The definition of PHN practice describes efforts to promote and protect the public’s health. When looking at Healthy Public Policy, PHN efforts to do so can take many forms from active participation as an informed citizen to actions taken as part of PHN practice to promote Healthy Public Policy (Bowman et al., 2012; Gottlieb, Fielding, & Braveman, 2012; National Collaborating Centre for Healthy Public Policy, 2010).
The PHN as an informed citizen, who has valuable knowledge and experience in health and health promotion, can be involved at a basic level by being aware of health policy and using this awareness for informed voting in elections across levels of jurisdiction. Individual PHNs might choose to increase their involvement by serving in a campaign to support a legislator that espouses public policies promoting health and preventing disease.
Additionally, the PHN might choose to share their expertise with others, as a means to inform their voting and citizen involvement. The PHN could also choose to be involved in professional organizations or citizen organizations to advocate for Healthy Public Policies and the legislators who promote them. PHN practice, looking broadly at health and the social determinants of health, can provide background that is valuable in any number of professional and civic organizations. For example, at the state level, the PHN can ensure that the state nursing organizations maintain a broad-based focus on the health of the public. And locally, PHNs can serve on health boards, but can also provide valuable input into health and education by serving on school boards or parent–teacher organizations.
Working toward eliminating health inequities, healthier built environments, HIAs, and sharing knowledge are all worthwhile endeavors for nurses who want to affect population through health policy work (Kostas-Polston, Thanavaro, Arvidson, & Taub, 2015;
National Collaborating Centre for Healthy Public Policy, 2010).
PHN researchers can provide policy-relevant input by focusing on research questions related to the social determinants of health or health in all policies and sharing results in a clear and persuasive manner with policy makers and legislators. PHN research might include assessing the impact of public policies on community health outcomes or on evaluating public health promotion efforts in the community (Feetham & Doering, 2015).
Lastly, PHNs can provide input by serving on policy-making bodies. A PHN serving on a hospital board could be critical in helping the hospital better understand population health and the role of the hospital in enhancing it. Alternatively, the PHN could serve on state or national advisory groups such as MedPAC (http://www.medpac.gov/home) or the U.S.
Preventive Services Task Force
(http://www.uspreventiveservicestaskforce.org/Page/Name/home). The organization, Nurses on Boards, is campaigning to put 10,000 nurses on various boards at all levels by 2020. Types of boards may include advisory, elected, appointed, constituency, and regulatory (Rambur, 2015). The organization provides a wide variety of examples across
each state, along with guidance on how to prepare to serve on a board (http://nursesonboardscoalition.org/).
Public Health and Social Justice
The concept of social justice is seen as the very foundation of public health and public health nursing (deChesnay & Anderson, 2016; Donohoe, 2013). The American Association of Colleges of Nursing (n.d.) emphasizes that the guiding values of nursing include social justice at all levels of preparation, and the ANA Code of Ethics with Interpretative Statements (2015, preface) states that nurses should “act to change those aspects of society that detract from health and wellbeing.” The ANA’s Public Health Nursing: Scope and Standards of Practice document also highlights the basic value of social justice in community health nursing (2013). The many definitions of social justice depend on the discipline involved; for purposes of this chapter, social justice is a fair allocation of both the costs and rewards of being a member of a group focusing on the processes, perceptions, and roles (Barusch, 2012). This could also be characterized as balancing or equalizing societal costs and benefits. However, nurses are not always consistent in their abilities to fully comprehend or develop strategies to address injustice.
We often want things to be fair, but do not always clearly define what that means, or sufficiently promote specific actions needed to ensure it. We may feel frustrated about situations we see every day, but need to be better equipped to address them (Paquin, 2011).
You may be caught in a “Catch-22” situation, working within a market-based system that is inherently unfair and often leads to health and social disparities for ethnic and other disadvantaged groups while having pledged to alleviate suffering within the groups you serve (ANA, 2013, 2015).
As a public health nurse, you are expected to give voice to the disparities found in the communities you serve (e.g., substandard housing, high rates of unemployment, death, and disability)—disparities that often could be prevented or alleviated at early stages. Your efforts through nursing interventions can address not only health issues but also the educational, social, and economic issues that give rise to these disparities (deChesnay &
Anderson, 2016; Donohoe, 2013). The Minnesota Department of Public Health Nursing Section has developed a public health interventions model that gives a broad overview of public health nursing. The model is based on the type of intervention and practice levels that allows a range of activities, such as advocacy, community organizing, coalition building, case management, and policy development, which you as a public health practitioner can activate (see Chapter 14). The nexus between social justice, advocacy, and policy is interrelated, complex, and one that will affect every aspect of your community health nursing career.
History of Public Health Nursing Advocacy
Nurses have a long history of action in social justice and advocacy, which can be defined as pleading the case of another or championing a cause (see Chapter 2). Developing policy solutions is a fundamental role for nurses—for the welfare of patients and communities, as
well as the profession (Mason, Gardner, Outlaw, & O’Grady, 2016). To advocate is to try to influence outcomes that affect people, communities, and systems. Additionally, advocacy is a process, not an outcome, one that includes identifying an issue, collecting information, identifying who can be influenced/who can make the decision sought, building support, and taking action. Advocacy can present itself in a variety of ways— self-advocacy, which is advocating for oneself; individual advocacy, which is pleading the case of others; and legislative advocacy, which is changing or modifying state or federal laws. Advocacy also includes litigation and public education campaigns. Finally, advocacy is also the process of empowering those less able to present their views or needs, with the goal of giving them a voice and/or achieving their objectives. Nurses have long been advocates for their patients, and advocacy can and does affect the larger systems of care (deChesnay & Anderson, 2016;
Donohoe, 2013; Paquin, 2011). Community health advocacy refers to efforts aimed at creating awareness of and generating support for meeting the community’s health needs.
Both nurses and communities have a common goal—the best possible health services for all.
The term and concept of public health nursing was coined in 1893 by Lillian Wald, who described PHNs as nurses who worked outside the hospital “to provide decent health care” to those people living in poor communities and tenements (Jewish Women’s Archive, 2016, para. 2). These nurses specialized in both preserving health and prevention measures as they responded to referrals from patients and physicians and they were only paid if the patient was able to afford payment. In 1893, Lillian Wald and Mary Brewster established the Visiting Nurses Service, and a year later, the famed Henry Street Settlement House was established. Wald’s exposure to the plight of newly arrived immigrants to the Lower East Side and the appalling living conditions there spurred her to action. She was determined that these immigrants and other poor people, regardless of ethnicity or religious affiliation, would have access to health care and adequate housing. Wald went on to encourage the establishment of the Department of Nursing and Health at Columbia University’s Teachers College through a series of lectures she presented starting in 1910. She also was instrumental in creating the U.S. Children’s Bureau in 1912, an agency that oversaw fair child labor laws (see Chapter 2).
The importance of these nurses—Lillian Wald and her compatriots, Sojourner Truth, Margaret Sanger, Clara Barton, Mary Seacole, Susie King Taylor, Mary Mahoney, and others—is that they wielded influence at a time when women were not even allowed to vote. In fact, many women in the 1800s, regardless of socioeconomic status, did not attend school. African American women in the early 20th century were legally forbidden to learn to read and write (Foreman, 2009; Nickitas, Middaugh, & Aries, 2016). Historically, women—both Black and White—volunteered their services during crises although nursing, as a profession, didn’t exist (Whitfield, 2015). For these women to be successful and influential during the 19th century is a tribute to their ability to take on the system in which they lived and to triumph over it. Women during these times rarely, if ever, voiced their opinions about issues affecting their lives, the lives of their children, their families, or
their communities; it was neither expected nor accepted. These early pioneers also are seen as feminists, and the entrance of these women into the political arena opened the way for others, such as Nancy Pelosi, former (and first-ever) Speaker of the house of representatives, and the four women Supreme Court justices (including one retired). In 2016, there 20% of members of the senate were women, and close to that number served in the house. In state legislatures, those numbers were 22.6% and 24.6%, respectively (Rutgers Center for American Women and Politics, 2016).
Professional Advocacy
One of the chief ways in which nurses have been successful in advocating is through membership in their professional organizations. The late 19th century may be seen as the beginning of nurse activism. The Nurses Associated Alumnae of the United States and Canada and the American Society of Superintendents of Training Schools of the United States and Canada were formed in 1890s (ANA, n.d.; National League for Nursing, 2016).
Out of these groups came the ANA and the National League for Nursing. However, in the 1980s, with the stratification of nursing into various specialties and organizations, representing an assortment of specialty groups, came the realization that the many nursing groups needed to coordinate efforts in order to be more successful (Cohen et al., 1996).
Throughout the next few decades, the nursing organizations realized, regardless of internal differences and competition, that to be politically successful, they must join together to work toward their common political goals. The formation of the following coalitions occurred:
Tri-Council for Nursing—comprising ANA, the American Association of Colleges of Nursing, National League for Nursing, and the American Organization of Nurse Executives
American College of Nurse Practitioners (NPs)—state and national NP groups initially met for a national forum and eventually to influence health policy
Nursing Organizations Alliance (The Alliance)—an alliance of National Federation of Specialty Nursing Organizations and Nursing Organizations Liaison Forum
These and other coalitions permitted the organizations to lobby for common nursing issues (e.g., maintenance of federal funding for nursing education and research) and ultimately the establishment of the National Institute of Nursing Research within the National Institutes of Health (Milstead, 2016). Many of the current state nurse practice acts and expanded responsibilities for NPs are the result of these new coalitions. But more significantly, nursing now has a better understanding that there is a difference between
“self-interest” and “selfishness” (Matthews, 2012; Milstead, 2016). One of the most significant outcomes of this time was the development of Nursing’s Agenda for Health Care Reform (ANA, 1994), this document exemplified the maturing of nursing as a special interest group, but more importantly demonstrated consensus building and collaboration among the more than 60 nursing and various health care provider organizations. Despite nursing’s early history of political activism and the fact that nurses are the largest group of health care providers in the United States, widespread political involvement has yet to be fully realized (Nickitas et al., 2016). Nursing has the potential to be a major player in Washington when discussing health care policy. Currently, the call for political action and participation in health policy work among nurses encompasses the global view of “One World, One Health” (Premji & Hatfield, in press, para. 1). For a more recent example of successful professional advocacy, see From the Case Files IV: Nurse Practitioners.
From the Case Files IV
Nurse Practitioners
With full implementation of the Patient Protection and ACA, it is estimated that 32 million more Americans will have access to primary health care; by 2020, there is an expected shortage of 45,000 primary care physicians (Poghosyan, Lucero, Rauch, &
Berkowitz, 2012). The demand for nurse practitioners (NPs) or advanced practice nurses (APNs) is increasing; nationally, it is expected to reach an increase of 30%
between 2016 and 2020 (Xue & Intrator, 2016). NPs are often thought by patients to be better communicators and provide clearer education about self-management of chronic conditions (e.g., diabetes), but the terms “physician extender,” “midlevel practitioner,” and “nonphysician provider” are thought to lead to misconceptions about the quality of their care (Poghosyan et al., 2012, p. 147). Many new policies and programs related to the ACA are beneficial to NPs, including
Graduate Nurse Education funding for demonstration awards to expand NP education programs.
Increased funds for hiring NPs into the National Health Service Corps; about 1,900 have been hired to practice in medically underserved areas with
increasing levels of retention and extension of their contracts.
Both Federally Qualified Health Centers (FQHC) and Nurse-Managed Health Clinics (NMHCs) have received increased support, as safety-net providers, to hire NPs to care for their often vulnerable, high-risk clients.
Medicare beneficiaries with functional limitations and chronic illnesses are able to receive home-based primary care from NPs through a 3-year project, Independence at Home Demonstration (Carthon, Barnes, & Sarik, 2015).
Although these gains have been the hard won result of consistent lobbying and advocacy efforts on the part of professional nursing organizations and individuals, the bright future on the horizon for NPs is at risk because of inconsistent scope of practice laws at the state level (Poghosyan, Boyd, & Clarke, 2016). In 2015, only 21 states and the District of Columbia had full autonomy rules for NPs (e.g., NPs could evaluate/treat patients, order/interpret diagnostic tests, prescribe medications). That leaves 29 states with laws for NPs that restrict or reduce their scope of practice; often, this involves requiring physician oversight or collaboration (Xue & Intrator, 2016).
Some states prohibit NPs from certifying home health or long-term care, and limit their admitting privileges to hospitals. This practice leads to barriers to practice and uneven distribution of primary health care providers, with per capita rates for NPs ranging from 1.7 to 8 per 10,000 people in rural areas of the country. Most are working in large cities and urban areas (Xue & Intrator, 2016). Those states with fewer restrictions on NP practice have 30% higher enrollments in advanced practice nursing (APN) programs (Poghosyan et al., 2012).
Another important consideration is the fact that NPs often work with the most vulnerable populations in areas where other health care providers are scarce, and
“their active participation in advocating for both health and social policies” for their clients is helpful in promoting health equity in access and quality (Xue & Intrator, 2016, p. 5). Although NPs are achieving success in the area of policy making and expanded practice opportunities, it is still vitally important for them to advocate and politically support health policies that benefit the clients they serve.
Carthon, J. M. B., Barnes, H., & Sarik, D. A. (2015). Federal policies influence access to primary care and nurse practitioner workforce. Journal for Nurse Practitioners, 11(5), 526–531.
Poghosyan, L., Boyd, D. R., & Clarke, S. P. (2016). Optimizing full scope of practice for nurse practitioners in primary care: A proposed conceptual model. Nursing Outlook, 64(2), 146–155.
Poghosyan, L., Lucero, R., Rauch, L., & Berkowitz, B. (2012). Nurse practitioner workforce: A substantial supply of primary care providers. Nursing Economics, 30(5), 268–274.
Xue, Y., & Intrator, O. (2016). Cultivating the role of nurse practitioners in providing primary care to vulnerable populations in an era of health-care reform. Policy, Politics, & Nursing Practice, 17(1), 24–31.
Large professional organizations have the resources, relationships with policymakers, success at coalition building, and reputation for the ability to compromise needs to assure viable outcomes. Being a part of your professional organization demonstrates your
professionalism, promotes your organization’s viability, and demonstrates your social responsibility to advocate for the needs of your patients. Nurses must take advantage of how the public views the profession. For more than a decade, nurses have ranked highest in a Gallup poll for honesty and ethical standards (Gallup, 2016). Clearly, there is favorable impression of nursing as a profession among the general public. Despite criticism about special interest and professional organizations “protecting their turf,” professional nursing organizations demonstrate how a critical mass can be influential and successful in moving the discussion forward on health care and the public’s perception of nursing. It is the professional nursing organizations that have elevated nursing professionalism, given voice to the inequities that affect our society, and developed the paradigms that influence and affect public health at the institutional, state, and national level in the 21st century. A united voice on public policy is more powerful than individual nurses pleading with their legislators (Duncan, Thorne, & Rodney, 2015; Taylor, 2016).
The pursuit of personal agendas over the common good results in a piecemeal approach to problems and promotes polarization. Polarization is the process by which a group is severely split into two or more factions over a political issue. Polarization can be so intense that people perceive one another as good or wicked, depending on their ideological opinions. One of the primary goals of a professional nursing association is to build a collective voice for nurses. A strong professional association limits polarization by developing the political skills of its members and ensures that its structure and processes equitably meet the needs of its constituencies. This is the essence of politics: people must listen to each other, learn from others’ viewpoints, and compromise to ensure the most positive outcomes from their endeavors (Nickitas et al., 2016).
Nursing’s Role in Health Care Reform
Since the 1950s, the ANA has advocated for reforms in health care that will benefit both nurses and their patients. Their involvement in federal health care reform began in the 1960s with the passage of Medicaid and Medicare. In the 1970s, ANA formed a political action committee (PAC). PACs are organizations that raise money to contribute to political parties or candidates, with the understanding that those receiving financial and political support will be sympathetic toward issues of interest to members of the PAC.
In 1991, ANA released Nursing’s Agenda for Health Care Reform: A Call to Action—a plan so ambitious and forward looking that Senator Kennedy referenced this document when introducing his legislation on health care reform. Even though this legislation failed to pass, ANA and other nursing organizations gained wide recognition for their policy acumen and leadership abilities. During the Clinton-era health care debate, ANA continued to play a key role in the policy and political discussions on health care reform. As research and experience continued to show the need for health care reform, ANA remained steadfast in its advocacy and updated the policy agenda on health care reform and progress toward a more balanced approach incorporating primary care, community-based care, and preventive services. ANA supported the development of a single-payer system.
Understanding the time was ripe for health care reform, the ANA-PAC identified those legislators supportive of ANA’s legislative and regulatory agenda. They provided financial and political support and increased their grassroots organizing. RNs nationwide responded and through multiple activities (e.g., contacting members of Congress, testifying at hearings, sharing personal stories, participating in high-profile press conferences, attending rallies and events) lobbied for action (see Display 13–1). The frontline nurses also joined ANA’s health care reform team, and through these concentrated efforts and collaborations, health care reform became a reality in March 2010 (Lewenson, 2015).