Built for Advocacy

The scenario described above is just one example of nurses’ activism on behalf of patients. When you call in the social worker because your patient is homeless; when you ensure that discharge medications are filled at the hospital pharmacy because your patient’s Social Security check will not arrive for another 2 weeks; when you complete daily menus because your patient with diabetes cannot read English—you are acting on the knowledge that speaking up can improve (if not determine) the outcome.

Nurses also act on this knowledge in other impactful ways. When you serve on a multidisciplinary hospital committee solving a work-flow problem; when you take team concerns to the unit manager; when you attend drop-in coffees with the chief nursing officer—you are bringing nurses’ perspective, voice, and presence to situations that can affect nursing practice and patient care in the short or long term.

Advocacy is one of our superpowers. This is why I am puzzled when I meet nurses who see this skill as being limited to their workplace. We need to use it to speak out and improve outcomes outside of health care settings, especially in the policy arenas of local, state, and federal government. Here is how I learned about the critical role nurses play as advocates in the broader world.

I have been a nurse practitioner for 36 years and a registered nurse for much longer. During my first dozen years in nursing, I experimented with and enjoyed a variety of inpatient and outpatient settings. After graduate school, I found my niche at a global software company managing operations of an onsite family practice that provided free primary care for 14000 employees and family members.

My career path may have meandered a bit, but my focus was always clinical practice. When I joined my state nurses’ association in my mid-20s, I was surprised to discover an avid interest in grassroots activism. With no political experience beyond casting votes in 2 presidential elections, I jumped into the association’s ambitious 2-year initiative to rewrite the nursing practice act. Reflecting on that beginning, I was blessed with ignorance. What may have looked like courage was simply not knowing what I did not know. I was also fortunate to work alongside nursing leaders who modeled the skills and behaviors I lacked. Apparently I had missed an important message as an undergraduate: nursing was legally defined by well-meaning but uninformed laypeople. The state legislators I met had a rudimentary understanding of health care and no grasp of contemporary nursing practice. Despite these deficits, they had the power to fundamentally change nursing. This was not just illuminating; it was frightening.

My crash course in advocacy was followed by some leadership opportunities that included being president of the nurses’ association and, years later, a member of the board of nursing. I leaned into my new-leader anxiety, took some risks, survived a few spectacular failures, and became more resilient and confident. Observers began to encourage me to run for office. After a decade of laughing this off, I decided to explore the idea and enrolled in a political campaign school. I quickly discovered the built-in advantages of being the only nurse in my 22-member cohort. I was able to connect easily with strangers and use common language instead of jargon. I asked a lot of questions, eager to learn and not embarrassed to admit what I did not know.

After completing that 6-month program, I set my sights on the legislature and statewide health policy. My plan was to wait a few years for the state house incumbent to run for higher office, as we were in the same party. But instead, recruited by a group of community leaders, I ran for an open seat on my town council. In the fall of 2007 I won that 3-way race with 55% of the vote. After holding local office for 7 years, I was recruited for and won a competitive seat in the North Carolina House and served 8 years there before winning election to the state senate in 2022. I am the first nurse to serve in the North Carolina Senate—and the only senator who is also a health care professional.

Thirty-five years in the trenches as a grassroots advocate and legislator have convinced me of 2 things: nursing must be present and vocal at health care policy tables, and it is on us to get there. Medicine is the best example of a profession that recognized this situation long ago. The American Medical Association and its member state medical societies have spent decades (and millions) establishing a foothold in Congress and state legislatures. That investment of time and money is reflected in their inordinate influence over health policy and funding decisions. They have also promoted the worldview that physicians must be consulted on and must agree with legislation to update other health care disciplines’ scope of practice. This stance has proven to be a significant roadblock in updating state laws to authorize nurse practitioners and other advanced practice registered nurses to practice within the full extent of their education, training, and certification (known as “full practice authority”). Despite 3 decades of research demonstrating the safety, efficacy, and quality of advanced practice registered nurse care, state medical societies oppose these bills and use their established “gatekeeper” status to block them. In these and other health care policy debates, the voices and perspectives of nurses are muted, marginalized, or simply ignored. This is bad news not just for nurses. How such laws are written can improve or restrict access to care in provider shortage areas and for marginalized and underserved patient populations.

How do nurses position ourselves to influence lawmakers? Step-by-step.

• Be a member. You need membership in your specialty organization and in your state nurses’ association. The American Association of Critical-Care Nurses provides industry-specific continuing education among its valuable member benefits. Your state association plays a different, equally important, role. As the one group representing all nurses regardless of specialty and practice setting, it proposes, monitors, and lobbies for or against bills affecting nurses and nursing practice. It has professional lobbyists who work with association members to ensure that nursing’s perspective is heard and considered.

• Get acquainted. If you do not already know who represents you, consult your state legislature website. Send your House and Senate member each a brief email, thanking them for their service, introducing yourself as their constituent and a nurse, and offering to be a resource for them on nursing issues. Always conclude by thanking them again and including your full name, home address, and phone number. Be sure to use their formal title (eg, Hello, Senator Adcock).

• Stay in touch. As a state association member, you will receive email alerts when important bills are moving. Use the suggested talking points, but always personalize your message so it is not dismissed as an effortless copycat. Constituent messages matter. Legislators want to be seen as responsive, and above all, they want to be reelected. We do not have time to pay attention to individuals living outside our districts.

• Have a field trip. Invite your legislators to visit your practice setting to see what you do and how you affect the community. Such eye-opening visits leave an indelible impression. Legislators often use them to tell compelling stories about why they support or oppose a bill.

• Attend “lobby day.” These 1-day events at the state capitol are a powerful demonstration of collective action. Attendees start the day as a group to hear background and get talking points on important bills. Then they visit their own legislators alone or as part of a small group and may attend committee meetings or observe a floor session. Seeing advocacy in action increases your comfort level and demystifies the process.

• Elect nurses and nurse-friendly candidates. Vote for them. Use your social media network to raise their profile and increase their name recognition. Put a campaign sign in your yard. Attend a meet-and-greet event or a fundraiser. Make a campaign contribution of any amount. Volunteer to knock on doors, make phone calls, or work a few hours at the polls on election day. Any one or a combination of these actions will start or strengthen your relationship with an elected official as they begin or resume their time in office.

• Get appointed. Local, state, and federal officials make appointments to numerous advisory boards and commissions. Search the website of your county, city or town, and governor for information about existing boards and commissions, any board-specific qualifications, when and how to apply, term length, meeting frequency, and so on. Note: Your chances of a gubernatorial appointment are increased if you are a member of the same political party.

• Run for office. Nurses already possess many skills needed to serve in office. We learn new information and adopt new language quickly, identify root problems, formulate actionable solutions, assess results, and regroup as needed (think nursing process!). We are comfortable working with diverse individuals and are respectful of differences. We communicate clearly, build consensus, and understand teamwork. We are also courageous.

Elected office is not limited to the state legislature or Congress. Local government is a good option for nurses interested in public service. It is known by different names regionally; in North Carolina we have city and town councils, county commissions, and school boards. Local officials pass local laws (“ordinances”) that directly or indirectly affect the health and well-being of their communities. Because local government is closest to the people, their decisions are implemented more quickly and felt more acutely than those made at the state and federal levels. In addition to the importance of the work itself, the time commitment for local government is scalable for the lives of busy nurses who work full time, have young children, or head single-parent families.

If running for office is in your future, campaign training is a must. Whether such training is an immersive multiday program or takes some other format, candidates with this specialized education and set of skills have a distinct advantage over those who decide to “wing it.” In addition to the nuts and bolts of campaign finance law, participants learn how to write a campaign plan that includes voter demographics, a calculated “win number,” use of opposition research, and specifics on fundraising, a field program, direct mail, social and traditional media, and candidate events like forums and debates. Just as nurses would not change specialties without a plan, running for office requires a specific type of preparation. An internet search can identify campaign training options that fit your locale and timetable. Be sure to check out Healing Politics, the nation’s first campaign school created specifically to train nurses to run for office (see Table).

When I was a novice nurse, my motivation for advocacy was purely defensive: a combination of fear of the unknown (what could happen?) and curiosity (what could I do about it?). Decades later, I have come to understand that advocacy is a lever for positive change and is most effective and satisfying when used proactively. Short of being the policy maker yourself, the best way to affect outcomes is to use influence with policy makers you know and trust, and who know and trust you. Nurses do this with patients every day. If we leave this ability at work, we are missing the bigger picture. Our voices—and those of people we provide care for—will be absent from crucial conversations about increasing access to care, lessening health inequities, and addressing upstream problems that affect people’s health.

Here is what I know: nurses cannot expect an invitation to participate. Although lauded as “health care heroes” by the public, the media, and employers, we are not automatically or routinely included when critical problems in health care are discussed. Because nurses make up the largest segment of the health care workforce, it might seem logical to include them when discussing the nursing shortage, safe staffing ratios, and workplace violence. But the politics of power is not built on logic; therefore, we must insert ourselves into the process. Influence is not reserved for the rich and powerful, but it is unattainable for the invisible and silent.