Chapter 15: Political Activism in Nursing

Deciding Which Associations to Join

As you decide whether to belong to an association, visit the group's website to find out more about its activities. Then ask yourself the following questions: 1. What is the mission and what are the purposes of this association? 2. Are the association's purposes compatible with my own? 3. How many members are there nationally, statewide, and locally? 4. What activities does the association undertake? 5. How active is the local chapter? 6. What opportunities does the association offer for involvement and leadership development? 7. What are the benefits of membership? 8. Does the association offer continuing education programs? 9. Does the organization lobby for improved health care legislation? How successful is it? 10. Is membership in this association cost-effective? 11. Even if I am not active, what benefit will I derive from the legislative agenda and other activities that the association undertakes to advocate for nurses and patients? Answering these questions and speaking with current association members should provide nurses with adequate information to make reasoned decisions.

Benefits of Joining a Professional Organization/Discussion

Developing leadership skills, certification and continuing education, political activism, practice guidelines and position statements, other benefits, deciding which associations to join

Promoting Civility in Nursing (CHAPTER 16)

Incivility in nursing is a troubling problem that is getting increasing attention. In a profession dedicated to caring for strangers, the spiral of incivility is difficult to explain but crucial to address. In March 2011 Medscape Nurses, a widely read web-based source of information about nursing, featured an interview with Cynthia Clark, PhD, RN, and Sara Ahten, MSN, RN, who addressed several aspects of nursing incivility (Stokowski, 2011). They described a continuum of incivility (Figure 16-3). Incivility in nursing is manifested as bullying between colleagues and between faculty and students in academic settings. The latter is particularly troubling because nursing school is a potent agent of professional socialization (Luparell, 2011). The continuum of incivility starts with common behaviors that are distracting, annoying, or irritating to others. Examples of these behaviors are talking on one's cell phone in a restaurant or sending and reading text messages while someone is talking to you. These behaviors are a matter of poor manners in some cases but that leave the recipient of the behavior feeling annoyed. Increasingly disruptive behaviors include taunting, using ethnic slurs, and intimidation even without physical contact. At the most extreme of the continuum, bullying, aggression, and violence occur (Stokowski, 2011). Incivility in the workplace has implications for nurses, patients, and health care organizations, with poor communication and unprofessional behaviors negatively affecting patient outcomes and safety (Luparell, 2011). (FROM SLIDES): Promote civility Cynthia Clark and Sara Ahten described a continuum of incivility (Stokowski, 2011) on page 328 Incivility is manifested as bullying between colleagues and between faculty and students in academic settings

Politician Activism in Government/PowerPoint Slides

Laws define nursing practice Periodic need to influence lawmakers to modify the nurse practice act to reflect current clinical practice NPs reimbursement, autonomy, and prescription writing FDA sets rules for administering and documenting the administration of narcotics Need to influence legislators regarding broader issues like pay equity, staffing ratios, etc. California first to pass ratio legislation 1999 (enacted 2004) CE requirement added for NJ license renewal (30 hours/2 years, organ and tissue donation) - many professions require EXTRA (As discussed in Chapter 6, state licensure of an RN derives from legislation that defines the scope of nursing practice. The defined scope determines what a nurse legally can and cannot do. As a result of changes in education and clinical practice, nursing organizations influence legislators to change state nursing practice acts to reflect what nurses are qualified to do. For instance, at one time the administration of intravenous medications was not within the scope of nursing practice but instead was limited to medical practice. It is difficult to imagine how a hospital or other health care setting could function today if this were still the case. Regulations are developed to guide the implementation of legislation. They affect practicing nurses and their work environments. For example, the Food and Drug Administration (FDA), a regulatory agency of the federal government, sets the rules for administering and documenting the administration of narcotics. The FDA is a division of the Department of Health and Human Services. The way in which such regulations are written can greatly affect nursing practice. The regulations in each state governing nursing practice are contained in state's nursing practice act. When the regulations change—for example, adding a requirement for continuing education for license renewal—it affects all nurses in the state. For advanced practice nurses, there are a variety of regulations related to prescription writing and autonomy issues. These change from time to time, and if nurses do not actively participate in changes, new regulations can restrict rather than enhance nursing authority for regulated activities. Broader issues affecting the nursing profession are also political in nature. Issues of pay equity, or equal pay for work of comparable value, are of concern to 317nurses because they have been chronically underpaid for their work. One of the earliest cases demonstrating the inequality of nursing salaries involved public health nurses in Colorado. These nurses brought a case against the city of Denver, stating that they were paid considerably less than city tree trimmers and garbage collectors. The nurses demanded just compensation for their work by demonstrating that nursing requires more complex knowledge and is of greater value to society than the other occupations (although certainly the value of these other workers is not to be trivialized). As a result of this suit, recognition of nursing's low pay was brought to public attention, which in turn mobilized public support for increasing nursing salaries. This is an example of political action by nurses that resulted in both policy outcomes (regulations that expanded comparable pay issues to other jobs) and professional outcomes (salary increases for the individual nurse). More recently, the issues of nurse-patient ratios and staffing have become increasingly under scrutiny. Nurses in California mobilized the public and other constituency groups to get the first legislation requiring specific nurse-to-patient ratios passed in 1999; however, the regulations were not implemented until 2004. As of 2015, 14 states had implemented legislation or adopted regulations related to nurse staffing (California, Connecticut, Illinois, Massachusetts, Minnesota, Nevada, New Jersey, New York, Ohio, Oregon, Rhode Island, Texas, Vermont, Washington) (ANA, 2015). As of 2015, California was the only state requiring minimum nurse-patient ratios to be met at all times by unit. Massachusetts's law requires ICU staffing at a 1:1 or 1:2 nurse-to-patient ratio depending on how stable the patients are.)

Political Activism

Nurses depend on activism to protect their interests. For instance, nurses can obtain master's- or doctoral-level preparation to become nurse practitioners and practice independently. These nurses deserve direct reimbursement for their work and need state laws that mandate direct reimbursement. Others work in settings in which there are not enough RNs available to provide the quality of care the residents need. These nurses need laws that ensure appropriate RN staffing and control educational requirements for unlicensed assistive personnel. In each of these instances, the ANA, labor unions, and specialty organizations are involved in political action with legislators and regulators in the government arena. There are those within these organizations who develop the positions that nursing organizations believe are in nursing's best interests. There are a number of people within these organizations whose responsibilities are to advocate for legislation to support nursing's position. The process of political action and policy recommendations involves both paid staff, usually in the government affairs department, and volunteer members of the organizations, usually practicing nurses. The legislative agenda, that is, the public policy issues the organization supports, is developed by members appointed by the board of directors, as well as by staff who are experts in political and policy issues. The board of directors approves the legislative agenda. Organizations with legislative agendas depend on members to lobby legislators. They provide members with background information and also create "talking points" to use when lobbying for the selected issue. You can read about the ANA's particular legislative interests online in the Policy and Advocacy section (www.nursingworld.org). As part of the process of encouraging nurses to lobby, information is given on the website about specific bills along with talking points for writing or speaking with congressional representatives. Association members can be very influential in lobbying legislators, particularly when the constituency is nationwide and representative of different stakeholders. Learning how to be politically active increases the power of both the individual and the organization represented. Nursing organizations also work collaboratively through coalitions with other health professional and consumer groups. Such coalitions are focused on specific issues. For example, Health Care Without Harm is a group of 514 organizations in 53 countries whose mission is to "transform the health sector worldwide, without compromising patient safety or care, so that it becomes ecologically sustainable and a leading advocate for environmental health and justice" (Health Care Without Harm, 2015). Hollie Shaner-McRae, DNP, RN, FAAN founded this organization when she became concerned about the waste created by disposable instruments in an operating room. The organization is now a significant national and international force advocating for a healthy climate, safer chemicals, healthy and sustainable food, zero waste from the health care sector (including pharmaceuticals), clean air and water, green buildings, and human rights, including access to health care for all (Health Care Without Harm, 2015).

Nurse Politicians

Once a nurse realizes and experiences the empowerment that can come from political activism, he or she may choose to run for office. No longer satisfied to help others get elected, the nurse politician desires to develop the legislation, not just influence it. Five nurses were elected in 2014 to the 114th Congress of the United States. Two of these nurses have been serving in the House of Representatives for 17 years or more. In 1992 Congresswoman Eddie Bernice Johnson (D-TX) (Figure 15-4) was the first nurse elected to the U.S. House of Representatives and has been consistently reelected since. She received her BSN from Texas Christian University in 1967 and later earned her master's degree in public administration from Southern Methodist University. In 1998 Congresswoman Lois Capps (D-CA) (Figure 15-5) became the third nurse to be elected to the House of Representatives. Congresswoman Capps was a long-time leader in health care and a school nurse. After her election to Congress, she drew on her extensive health care background to co-chair the House Democratic Task Force on Medicare Reform, and in 2003 she founded the Bipartisan Congressional Caucus on Nursing and the Bipartisan School Health and Safety Caucus. Capps founded and serves as chair of the House Nursing Caucus. Newer members of Congress include Congresswoman Karen Bass (D-CA), who was a nurse who became a physician's assistant and participated in community organizing. She is the former speaker of the California Assembly and the first African American woman to lead the Assembly. Diane Black (R-TN), a former emergency department nurse and community organizer, had served as a member of the Tennessee State House and Tennessee State Senate. Renee Ellmers (R-NC) was a surgical intensive care nurse and hospital administrator and is the clinical director of a wound care center (ANA, 2015b). Nurses have shown that they can take on important and public roles in speaking for health care and for the profession of nursing. To be effective agents of change, nurses can do the following: • Run for an elected office • Seek appointment to a regulatory agency • Be appointed to a governing board in the public or private sector • Use nursing expertise as a front-line policy maker who can enhance health care and the profession Nurses who have achieved success as leaders often started with no knowledge of the political process and no expectations of the greatness they would achieve. Instead, they became involved because some issue, injustice, or abuse of power affected their lives. Instead of complaining or feeling helpless, they responded by taking an active role in bringing about change. The story of nurse and retired Congresswoman Carolyn McCarthy (D-NY) is such an example. Recently retired, McCarthy was a licensed practical nurse who ran for office as a result of her stance on gun control. Her husband was killed and her son critically injured after a lone gunman with a 9-mm semiautomatic pistol walked through a train on the Long Island Railroad and killed 25 people and wounded 19 others. McCarthy was suddenly thrown into the national spotlight when she challenged the incumbent congressman running for office on his stand supporting a repeal on a ban for assault rifles. Her ability to speak passionately about the issue led to her campaign against the incumbent and her election to his seat. For 18 years, McCarthy was a leader in the House of Representatives on gun control, as well as on nursing issues. She retired in 2015. The mark of a leader is the ability to identify a problem, have a goal, and know how to join others in reaching that goal. A leader must ask the right questions, analyze the positive and restraining forces toward meeting the goal, and know how to obtain and use power. A leader must know how to ask for help and how to give support to those who join the effort. These are the marks of nursing leaders who have become political experts.

Practice Guidelines and Position Statements

Organizations serve an important function by defining practice standards, taking positions on practice issues, and developing ethical guidelines. For example, the ANA has positions on blood-borne and airborne diseases that include statements about HIV infection and nursing students. These positions are consistent with the ANA's recommendation to require educational content about such infections by qualified faculty, mandating universal precautions, and providing postexposure support for students who may sustain a needle stick injury. These statements serve to guide the organization's work in both the practice and the policy arenas and to help individual nurses within workplaces implement the policy. Guidelines and position statements are based on evidence from research, as well as opinions of nurse experts in the field. Another example is the recent revision of the Code of Ethics for Nurses (ANA, 2015). A task force was appointed by the board of directors to review the previous Code and create revisions and recommendations. The revisions went through a process of approval by many entities within the ANA: the Congress of Nursing Practice, the Board of Directors, and the House of Delegates, which speaks on behalf of all the members. Approval from so many groups within an organization ensures "buy-in" by the membership. Buy-in is important because the Code serves as an ethical standard for all practicing nurses, whether they are ANA members or not, and is therefore of critical importance. The NSNA also has a Code of Conduct (Box 15-2), which provides guidance for nursing students. This Code serves as the ethical foundation of student practice.

Certification and Continuing Education

Practicing nurses want to be recognized, through both compensation and position, for their level of professional expertise. Toward those ends, they may pursue certification in a specialty area. Certification is granted through professional associations. As discussed in Chapter 4, certification is a formal but voluntary process of demonstrating expertise in a particular area of nursing. Certified nurses may receive salary supplements and special opportunities. For information about credentials in nursing, visit the website of the ANA's subsidiary, the American Nurses Credentialing Center, which offers a range of certification credentials

Developing Leadership Skills

Students who join the NSNA have opportunities to learn from and socialize with their peers in school and at the state and national levels. As NSNA members, they benefit from developing leadership and organizational skills that can be vital in their professional careers and personal lives. Through the NSNA Leadership University, the NSNA recognizes students for their leadership and management competencies with a certificate presented at the annual NSNA convention. The NSNA Leadership University provides an opportunity for nursing students to earn academic credit for their participation in NSNA's many leadership activities. From the school chapter level to the state and national levels, nursing students learn how to work in shared governance and cooperative relationships with peers, faculty, students in other disciplines, community service organizations, and the public. In addition to preparing students to participate in professional organizations, practicing shared governance also prepares students to work in health care delivery settings that incorporate unit-based decision making, such as Magnet® hospitals. By participating in the NSNA Leadership University, students learn and practice the skills needed for future leadership. A list of those attributes and competencies is provided in Box 15-1. For complete details about the NSNA Leadership University and all of the NSNA's programs, visit their websites (www.nsna.org and www.nsnaleadershipu.org). Leadership skills are foundation blocks for nursing professional practice. Nurses have multiple opportunities to exercise leadership at the bedside, in clinical teams, and in management teams. The Nursing Alliance Leadership Academy (Nursing Organizations Alliance, 2012) was created to help nurses enhance leadership skills and focus on patients and care issues. The academy also focuses on developing political skills and policy awareness

The "American Nurse" Film Summary

THE AMERICAN NURSE is a heart-warming film that explores some of the biggest issues facing America - aging, war, poverty, prisons - through the work and lives of nurses. It is an examination of real people that will change how we think about nurses and how we wrestle with the challenges of healing America. THE AMERICAN NURSE is an important contribution to America's ongoing conversation about what it means to care. The film follows the paths of five nurses in various practice specialties including Jason Short as he drives up a rugged creek to reach a home-bound cancer patient in Appalachia. Tonia Faust, who runs a prison hospice program where inmates serving life sentences care for their fellow inmates as they're dying. Naomi Cross, as she coaches an ovarian cancer survivor through the Caesarean delivery of her son. Sister Stephen, a nun who runs a nursing home filled with goats, sheep, llamas and chickens, where the entire nursing staff comes together to sing for a dying resident. And Brian McMillion, an Army veteran and former medic, rehabilitating wounded soldiers returning from war.

Nurse Activists

The nurse activist takes a more active role than the nurse citizen and often does so because an issue arises that directly affects the nurse's professional life. The need to respond moves the nurse to a higher level of participation. An early nurse activist, Lillian Wald, whose picture opens this chapter, has left a notable and lasting legacy after responding to the needs of vulnerable populations in New York City by establishing the Henry Street Settlement, which still is in operation over a century later. Credited with establishing public health nursing, her tireless work on behalf of impoverished immigrants in New York City embodied her belief that the work of nurses was significant in improving the health of vulnerable people. Wald was also a member of the founding group of the National Association for the Advancement of Colored People (NAACP). Today's nurse activist may respond to a specific need not possibly envisioned in Wald's day. Several nurse activists are presented at various points in the chapter, some of whom became activists in response to a specific issue that became salient to their lives. Nurse activists can make changes by doing the following: • Joining politically active nursing organizations • Contacting a public official through letters, emails, or phone calls • Registering people to vote • Contributing money to a political campaign • Working in a campaign • Lobbying decision makers by providing pertinent statistical and anecdotal information • Forming or joining coalitions that support an issue of concern • Writing letters to the editor of local newspapers • Inviting legislators to visit the workplace • Holding a media event to publicize an issue • Providing or giving testimony to legislators and regulatory bodies Box 15-4 includes guidance on how to affect health policy development.

Other Benefits

There are many other benefits of membership, such as access to journals, newsletters, and action alerts about particular topics that need immediate response; eligibility for group health and life insurance; networking with peers; continuing education opportunities; and discounts on products and services, such as car rentals, computers, or books.

Professional Organizations: Types of Organizations

There are more than 100 national nursing organizations and many more state and local groups. Nurses often express confusion about which group to join. In general, organizations (associations) can be classified as one of three main types: 1. Broad-purpose professional organizations 2. Specialty practice organizations 3. Special interest organizations The American Nurses Association is an example of a broad-purpose organization. Individual nurses who belong to the ANA typically become members of their state's constituent member association. As the nursing profession's body of knowledge and research grows and diversifies, many nurses limit their practices to specialty practice areas such as maternal/infant care, school or community health, critical care, or perioperative or emergency/trauma nursing. They often join the specialty organization for their area of clinical interest. Members of specialty practice nursing associations also may choose to belong to the ANA or one of its constituent member associations (at the state level) to support the entire profession because specialty associations focus only on standards of practice or professional needs of 311the particular specialty. More than 60 specialty organizations and other nursing organizations are represented in the Nursing Organizations Alliance (The Alliance), a coalition of nursing organizations promoting the voice of nursing and cohesive action on issue of concern to nursing (Alliance, 2015). Examples of special interest organizations include Sigma Theta Tau International (the Honor Society of Nursing), which one must be invited to join, and the American Association for the History of Nursing, which focuses on a particular area of study in nursing. Comprehensive and frequently updated lists of nursing organizations are available online at www.nurse.org/orgs.shtml. Nurses are connected internationally through the International Council of Nurses (ICN). The ICN is a federation of national nurse associations representing nurses in 118 countries. The ANA represents U.S. RNs in the ICN, and the NSNA represents U.S. nursing students in the ICN. Founded in 1899, the ICN is the world's first and widest-reaching international organization for health professionals. Operated by nurses for nurses, the ICN works to ensure quality nursing care for all, sound health policies globally, the advancement of nursing knowledge, the presence worldwide of a respected nursing profession, and a competent and satisfied nursing workforce. For additional details about the ICN's activities in professional nursing practice, nursing regulation, and the socioeconomic welfare of nurses, visit the ICN home page

Getting Involved

To get involved, a nurse must begin to understand the connections between individual practice and public policy. Once that happens, it is easy to get started. Three levels of political involvement in which nurses can participate are as nurse citizens, nurse activists, and nurse politicians.

Becoming active in politics

Women involved in the feminist movement in the 1960s coined the phrase "The personal is political." This statement recognized that each individual—woman or man—could use personal experience to understand and become involved in broader social and political issues. This concept enabled individuals who did not consider themselves political to gain insight into what needed to be changed in society and how they could help bring about the change. It gave power to each individual and resulted in people becoming involved in the political process—usually for the first time. This premise of personalizing the political process has become a fundamental activity for organized nursing. Nurses at the grassroots level become involved in advocating for legislation and supporting candidates for elective office, because they understand the relationship between public policy and their professional and personal lives. Most associations, such as the ANA, American Association of Colleges of Nursing, American Hospital Association, and numerous specialty nursing organizations, actively engage in lobbying to advocate for the professional concerns of their members. Contemporary nursing leaders recognize that "being political," both through professional associations and as individuals, is a professional responsibility essential to the practice and promotion of the nursing profession. This chapter started with a discussion about national politics because this was the source of a great deal of media coverage and public interest during the primary season and presidential elections of 2012 and 2016. However, remember that an important premise in the earlier discussion was that much of what affects our day-to-day lives occurs at the state and local levels. When you work in a practice setting, your scope of practice is set by state law in the nursing practice act and is enacted by your state board of nursing, which also is also the governmental agency that licenses you and certifies your ongoing safety for practice. You may be late for work today because of repairs being done on an old bridge, from funding through America Fast Forward bonds, an initiative to fund the improvement of state and local infrastructure. Because you were then in a hurry to get to work, you may be pulled over by your local police officer for speeding, and although she was sympathetic with your need to get to work, she could not overlook the fact that you were both speeding and driving with an expired license, which you had been meaning to renew but had not gotten around to it. You have been busy working extra shifts because your unit is short staffed, and the local economic conditions have required a hiring freeze, meaning that you are going to continue to be busy for a while. Each of these situations affecting your day-to-day life reflects the notion that you are always, one way or another, in some situation that involves legislation, regulation, or another form of government intervention. The personal is political, and the political is personal. During the last 50 years of changing national and state health policies, nurses have increased their political astuteness. Through the well-orchestrated efforts of the ANA, other professional organizations, constituent member associations, and political action committees (PACs), nurses are now participating more effectively in both governmental and electoral politics than in the past. Nursing PACs 318raise and distribute money to candidates who support the profession's stand on certain issues. Nurses' endorsements of candidates have become a valued political asset for many local, state, and national candidates. Nurses can make a difference in health policy outcomes. Through the political process, nurses influence policy in a variety of ways: by identifying health problems as policy problems; by formulating policy through drafting legislation in collaboration with legislators; by providing formal testimony; by lobbying governmental officials in the executive and legislative branches to make certain health policies a priority for action; and by filing suit as a party or as a friend of the court to implement health policy strategies on behalf of consumers. All major nursing professional associations engage in these activities. Because the ANA is the major organization that speaks for all nurses, specific examples of influencing public policy will be drawn largely from ANA's activities. The ANA reports on the progress of nursing influence with the President, members of Congress and their staffs, and the regulatory agencies that set policy for health programs online on the Policy and Advocacy section of nursingworld.org. Such activity reflects the work of both ANA members and ANA staff. The ANA's political activity in Washington, D.C., is mirrored throughout the United States by other nursing organizations and by ANA constituent member associations conducting similar work with their state governments. Nurses Strategic Action Teams (N-STAT) are ANA's grassroots network of nurses across the country who keep elected representatives in Congress informed about issues of concern to patients and nurses. By notifying network members, ANA can rapidly mobilize nurses to lobby their federal representatives to support or oppose particular legislation and/or rules and regulations. Through the use of digital media and other resources, N-STAT members can respond by sending well-timed, well-targeted messages to members of Congress. Organized activity in identifying, financially supporting, and working for candidates who are committed to nursing and "nurse-friendly" issues has dramatically increased in the past two decades. The electoral process is an essential function of the professional association. Individual nurses can make a difference in policy development and elections. Either by election or by appointment, nurses need to be making health policy decisions, not just influencing them. Getting elected or appointed requires visibility, expertise, energy, risk taking, and a belief that policy and politics are critically important in achieving nursing's goals.

Nurse Citizens

A nurse citizen brings the perspective of health care to the voting booth, to public forums that advocate for health and human services, and to involvement in community activities. For example, budget cuts to a school district might involve elimination of school nurses. At a school board meeting, nurses can effectively speak about the vital services that school nurses provide to children and the cost-effectiveness of maintaining the position. Nurses tend to vote for candidates who advocate for improved health care. Here are some examples of how the nurse citizen can be politically active. • Register to vote. • Vote in every election. • Keep informed about health care issues. • Speak out when services or working conditions are inadequate. • Participate in public forums. • Know your local, state, and federal elected officials. • Join politically active nursing organizations. • Participate in community organizations that need health experts. Once nurses make a decision to become involved politically, they need to learn how to get started. One of the best ways is to form a relationship with one or more policy makers, and clear communication is key in influencing them Cultivate a relationship with policy makers from your home district or state. Communicate by visits, phone, email, and letters. When contacting policy makers, do all of the following: • State who you are (a nursing student or RN and a voter in a specific district). • Identify the issue by a file number, if possible. • Be clear on where you stand and why. • Be positive when possible. • Be concise. • Ask for a commitment. State precisely what action you want the policy maker to take. • Give your return address, email address, and phone number to urge dialogue. • Be persistent. Follow up with calls or letters. • If you plan to visit your policy maker, make your appointment in advance in writing and indicate what issue you are interested in discussing. • Be quick to thank policy makers when they do something you support.