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Introduction   

Nursing advocacy extends beyond the bedside and into the political arena. Many changes you see in the healthcare space result from the hard work of nursing groups (like federal and state nursing associations). Nurse and nursing faculty shortages, the need for healthcare reform, the rising complexity of care, and the aging population are among many factors that influence healthcare reform [8].  

This course will define health policy, introduce nursing’s role in health policy, and then present a real-life example of how national nursing organizations come together to determine the types of issues they will lobby for. The course will transition into how healthcare laws are developed and end with the nurse’s professional and ethical responsibilities in health policy and advocacy. 

Health Policy in Nursing 

Health policy, also termed public health policy, are laws and practices supporting the public’s health and health equity [7]. Health policy includes healthcare policy, which supports improvement of the system of healthcare, such as improving access to care, affordability of services, and efficiency and quality of services/care [1].  

Health policy in nursing occurs at the international, federal, state, regional, and local levels, and all nurses may contribute at any level. Making changes in the political arena requires knowledge about healthcare laws and trends, and the lawmaking process. Nurses have a powerful role in not only changing laws associated with patient care but also laws associated with the profession as a whole. For example, safer nurse-to-patient ratio laws benefit both patients and nurses. If nurses don’t speak up for the profession, who else will? 

Health policy in nursing has a long history. Nurses have been advocating for patients, families, and communities since the beginning of the profession. Examples of advocacy and health policy in nursing:  

• Florence Nightingale advocated for changes to improve environmental conditions and reduce life-threatening infections [9]. 

• Dorothy Sutherland of the U.S. Department of Health, Education, and Welfare fought to establish a “Nurse Day” at the White House in the 1950s [6]. 

• Lillian Wald established the public health nursing profession to better the health of immigrant communities [9]. 

Nurses have also advocated collectively for the betterment, recognition, and advancement of the profession through voices like the American Nurses Association (ANA) – a highly influential national professional organization run by nurses in support of nurses. The ANA empowers nurses to excel in their fields and advocates for better policies that support high-quality care for patients and communities [5].  

Nurses are often identified as individuals wearing scrubs and caring for patients directly, but many nurses serve in leadership positions in the community, speaking with global leaders about the health and wellness of the world at large. 

Advocacy in Nursing and Ethical Implications 

The American Nurses Association (ANA) defines advocacy as the “act or process of pleading for, supporting, or recommending a cause or course of action” [3]. Nurses advocate for patients by protecting their rights and ensuring their needs are met. Nurses serve as the voice for patients when they are unable to speak for themselves.  

We can’t speak about advocacy without addressing ethics. When nurses practice ethically, they practice according to the four core ethical principles of nursing: respect for autonomy, beneficence, nonmaleficence, and justice. 

• Respect for Autonomy: The ANA defines autonomy as the “rational self-legislation and self-determination that is grounded in informedness, voluntariness, consent, and rationality” [3]. Essentially, nurses must respect a patient’s right to make their own decisions regarding their care.  

• Beneficence: The ANA defines beneficence as the “bioethical principle of benefiting others by preventing harm, removing harmful conditions, or affirmatively acting to benefit another or others, often going beyond what is required by law” [3]. Practicing beneficence is “doing good” for others. Nurses must practice with the mindset that all of their actions will benefit the patient. 

• Nonmaleficence: The ANA defines nonmaleficence as “the bioethical principle that specifies a duty to do no harm and balances avoidable harm with benefits of good achieved” [3]. When nurses practice nonmaleficence, they avoid harming the patient, both intentionally and non-intentionally (For example, checking the rights of medication administration to avoid a medication error). 

• Justice: The ANA defines justice as “a moral obligation to act on the basis of equality and equity and a standard linked to fairness for all in society” [3]. Justice refers to ensuring all patients, families, and communities receive the same level of care and respect for human dignity.  

When nurses advocate for patients, they must refer to these core ethical principles as a basis for their actions/stance. Protecting the rights of patients is impossible without understanding and respecting patients’ rights in the first place. Speaking up for patients is not possible without knowing what is best for patients and what is not.  

The Code of Ethics for Nurses (“The Code” for short) outlines specific obligations nurses have in protecting patients’ rights and ensuring they receive high-quality care. The Code encompasses all four core ethical principles. This way nurses have a clear understanding of how they should advocate, under what circumstances, and according to what ethical principle. Nurses advocate based on a moral stance, and this “morality” is defined in The Code. 

Health Policy in Action 

The American Nurses Association (ANA) holds membership assembly meetings each year attended by nurses and professional nursing organizations across the country, including the National Student Nurses Association. For the 2023 assembly meeting, the ANA came up with three recommendations in which it would advocate for health policy change for the upcoming year(s). Topics included [4]: 

• Virtual Nursing as a Practice Model Innovation 

• The Role of Nurses in Promoting Gun Safety and Preventing Violence 

• Addressing Nursing Documentation During a Time of Crisis 

Virtual Nursing as a Practice Model Innovation 

This motion by the ANA was planned as a way to alleviate the nursing shortage. Maintaining the standardized nurse-to-patient ratio practice model is challenging due to staffing shortages. For this reason, virtual nursing has been introduced. Virtual nursing serves as a way to meet the need for additional nurses as the virtual nurse can oversee numerous patients while also alleviating the bedside nurse. The ANA developed the following recommendations for 2023 [4]: 

• Develop a national policy that addresses the standardization of virtual nursing practice as a modality and considers funding and reimbursement models, as well as implications associated with licensure, regulation, and liability.  

• Advocate for technology that meets nurse and patient needs.  

• Support data collection on virtual nursing to understand the impact on nurse and patient satisfaction, as well as patient outcomes.  

About 87% of the ANA’s assembly members were in favor of the new recommendations and 13% were opposed. The final result: The ANA agreed to begin advocating for these changes in health policy. 

The Role of Nurses in Promoting Gun Safety and Preventing Violence 

This motion by the ANA was developed to address health inequities related to gun violence. The ANA pointed out that gun violence disproportionately affects minorities and marginalized communities, and the likelihood of gun violence is increased when there is exposure to violence, easy access to guns, poverty, and lack of economic opportunity [4]. The ANA has long advocated for gun safety, particularly in limiting the availability of handguns, banning assault weapons, and requiring a waiting period and background check for gun purchasers. The ANA developed the following recommendations for 2023 [4]: 

• Advocate for meaningful legislation to address gun safety and firearm access, and increase funding allocated towards mental health services, gun violence and prevention research, including research on gun violence against health care workers and in health care settings.  

• Promote nursing knowledge on the relationship between gun violence and public health, the risk factors of and protective factors against violence, evidence-based strategies to prevent violence, and the role of nurses in promoting gun safety and preventing violence, especially among children, adolescents, and young adults. 

About 96% of the ANA’s assembly members were in favor of the new recommendations and 4% were opposed. The final result: The ANA agreed to begin advocating for these changes in health policy. 

Addressing Nursing Documentation During a Time of Crisis 

This motion by the ANA stemmed from the COVID-19 pandemic, as many nurses called for action to reduce documentation requirements. High patient acuity, increased nursing shortages, increased travel nursing, and increased use of new technologies have changed the workflow for many nurses, and documentation can be an added burden, even more so during times of crisis [4]. While electronic health records have helped to alleviate the burden of documentation, there are no clear guidelines on what documentation is required, not required, or can be eliminated, particularly during times of crisis [4]. The ANA developed the following recommendations for 2023 [4]: 

• Generate a national consensus for research and policy development to lessen the burden of nursing documentation, particularly during a crisis or emergency using an all-hazards approach.  

• Partner with regulatory agencies and stakeholders to review current documentation standards and revise policies that reflect a national standard for crisis documentation, specifically for nursing. 

• Involve experts on nursing professional liability and state regulation to ensure that revised standards of documentation do not expose nurses to additional legal or regulatory risk. 

About 99% of the ANA’s assembly members were in favor of the new recommendations and 1% was opposed. The final result: The ANA agreed to begin advocating for these changes in health policy. 

This three-topic example of health policy outlines how professional nursing organizations come together to decide which public health or healthcare issues they will address each year. After establishing a plan, the organization members lobby for policy changes in hopes of making each proposition a law.  

Policymaking 

To make changes in health policy, nurses need a collective voice. While one nurse is important, policy change typically occurs in numbers, the more the better. Additionally, nurses need to present a strong base of evidence to support their recommendations/stance. Making changes in health policy can be laborious and time-consuming. It took the American Nurses Association (ANA) 40 years of fighting to establish something as simple as national recognition for nurses, ultimately advocating for the establishment of a national holiday week for nurses (National Nurses Week) in 1993.  

Policymaking involves sending propositions (or proposed rules) to branches of the U.S. government: executive, congressional, and judicial. Proposed rules may be entirely new propositions or modifications of existing laws. These rules (like the ANA’s recommendation for gun safety above) do not always make it successfully through the branches of government on the first try. The process can be cyclic and lengthy. Let’s take a look at the eight-step process in which a proposed rule becomes law [10][11].  

• Step 1: The proposed rule is drafted by a federal agency 

Contrary to popular belief, lobbying politicians doesn’t start with nurses holding signs and shouting through megaphones in front of the White House. The process starts with a well-written proposed rule that is drafted by a federal agency. Examples of federal agencies include: 

• U.S. Department of Health and Human Services (DHHS) 

• Centers for Disease Control and Prevention (CDC) 

• Centers for Medicare and Medicaid Services (CMS) 

• Food and Drug Administration (FDA) 

Nursing organizations (like the ANA) send petitions (like gun safety recommendations) to the appropriate federal agency, who then drafts a proposed rule to the branches of government. A federal agency can also draft a proposed rule on its own if it feels there’s a need for reform in a particular area of public health and safety. The federal agency may also draft a proposed rule if summoned to do so by the government. 

• Step 2: Proposed rule is sent to the White House 

The first stop for a proposed rule is the presidential office (executive branch). The president must review and approve all proposed rules before they are sent to the other branches of government. 

• Step 3: Entities/groups comment on the proposed rule 

During this step, the proposed rule is published to a federal registry for 30 days, allowing entities/organizations/groups to comment on the rule, offering rebuttals, corrections, suggestions, or additions. This is also where groups like the ANA and other organizations in support of patients and nurses can be highly influential, offering their opinions in support or opposition of the proposed rule (backed by evidence of course). Other groups like non-profit organizations, health insurance companies, and state boards of nursing, among others can comment on the proposed rule. 

• Step 4: Proposed rule is modified as needed by the federal agency 

• Step 5: Proposed rule is sent to the White House again for approval 

• Step 6: Proposed rule is published in the federal registry again for another 30 days 

• Step 7: Final draft of the proposed rule is sent to the judicial or congressional branch  

• Step 8: If the proposed rule is approved, it becomes law. 

As noted, the nursing collective can influence policy by petitioning recommendations for policy change to federal agencies, or by commenting on proposed rules already drafted by federal agencies. If nurses do not advocate for policy changes, proposed rules (those not in favor of patients or nursing) may successfully pass through the policy-making process and negatively affect patients or the profession. This is why staying up to date with proposed rules and remaining engaged in health policy and advocacy is so important.  

Professional and Ethical Nursing Obligation 

Nurses have both a professional and ethical obligation to engage in advocacy and health policy. These responsibilities are not optional. You are required to meet these obligations as long as you hold an RN license. Some of the responsibilities refer to a collective of nurses (the nursing profession as a whole), and the individual nurse is not expected to engage in all activities alone, such as advancing the profession globally. 

Advocacy as a Professional Obligation 

Advocacy in nursing isn’t a matter of “should,” but rather a matter of “ought.” Nurses are professionally obligated to advocate for patients according to the Standards of Professional Nursing Practice. These standards, developed by the American Nurses Association (ANA), outline how nurses should practice at all times. According to the ANA, the Standards of Professional Nursing Practice are “authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently” [2]. Of the 18 standards in the document, “Advocacy” ranks at number eight.  

Responsibilities of the nurse regarding advocacy include, but are not limited to [3][9]: 

• Champions the voice of the health care consumer (patient). 

• Recommends appropriate levels of care, timely and appropriate transitions, and allocation of resources to optimize outcomes. 

• Promotes safe care of health care consumers (patients and families), safe work environments, and sufficient resources. 

• Empower all members of the health care team to include the health care consumer (patient) in care decisions, including limitation of treatment and end-of-life care.  

• Embraces diversity, equity, inclusivity, health promotion, and health care for individuals of diverse geographic, cultural, ethnic, racial, gender, and spiritual backgrounds across the lifespan. 

• Role models advocacy behavior. 

Advocacy is often associated with ethical dilemmas – situations in which the nurse must take a stance on an issue or decide if an action is right or wrong. However, according to the Standards of Professional Nursing Practice, advocacy also refers to basic nursing tasks, such as promoting safe and timely care (note: beneficence and nonmaleficence), embracing diversity, equity, and inclusion (note: justice), and encouraging other care team members (such as providers you interact with) to include the patient in all care decisions (note: respect for autonomy).  

Advocacy and Health Policy as an Ethical Obligation 

Nurses also have an individual and collective ethical obligation to engage in health policy and advocacy, locally and internationally. The Code of Ethics for Nurses lists provisions (standards) regarding your ethical responsibilities in health policy and advocacy. These include but are not limited to [2]: 

• For you as an individual nurse: “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.” 

• For you as part of a nursing collective: “The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.” 

The Code then lists tasks to help nurses (and nursing organizations like the ANA) embody these provisions. Tasks include: 

• Protect patients’ rights to privacy (including individuals, families, and communities).  

• Advocate for environments in which patients have privacy (physical privacy and privacy for discussions).  

• Model professional commitment to social justice. 

• Serve, mentor, and lead on policy committees within the workplace (Your workplace’s nursing leaders meet this standard for you, although you can join committees as well). 

• Participate in advocacy activities at the local, regional, and national levels (Local and state-level nursing associations and the ANA meet this standard for you). 

• Participate in the global nursing community to represent a collective voice of U.S. nurses around the globe (the ANA meets this standard for you). 

Conclusion

If interested in lobbying for health policy changes at the federal, state, or local level, reach out to the American Nurses Association and get involved in its political action committee. You can make a difference by either participating in political activities or contributing financially. 

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