANA) was formed in 1911 as the successor to the NAA. State nurses' associations were organized in 1901 to enhance nurses' influence in state legislative initiatives for the registration of nurses and to control nursing practice, including improving employment conditions, limiting duty hours, and advocating hospital employment of greater numbers of graduate nurses ( Reverby, 1987 ).

The International Council of Nurses (ICN), founded in 1899, is the oldest international association of professional women ( ICN, n.d. ). The underlying philosophy of the ICN acknowledges nurses' four fundamental responsibilities: to promote health, to prevent illness, to restore health, and to alleviate suffering. Today, the ICN is a federation of more than 130 national nurses associations (NNAs) representing the world's 16 million nurses.

Today's Nurse

Most nursing organizations are voluntary membership associations, requiring licensure as registered or vocational (or practical) nurses for access to full member benefits. Other levels of membership (honorary and corporate memberships, for example) are offered by some organizations to individuals and entities with expressed interest, commitment, and/or major contributions (financial or otherwise) to the mission of the organization. Elite organizations, exemplified by Sigma Theta Tau International (STTI) and the American Academy of Nursing (AAN) have restrictive member qualifications. Such entities are referred to as professional peak bodies (or peak professional bodies) ( Middleton, Walker, & Leigh, 2009 ).

STTI was founded in 1922; founders chose the name from the Greek words storgé, tharsos, and timé, meaning love, courage, and honor. Its mission is to “support the learning, knowledge and professional development of nurses committed to making a difference in health worldwide” ( STTI, n.d. ). Membership is by “invitation to baccalaureate and graduate nursing students who demonstrate excellence in scholarship and to nurse leaders exhibiting exceptional achievements in nursing.” Today, STTI has some 130,000 active members and 490 chapters in more than 85 countries. STTI supports its mission through products and services in education, leadership, career development, evidence-based nursing, research, and scholarship.

The AAN, affiliated with the ANA, held its inaugural meeting in 1973, welcoming the first 36 charter members, referred to as Fellows. Today, the AAN's more than 2300 Fellows are nursing's most accomplished leaders in education, management, practice, and research ( AAN, 2014 ). Fellows are recognized for extraordinary contributions to nursing and health care, although invitation to the fellowship represents more than recognition of accomplishments: Fellows assume responsibility to contribute time and energies to the Academy and to engage with other leaders in transforming U.S. health care through a focus on health policy.

Nurses have historically been expected to join professional organizations, at least one, if not multiple organizations, as an obligation or duty of a professional ( Felton & Van Slyck, 2008 ). However, this sense of professional obligation has dwindled over the past recent decades ( Coerver & Byers, 2011 ). Organizations must adapt to changing circumstances to remain relevant and attend to potential and existing members' decisions to join. As a reflection of professional realities, the number of specialty nursing organizations continues to increase: today, most of the more than 120 nursing organizations are focused on specialty practice and offer means to get and maintain competencies, get information, find peer networks, and access other products and services that focus on their needs.

The IOM's The Future of Nursing contends that:

…nursing organizations must continue to collaborate and work hard to develop common messages, including visions and missions, with regard to their ability to offer evidence-based solutions for improvement in patient care. ( IOM, 2011 , pp. 239-240)

Establishment of common ground is an essential first step to eliminating fragmentation and maximizing nursing's leadership and influence. When common ground is established, organizations need to activate members and constituents to work together in support of shared goals. Only when confronted with the United States' largest group of health professionals acting in agreement on important issues, speaking with one voice, will policymakers listen and take action.

Quality and safety are practice areas in which nursing organizations can and do find common ground and provide needed leadership. For example, the Nursing Alliance for Quality Care (NAQC), now managed by the ANA, is a partnership of nursing organizations, consumers, and other stakeholders and is a model initiative designed to advance quality, safety, and value of patient-centered care ( NAQC, 2013 ).

Organizational Purpose

The Code of Ethics for Nurses ( ANA, 2001 ) is an explicit statement of the primary goals, values, and obligations of those who enter the profession. Provisions 3 and 6 emphasize expectations of individuals and groups to advocate for social justice and the welfare of the sick, injured, and vulnerable, establishing a foundation for complementary roles of professional associations and association members. Provision 9 specifically articulates the complementary roles of the profession, associations, and individual members, as noted in the quotation that opens this chapter.

Nursing associations contribute to the work of the profession by means typically described in mission statements, bylaws, and charters of committees and other work groups. The existence of so many diverse nursing organizations has advantages and disadvantages for the profession. On one hand, the diversity and large number of organizations suggests that there is an organization to fit most, if not all of nurses' professional needs and interests. Conversely, the large number of diverse organizations creates competition for members, and resources, and, in general, complicates and weakens efforts of the profession to speak with a single and forceful voice.

Mission statements define organizational purpose—the reason to exist ( Nanus, 1992 ). Organizational missions stipulate the “work” of the profession, sharing intentions to advance the profession and practice and enhance health-related outcomes. The ANA mission is “Nurses advancing our profession to improve health for all” ( ANA, 2013 ). The ANA adds a more lengthy “statement of purpose” to claim a role in shaping health policy:

ANA advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regulatory agencies on health care issues affecting nurses and the general public. ( ANA, 2013 )

The mission of the American Organization of Nurse Executives (AONE), a subsidiary of the American Hospital Association, is “to shape the future of health care through innovation and expert nursing leadership” ( AONE, 2013 ). The AAN's mission is to “serve the public and nursing profession by advancing health policy and practice through the generation, synthesis, and dissemination of nursing knowledge” ( AAN, n.d. ).

Associations and Their Members

Nursing associations need members, and nurses need associations. Benefits flow both ways: from the association to its members and from members back to the association. Traditional benefits of organizational involvement blend products and services that define the value of membership, including ( Cardillo, 2013 ;  Smith et al., 2008 ):

• Information and knowledge collection and dissemination

• Personal and professional development

• Chapter benefits (local, regional, and special interest networking and project participation)

Ultimately, products and services created and disseminated under the auspices of professional associations advance advocacy in the care of individuals, families, and populations. Guided by profession- and/or specialty-wide preparation, values, regulations, scope and standards of practice, and competencies, nurses are prepared to speak in one voice and assume advocacy as a fundamental aspect of nursing practice. The second edition of ANA's Nursing: Scope and Standards of Practice ( ANA, 2010 ) identifies advocacy priorities, including health care evaluation and restructuring, reimbursement and value of nursing care, funding for nursing education, nursing roles in health and medical homes, and comparative effectiveness.

Benefits attributed to organizational engagement may contribute to career satisfaction among nurses. Societal expectations that nurses provide continual and compassionate care, even in the face of physical and emotional exhaustion, constant exposure to suffering, intense emotional experiences, limited budgets, diminished staffing levels, administrative demands, and workplace communication issues (a few of the challenges nurses face), can undermine career satisfaction among nurses, setting the stage for burnout, compassion stress, and compassion fatigue ( Boyle, 2011 ;  Lombardo & Eyre, 2011 ). Nurses who participate in association conferences or who use association-sponsored networking tools report feeling professionally supported and invigorated as an outcome of these collegial interactions ( Sadovich, 2005 ).

Leadership Development

The Future of Nursing ( IOM, 2011 ) recommendations note that strong leadership is imperative for nurses to be full partners in redesigning health care systems. This transformation requires investment in nurse leadership development through experience and formal and/or informal education. Nursing organizations provide vital training grounds for personal and professional development, honing communication and writing skills, and enhancing big-picture awareness of nursing, political, and health care environments; in general, opportunities to learn and practice leadership skills ( Maryland & Gonzalez, 2012 ).  Table 74-1  lists examples of various nurse leadership training opportunities that have emerged in support of the IOM recommendations, many developed under the auspices of professional nursing associations. In addition to formal leadership training opportunities, associations offer members opportunities to develop and fine-tune critical leadership skills for nurses aspiring to influence within and outside of their professional organizations. Program and project development provides experience in group process, meeting facilitation, consensus building, negotiating, communication, and other essential leadership skills that will be useful throughout a lifetime, within and aside from nursing.

TABLE 74-1

Leadership Training Programs for Nursing Students and Nurses (partial list)

Program	Time/Location	Cost	Description	Link
AACN: Graduate Nursing Student Academy	Online	Free to AACN members	Websites and resources to advance leadership development in master's and doctoral degree students	www.aacn.nche.edu/students/gnsa
AACN: Student Policy Summit	Washington, DC: 3 days	$199 registration fee, scholarships available	Focus on federal policy process and nursing's role in professional advocacy	www.aacn.nche.edu/government-affairs/student-policy-summit
NSNA: Leadership U	Online	Free to NSNA members	Provides opportunities for professional growth	www.nsna.org/membership/leadershipuniversity.aspx
American Association of Critical-Care Nurses: Clinical Scene Investigator Academy	16 months at home institution	$10,000 to home institution to fund project	Teams of four nurses work with a leader and academy mentor	www.aacn.org/wd/csi/content/csi-program-information,content?menu=csi&lastmenu   =
ANA Leadership Institute	Live and recorded online seminars and self-paced courses	Costs vary by program	Programs sold as bundles, series, individually	www.ana-leadershipinstitute.org
AONE: Emerging Leader Institute	3 days: multiple locations	$800 for AONE members; $900 nonmembers	For nurse managers with less than 6 months' experience	www.aone.org/aone_foundation/ENLI.shtml
Nursing Alliance Leadership Academy	2 days: Louisville, KY	$350 to $400	Board leadership development for newly elected or emerging leaders	www.nursing-alliance.org/content.cfm/id/nala
American College of Health Care Administrators: Academy of Long-Term Care Leadership Development	Varies	1-year membership, $50; lifetime membership, $500	For health care and nursing home administrators and other professionals in long-term care	www.achca.org/index/php/acacemy
National Hartford Centers of Gerontological Nursing Excellence Leadership Conference	2.5 days: location varies	$400	Leadership, management, and communication skills for experienced and aspiring gerontological nurses	www.geriatricnursing.org
STTI: Leadership Academies	18 months: leadership project at home institution—required travel to conferences and workshops	$500 to $625 registration for participant and mentor plus travel	Programs focus on maternal child health, geriatric nursing, nurse faculty, and board participation, using  Kouzes and Posnner's (1995)  The Leadership Challenge as the foundational element for several offerings	www.nursingsociety.org/LeadershipInstitute/Pages/default.aspx

AACN, American Association of Colleges of Nursing; ANA, American Nurses Association; AONE, American Organization of Nurse Executives; NSNA, National Student Nurses Association; STTI, Sigma Theta Tau International.

From  Hassmiller, S. B., & Truelove, J. (2014) . Are you the best leader you can be? Leadership resources for every nurse. American Journal of Nursing, 114(1), 61-67.

Many associations invest in tangible resources aimed at extending members' leadership skills. The Oncology Nursing Society outlines a leadership development pathway, describing competencies in five domains (personal mastery, vision, knowledge, interpersonal effectiveness, and systems thinking) that equip nurses to understand where and how they need to develop to lead at every level and in a variety of care settings ( ONS, 2012 ).

The ICN identified three pillars crucial to enhancing nursing and health, each requiring an investment in leadership development, and focuses its activities in these areas: professional practice, regulation, and socioeconomic welfare ( ICN, 2013 ). The Leadership for Change and the Global Nursing Leadership Institute (GNLI) projects fall under the professional practice pillar. The annual GNLI is an advanced leadership program for nurses and midwives at senior and executive level positions in developed and developing countries ( ICN, 2014 ). Leadership for Change prepares nurses for leadership roles in nursing and the broader health sectors at country and organizational levels. Leadership in Negotiation, under the socioeconomic welfare pillar, is operational in Africa, Asia, Caribbean, Latin America, the Middle East, and Russia.

Opportunities to Shape Policy

Most nursing associations have missions that include advocacy around important nursing and health care issues. Often, the board or a legislative committee will set the policy agenda. The most sophisticated and well-resourced organizations have dedicated staff to organize the association's advocacy work, including engaging members to participate in lobby days and use of online tools for communicating with members' state and national policymakers around issues of importance to the association. In this way, local, state, and national organizations can provide a training ground for nurses to learn about policy and politics.

Often members get their first exposure to political advocacy work through participation in a lobby day, in which members go together to the state capitol or Washington, DC, to become oriented to the key policy issues of the association, learn the key messages to share with policymakers, and then meet with their individual representatives in to educate them about the issues and ask for their support. It is not uncommon for participants in lobby days to then volunteer to serve on a legislative or policy committee of the association or to get involved in its political action committee (PAC).

Membership in an organization that promotes interdisciplinary and interorganizational collaboration offers special opportunities to shape policy. Organizations whose members represent multiple disciplines connected to a specialty area, including nurses, physicians, industry, and administrators, expand the context of issues being considered.

Collaboration among the ANA, its affiliates, and specialty nursing associations is a way for nursing to speak with one voice with sufficient volume to achieve greater influence in health policy. In addition, the TriCouncil (ANA, American Association of Colleges of Nursing, the National League for Nursing, and the Organization of Nurse Executives) identifies important policy issues, seeks consensus on positions, and then mobilizes their membership to support this mutually agreed-upon agenda.

As interest groups, nursing associations provide an opportunity for nurses to bring a collective voice to the important nursing, health, and health care policy issues of the day. Clearly, however, an important issue is how members can influence the organization as it adopts a policy agenda.

Influencing the Organization

Prospective members can gain understanding of an organization's mission, goals, priorities, political agenda, structure, and support resources, as well as a member's potential to be involved and heard. Attending local or national meetings, observing the levels of collegial exchange, and speaking with current members are useful ways to get a complete picture of an organization.

Organizational Structure

It is important to understand an association's organizational structure and processes: why it exists, what it purports to do, how it runs, who runs it, and informal norms and expectations. Formal structure is determined by the organization's mission statement and bylaws, which are operationalized by governing policies and processes. These foundational documents are usually accessible to potential and current members and the general public. Procedural directions are most often available to members on request. The subtle, yet important, norms and expectations are discernible through formal and informal networking, collegial discussion, and astute observation.

Bylaws

Bylaws, the organizational rule book, govern internal affairs, identify who has power and how that power works, and define purpose, membership criteria, financial and legal procedures, and governance operations ( Tesdahl, 2003 ).

Governance Policies

An organization's values and perspectives are blended into policy that codifies what staff can or cannot do and also the governing board's process and relationships ( Carver, 1997 ).

Processes and Procedures

Step-by-step how-to directions are offered in organizational policy and procedure manuals. Processes available to members who wish to influence organizational direction or agendas include:

• Drafting and presenting organizational resolutions and position statements;

• Suggesting organizationally branded projects, products, and services;

• Introducing issues for consideration by the governing board; and

• Presenting issues for discussion in forums offered during general business, town hall, or open meeting agendas.

Resolutions reflect organizational mission and goals and are used to inform members and other constituencies about an issue and to show support (or lack of support) for legislative initiatives.

Position statements or simply positions are issued under the auspices of a governing board to articulate an official stance on issues relevant to its mission and are intended as instruments of change to promote a common understanding and a collective response to issues of importance. Position statements succinctly define organizational stance and guide policy-shaping efforts.

Governing Board, Committee, Task Force, and Other Volunteer Roles

Volunteer efforts are essential to an association's ability to survive and thrive. Governance roles relate to the elected leadership in the association: president, vice president, and/or president-elect, secretary, treasurer, and other members of the board of directors. The governing body is responsible for leading the organization in efforts consistent with stated values and mission, determining the priorities and goals, and providing stewardship and strategic planning efforts. In addition to governing board volunteer roles, nursing organizations use standing committees, task forces, and teams composed of volunteer members in functional areas to create programs, products, and services under the auspices of the organization. These structural elements differ primarily in the length of commitment involved and definition of function. Committees are likely to request longer-term commitments of committee members, although task force commitments are short term and last only for the duration of specific task-related efforts. Volunteer efforts allow the governing board to focus on “the big picture and critical decisions” ( Lawrence & Flynn, 2006 , p. 84). Any and all association work groups can influence the direction of the organization and health policy. The need for an organizational stance may be identified and suggested by general members and/or members in formal leadership roles. General members communicate this need via formal and informal member-leadership channels. Position statements are released only after the governing board gives final approval. Most nursing organizations post position statements on their websites so that perspectives are accessible to constituents and reach a broad audience.

Shepherding an idea from conception to completion and successful dissemination is probably one of the most rewarding aspects of membership. When the final product is perceived as valuable, it reflects well on the organization. This level of work is generally assigned to committees, teams, working groups, or task forces composed of appointed content-expert members. Through such involvement, nurses get to exercise creativity, use their skills and knowledge, and be part of a collaborative effort with opportunities to be mentored or to mentor others, to be exposed to new ideas and new ways of doing things, and to achieve success in a potentially complex process.

Political Action Committees

Some associations, particularly the ANA and state nurses' associations, create PACs to allow some engagement in political activities. It is illegal for incorporated nonprofit (designated 501[c][3] by the U.S. Internal Revenue Service) organizations to use funds to support candidates for federal elections, but association-related PACs can solicit funds and make contributions to candidates for federal office. PACs typically adopt bylaws and governing boards separate from the affiliated association, providing opportunities for members to focus on issues of political influence. Since they were legitimized in 1971, PACs have become effective in channeling members' contributions to candidates who are sympathetic with organizational aims ( Jacobs, 2007 ).

Conclusion

Nursing associations advocate, in one way or another, to advance the profession and promote the health and well-being of populations served. Opportunities to expand a nurse's level of influence beyond one-to-one direct care are the essence of association engagement for nurses. Volunteer contributions are essential for nursing associations to influence the well-being of individuals and the health of populations. Association involvement offers nurses opportunities to learn, practice, and polish the leadership skills that maximize their influence in associations, work, community, and health policy, and prepare the next generations of nurse leaders to continue the vital work of the profession.

Discussion Questions

1. How do the nursing organizations with which you are familiar determine policymaking courses of action?

2. Identify and discuss a policy issue that merits use of organized nursing's resources.

3. How might you engage a nursing organization to influence a nursing or health policy issue of importance to you?

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