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Influencing Health Care in the Legislative Arena

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Nurses are well aware that today’s health care system is in trouble and in need of change. The experiences of many nurses practicing in the real world of health care are motivating them to take on some form of an advocacy role in order to influence a change in policies, laws, or regulations that govern the larger health care system. This type of advocacy necessitates stepping beyond their own practice setting and into the less familiar world of policy and politics, a world in which many nurses do not feel prepared to operate effectively. Successful policy advocacy depends on having the power, the will, the time, and the energy, along with the political skills needed to ‘play the game’ in the legislative arena. This article describes the role of the nurse as health care policy advocate, identifies the power bases available to nurses as they assume that role, discusses the policy process in the legislative arena, and presents strategies for effective action. A list of selected online resources is included to help readers learn more about shaping and influencing future health policy.

Citation: Abood, S. (January 31, 2007). "Influencing Health Care in the Legislative Arena". OJIN: The Online Journal of Issues in Nursing. Vol. 12 No. 1, Manuscript 2.

DOI: 10.3912/OJIN.Vol12No01Man02

Key words: health policy, legislative arena, legislative process, nurse advocacy, policy advocates, politics, policy process, power bases, power of numbers.

[nurses] are often the first providers to see clearly when and how the health care system is not effectively meeting patient needs.

The current health care environment with a myriad of policies, laws, and regulations imposed by government agencies, private sector insurers, and institutions, challenges both nurses and patients who are often caught between the cross currents of cost constraints and access to appropriate quality care. De Navas-Walt, Proctor, and Hill Lee (2006) draw on the United States Census Bureau data collected in 2005 in reporting that the number of uninsured has grown to 46.6 million while the cost of health care continues to rise. A recent report compiled by the Commonwealth Fund found that a highly variable quality of care is delivered by a system that is too often poorly coordinated, thus driving up costs, and putting patients at risk (Schoen, Davis, How, & Schoenbaum, 2006). Given today’s rising costs, deteriorating access, and variable quality, improving health care performance is a matter of national urgency (Carey, 2006).

These discouraging reports noted above are not a surprise to most practicing nurses. As nurses interact with patients and their families, they are often the first providers to see clearly when and how the health care system is not effectively meeting patient needs. Every day nurses are positioned to see not only the impact of health policy on individual patients but also the need for more comprehensive changes in the policies that address many health-related issues (Kendig, 2006). Nurses come face to face with issues associated with patient safety and satisfaction, access to services, clinical outcomes, and health disparities. Dealing with these concerns and other workplace issues that having broad implications for whole groups of people, nurses have the choice to continue on trying to make do while feeling victimized by current changes (Mick, 2004) or to motivate themselves to take action and find opportunities to bring about change in the health care system itself.

...nurses often have to move out of the comfort zone of their practice arena and into less familiar arenas where the laws and regulations impacting patient care are developed.

When they choose to take on the role of policy advocate to change the system, nurses often have to move out of the comfort zone of their practice arena and into less familiar arenas where the laws and regulations impacting patient care are developed, and the battles for scarce resources are negotiated and decided. As challenging and time consuming as it may be, accepting this responsibility offers nurses the unique opportunity to make a difference and to have the satisfaction of being part of bringing a better health care system into reality for themselves and their patients. Advocacy adds a dimension to their professional practice that offers the reward of having more control over patient care and outcomes.

Successful advocacy to bring about changes in the health care system demands access to the resources of power, will, time, and energy, along with necessary political skills. In an effort to encourage more registered nurses to take action in the public health policy arena, this article describes the role of the nurse as health care policy advocate; identifies the power bases available to nurses as they assume an advocacy role to make changes in today’s health care system; discusses the policy process in the legislative arena; presents strategies for effective action; and lists selected resources to help develop the confidence and skills to shape and influence health policy.

Ways to Advocate for Health

Beginning with Florence Nightingale, there have been outstanding examples of individual nurses throughout the history of the profession who have demonstrated their capacity to shape health. Nurses have done this through initiating policy proposals, changing or vetoing others’ proposals, and/or substantially influencing the implementation of health policy. As in earlier times, many nurses today are inspired to take on some form of advocacy to bring about change in the current policies, laws, or regulations that govern the larger health care system. Becoming comfortable with the advocacy role takes a little preparation and some experience but does not need to be overwhelming.

Becoming comfortable with the advocacy role takes a little preparation and some experience but does not need to be overwhelming.

Many state nursing and specialty nursing organizations sponsor annual state legislative days, offer policy internships or fellowships (Hofler, 2006), and conduct policy workshops, all designed to give nurses the opportunity to learn more about current health care issues and the legislative process. They provide new advocates with easy access to more experienced nurse advocates willing to serve as mentors. Jan Howard, an experienced nurse advocate from New York, has served as a mentor to many fledging advocates. She reports that it’s exciting to watch a registered nurse with no legislative experience grow into the realization that she/he can make a difference for the profession legislatively. Another nurse stated, "I had no idea how important legislation was to my practice at the bedside." It’s rewarding to watch a nurse progress from saying, "Please go with me for the legislative visit. I won’t know what to say," to one who can independently discuss legislative issues and articulate his/her position so well that the legislator becomes supportive of the legislation being discussed.

Any nurse who has an interest in influencing the policy process, even one with limited time and resources, can find a way to become a confident advocate. It’s up to you as the advocate to decide on strategies you think will be effective, that you feel comfortable doing, and that are realistic given your time and energy. There are multiple ways to get actively involved ranging from simply writing a letter or making a call about an issue to getting elected to public office.

...very few policy changes take place without the concerted efforts of many advocates working together to bring about a common goal.

Once one is aware of a situation in which a change in policy would improve the health care environment or the delivery system, one can move to exploring the pros and cons of possible solutions, and then work to get others interested and involved in the issue. Depending one’s level of confidence and where the issue is in the policy process, one could also testify about the problem at public meetings and describe the merits of the solution one is advocating, lobby decision makers for or against proposed health policy changes under consideration, and/or work with the media to bring attention to the problem and the proposed solutions.

Many issues are too big or complex to be easily resolved by a few phone calls or even the dedicated efforts of one person. In reality, very few policy changes take place without the concerted efforts of many advocates working together to bring about a common goal.

Complex health care policies require the knowledge and efforts of organized groups, the help of professional lobbyists, and sustained activity of months or even years. Joining a professional nursing organization is an important way to enhance individual advocacy efforts. Nurses in an organized professional association have more resources, and are able to strategize more effectively to bring nursing’s perspective to health policy decision makers than do individual nurses. Professional nursing organizations are able to monitor public policy and offer ways for their members to learn about health policy. They also serve as a resource for reliable information related to policy issues and policy makers.

Another way that professional associations work for the benefit of nurse advocates is by providing information and tools to ensure that candidates who are supportive of nursing are elected to, or remain in, office. Registering to vote and voting in all elections is a must for every nurse advocate (Cherry & Trotter Betts, 2005). Here again, being part of a professional association with an established political action committee (PAC) can be very helpful in discovering where elected officials stand on issues and finding opportunities to work for the candidates who are supportive of nursing and health care issues.

Sources of Power for Nurse Advocates

The ability to successfully exert influence in the various arenas where future health care policy decisions are made and to take advantage of opportunities to present nursing’s perspective on the health care issues depends on having a power base and knowing where and when to exert that influence. Power is the potential to exert influence. Power is an inevitable part of human interaction, and those persons including nurses who deny this fact will be at a serious disadvantage when trying to make change (Kalisch & Kalisch, 1982). The following section addresses the power which can be found in numbers, along with five categories of interpersonal power originally described by French and Raven (1959; n.d.), namely expertise, one’s role, personal respect, and the abilities to reward and/or punish. These are sources of power available to even novice policy advocates when they speak up to alter existing policies, institutional systems, laws, or resource allocations in ways that potentially benefit not just one person but many individuals. Each of these six sources of power will be described in turn.

The Potential Power of Numbers

It's a common mistake to assume nurses lack the power to be effective in the legislative arena.

It’s a common mistake to assume nurses lack the power to be effective in the legislative arena. Nurses themselves have contributed to this myth by describing themselves as powerless. Nurses sometimes forget that as the largest group of health care providers, they could generate enough power to successfully reform the health care system based on numbers alone. According to the 2004 National Sample Survey of Registered Nurses, there are 2.9 million registered nurses who are dispersed in every voting district in the nation (U.S. Department of Health and Human Services, n.d.). This reality continues to offer the nursing profession a formidable power base that is largely untapped in the day-to-day world of the politics and legislation.

In spite of a serious and ongoing nursing shortage, wide-spread dissatisfaction among bedside nurses, the aging nursing workforce and teaching faculties, continuing conflicts with physicians, and lack of success to demographically diversify, the nursing profession has not been able to actualize their collective power. Nursing has not developed into a cohesive, increasingly powerful professional force that could be a partial counterweight to the dominance of medicine in the policy arena (Mick, 2004). However, involvement of only a fraction of the nation’s 2.9 million registered nurses in even the smallest way could become a force for change for the nursing profession and for the health care system and the patients it serves (Artz, 2006).

Expert Power

Another important source of power available to nurses is referred to as expert power which is related to possessing the knowledge and skill that some one else needs (Cohen, Leavitt, Leonhardt, & Mason, 1998; French & Raven, 1959; Lee, 1997; Rakich, Longest, & Darr, 1992). Expert power is the basis for collaboration and for advocacy in a variety of settings including the legislative arena and it provides nurses with considerable credibility to speak out on health care issues. Nurses have one of the better views of the health care challenges facing providers and patients and the very real impact of problems within the health care system, such as the existing nursing shortage. Nurses are in a unique position to share their expertise and knowledge when meeting with power players to educate them, to urge them to action, and to hold them accountable when their positions and voting records don’t match their rhetoric. Nurses, as providers and consumers of health care services, have professional and personal experiences regarding the problems and possible solutions to share with policy decision makers. It is expert power that allows nurses to bring their knowledge of nursing, health care, and patient safety to bear directly on the promotion and achievement of their policy goals.

Legitimate Power

Legitimate power is that bestowed by the particular status or the role of an individual (Cohen et al., 1998; French & Raven, 1959; Lee, 1997; Rakich et al., 1992). All registered nurses have legitimate power through their license granted by their State Board of Nursing to practice nursing. The rights and responsibilities that come with that license give the licensee standing in the health care community and the authority to speak out on nursing and health care issues. In addition, foundation documents developed by the American Nurses Association (ANA), such as the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) and Nursing’s Social Policy Statement, (ANA, 2003); provide additional sources of the profession’s legitimate power to address organizational, social, economic, legal, and political factors within the health care system and society (Fawcett & Russell, 2001).

Referent Power

Referent power is also a source of power available to nurse policy advocates. It is gained by having other people’s admiration and respect (Cohen et al., 1998; French & Raven, 1959; Lee, 1997; Rakich et al., 1992). Registered nurses are part of a profession that commands a level of credibility and trust that few others in health care or any other field can claim. The Gallup Organization’s 2006 annual poll on professional honesty and ethical standards ranked nurses as number one in terms of public respect (Saad, 2006). This trust is valuable and is transferable into action to improve what is failing in today's modern health care delivery system. Americans have entrusted us with their confidence to build a better system. We are in a position to foster change in the direction of public policy and influence the wisdom of the people who make decisions about the lives of the people we serve everyday. Nurses must be stewards in pushing an agenda that calls for quality health care for all. Referent power is an incredible asset to use when advocating on behalf of the nursing profession and patients. It opens the door to the offices of power brokers and decision makers. It is also an important asset when reaching out to other groups to gain support for an issue or when enlisting public support for an issue. A familiar example of the use of nursing’s referent power can be seen as part of the media campaign helping to reduce the nursing shortage sponsored by Johnson and Johnson.

Reward Power

Reward power is another available source of power. There are many more forms of reward -- in fact anything we find desirable can be a reward, from a promotion with more money to a pat on the back (Cohen et al., 1998; French & Raven, 1959; Lee, 1997; Rakich et al., 1992). Reward power is the ability to give other people what they want, and hence ask them to do things for you in exchange. Rewards can also be used to punish, such as when they are withheld.

In the give and take of the policy arena, it is the policy makers, the legislators at the state and federal level, who have the power to enact or not enact policy changes related to important nursing issues such as enhanced funding for nursing education, safe workplaces, appropriate staffing levels, and the removal of barriers to practice for advanced practice nurses. Because each elected official needs votes to attain and keep his or her office, the voice of every nurse voter is important to each person running for office. As voters, nurses have the ability to reward their own elected officials by voting them back into office and working for their reelection. Conversely, they have the ability to vote them out of office if they do not make decisions which strengthen the health care system.

Coercive Power

Lastly, there is coercive power which is the opposite of reward power. Coercive power is based on the ability to punish and is rooted in fear or perceived fear of one person by another (Cohen et al., 1998; French & Raven, 1959; Rakich et al., 1992). Coercion is the ultimate power of all governments. We are all familiar with this type of government power when we obey the state and federal taxation laws. We may not be eager to pay the taxes, yet we do not want to face the negative consequences of not paying up. Generally, coercive power is seen as a negative in our society and not appropriate in situations where you are trying to persuade someone to see your point of view. Although both rewards and threats of punishment are powerful motivators, advocates are better served by using reward power than coercive power.


These different power bases are not necessarily independent and may be complementary. Any individual can have more than one base of power. In fact more than being simply additive, the sum total of several power bases is usually greater than its individual parts. For example, physicians have effectively exercised coercive, legitimate, and expert power to dominate the health care policy process in both the private and public sectors for many years (Kalisch & Kalisch, 1982).

Power is a potential capacity which can provide opportunities to meet goals. A person may possess both a base of power and the capacity to exercise it. Yet the mere existence of a power base and capability is not the same as actualized power. If there is no interest or willingness to employ the power, it remains only a potential resource. Power is simply what you begin with. Being able to successfully work for safe, quality, patient care depends on being able to translate that potential capacity, i.e., power, into influence and accomplishments (Haass, 2005). Understanding and using the various sources of power available to you is critical to ultimate success in the legislative arena.

The Policy Process and the Politics of Health Care

Health policy is a set course of action (or inaction) undertaken by governments or health care organizations to obtain a desired health outcome (Cherry & Trotter Betts, 2005). The overall health care system, including the public and private sectors, and the political forces that affect that system are shaped by the health care, policy-making process. Public health-related policies come from local, state, or federal legislation, regulations, and/or court rulings which govern the provision of health care services. In addition to public policies, there are institutional or business policies related to health care. These policies are developed in the private sector by agencies, such as hospitals, accrediting organizations, or managed care organizations. Nurses are very familiar with institutional policies including those developed and implemented by the Joint Commission on Accreditation of Healthcare Organizations.

Policy making takes place in a wide variety of settings ranging from fairly open and public systems involving a relatively large number of actors to a closed system involving just a few actors. The location of decision making in the public or the private sector, the scope of the issue, and the nature of the policy all have an impact on the characteristics of a policy (Thurber,1996). Since a basic understanding of the policy process is the first step in strategizing how to activate potential power and influence meaningful changes in the health care system, this section will discuss the three phases of policy making, as well as the connection between policy and politics.

The Policy Process

The policy process refers to all the specific decisions and events that are required for a policy to be proposed, considered, and finally either implemented and/or set aside. It is an interactive process with multiple points of access providing opportunities to influence the multiple decision makers involved at each stage. Basically there are three phases of policy making: the formulation phase, the implementation phase, and the evaluation phase. During the formulation phase there is input of information, ideas, and research from key people, organizations, and interest groups. At this point the issue is framed; the purpose and desired outcomes are clearly identified; strategies most appropriate to the desired outcome are selected; and needed resources are identified and planned for.

The implementation phase involves disseminating information about the adopted policy and putting the policy into action. In this phase, the proposed policy is transformed into a plan of action (International Council of Nurses, 2005). Public policy enacted by local, state, or federal governmental bodies is usually implemented through the regulatory process that translates the policy into a written set of rules issued by the government agency which has the responsibility for administering the policy.

The policy process also includes an evaluation and modification phase when existing policies are revisited and may be amended or rewritten to adjust to changing circumstances (Longest, 2006). Most major public policies are subject to modifications in this incremental fashion. Making smaller changes in existing policies are usually less controversial than making major changes as they require less understanding of comprehensive relationships and less effort to achieve. An example of incrementalism in health policy can be seen in the many changes that the Medicare Program has undergone since its enactment in 1965. A change to the program of importance to advanced practice registered nurses came in 1998, when the U.S. Congress added nurse practitioners and clinical nurse specialists as providers who can bill for Part B services they provide to Medicare beneficiaries. Since then, Congress has tweaked Medicare program many times and added a number of preventive services to the Medicare program. Most recently Medicare Part D, an optional prescription drug program available for Medicare beneficiaries, has been added.

The Connection Between Policy and Politics

Decision makers rely mainly on the political process as a way to find a course of action that is acceptable to the various individuals with conflicting proposals, demands, and values.

As any health care issue moves through the phases of the policy process, from a proposal to an actual program that can be enacted, implemented, and evaluated, the policy process is impacted by the preferences and influences of elected officials, other individuals, organizations, and special interest groups (Longest, 2006). These different factions do not necessarily view the issue through the same lens and often have diverse and competing interests. Added into the mix are the partisan agendas of the two political parties, the Democrats and the Republicans. The political party holding the majority usually has the political advantage.

Decision makers rely mainly on the political process as a way to find a course of action that is acceptable to the various individuals with conflicting proposals, demands, and values. As a general rule, any policy involving major change, significant costs, or controversy will be relatively more time consuming and difficult to achieve and will require the use of more political skills and influence than will policies involving less complex changes.

Throughout our daily lives, politics determines who gets what, when, and how.

Throughout our daily lives, politics determines who gets what, when, and how. Politics has been defined as "the process of influencing the authoritative allocation of scarce resources" (Kalisch & Kalisch, 1982, p.31).

Political interactions take place when people get involved in the process of making decisions, making compromises, and taking actions that determine who gets what in the health care system. Special interest groups and individuals with a stake in the fate of a health care policy use all kinds of influencing, communication, negotiation, conflict management, critical thinking, and problem solving skills in the political arena to obtain their desired outcome (Cherry & Trotter Betts, 2005; Kalisch & Kalisch, 1982).

Strategies for Effective Action in the Legislative Arena

As nurses get ready to take their issues into the legislative arena and to use their legislative power and political clout, it is essential to determine which strategies will be timely and most effective. This section briefly addresses the five following strategies: entering the legislative arena, understanding steps in the process, understanding the power players, understanding committees, and communicating with legislators.

Entering the Legislative Arena

The legislative arena is where most advocates concentrate their efforts to make their point of view on a particular issue known. It is where citizens go to meet their legislators

Entering the legislative arena is the first step in bringing about policy change.

and meet with people who are staff for the legislators and the various committees, and where they testify at hearings and briefings.Entering the legislative arena is the first step in bringing about policy change. When Maggie Flanagan (n.d.) found herself with a musculoskeletal injury after years of bedside nursing, she spoke up in the legislative arena in her state to educate policy makers about the need for Safe Patient Handling legislation. When Karen Daley (n.d.) suffered a needle stick injury at work, she courageously carried her own experience into the legislative arena to advocate for Safe Needle Protection policy. When Patti Moss and Iva Hall, nurse researchers from Texas, identified the need for legislation to develop a comprehensive disaster preparedness plan that included home bound medically fragile patient populations, they went to the legislative arena to get needed legislation enacted (Hall & Moss, 2000).

Understanding the Steps of the Legislative Process

In addition to entering the legislative arena, all the nurses described above learned first hand how to effectively play a part in the legislative arena by influencing policy designed to have a positive impact on patients and their profession. This section will describe the legislative process since knowing these steps is fundamental to the movement from a problem to a viable program. It is the process that enacts laws, creates and funds health programs, and balances health policy with other policy domains. Once an issue takes its place on the public agenda, a bill must be introduced, delegated to a committee, hearings held, and committee action taken on the bill before the legislation is taken to the floor for a final vote. (For a review of how a bill becomes a law and other nuts and bolts of political action go to The Legislative Process). Each state has a similar legislative process to authoritatively make policy decisions.

Patti Moss and Iva Hall learned first hand lessons of how to use the legislative process effectively for patients and the profession. When the results of their research revealed the need for a change in the Texas law, they went to work. Working with a consultant, they developed a bill that would make the changes needed to remove barriers to a comprehensive disaster plan. Once the bill was drafted, they had to identify a legislator willing to introduce and sponsor the bill. They used posters, slide presentations, and verbal explanations to present the highlights of their research and the bill they were proposing to local legislators and their staff. Newly elected state Representative Joe Deshotel agreed to introduce the bill and shepherd it through the process. A companion bill was introduced in the state Senate by Senator David Bernsen. Making many trips to Austin for visits to the offices of key legislators, these nurse advocates learned to present their issue in a concise two-minute speech. They also made a point of actively listening to the legislators in an effort to help support the legislators’ causes as the legislators supported theirs. By the end of the legislative session, the efforts of these two nurses were rewarded with the enactment of their legislation paving the way to the establishment of an improved state disaster plan for individuals with special disaster needs (Hall & Moss, 2000).

Knowing the Key Players

In the legislative arena there are always key players who have the ability to impact the outcome of proposed legislation.

In the legislative arena there are always key players who have the ability to impact the outcome of proposed legislation. Final voting decisions are influenced by many factors other than the merits of the issue. These factors include party politics, personal preferences, district voters’ preferences, and the pressure of organized interest groups. Shaping the final outcome and content of the proposed policy change depends on identifying the supporters as well as the non-supporters among legislators, contacting the chairperson and the members of relevant committees, and most importantly contacting one’s own legislator.

As constituents, nurses have considerable power to influence legislation especially when nursing has a firm, cohesive preference on an issue. When potential voters are divided or don’t care, a legislator is less likely to take their preferences into consideration when voting. Legislators ask themselves many questions before they vote to support or oppose a bill. Some of their considerations will likely include: Does this measure affect my district and if so, how? What do people in my district think? Have they communicated with me? Does my political party support or oppose this bill? Who are the individuals or groups supporting/opposing this bill and what kind of relationship do I have with them? Building credibility with one’s legislators and their staff should start before one needs their support. Don’t overlook the importance of finding out which staff person advises one’s legislator on health care issues and scheduling a meeting with that person early in the legislative session to get to know the staff persons by name and share your expertise with them.

The immediate impact of nurses speaking out and being visible at the Capitol cannot be overstated. Following a recent lobby day, when nurse advocates made visits to a hundred Congressional offices, a significant number of legislators signed on to support increased funding for nursing programs.

Understanding Committees

Committees are the centers of policy making and public education at both the federal and state levels. Proposed legislation is given the most intensive consideration at the committee stage. This is when conflicting points of view are discussed and where legislation is hammered out. The committee chairperson controls the work of the committee; and by negotiating with committee members, establishes the agenda for the consideration of a given bill. Committee procedures perform a gate keeping function by selecting from the hundreds of measures introduced in each session those that merit floor debate and ignoring the rest. Committees conduct hearings to educate committee members and the public about a particular bill under consideration. Hearings provide an opportunity for various views to be discussed. Nurses can influence the process at this point by requesting an opportunity to testify. However, invitations to testify are usually offered to larger, organized groups which have developed a position on the issue, rather than to individuals. Even though you may not be invited to testify in person at a committee hearing, there are still opportunities to communicate your position to committee members and or their staff and to explore who supports the bill and who opposes it. Thus it is important to know which committee or committees will address your area of concern.

The nursing profession is fortunate to have Representative Lois Capps, RN, one of the three nurses currently in Congress, serving on the powerful Committee on Energy and Commerce and its Subcommittees on Health, Energy and Air Quality, and Environment and Hazardous Materials. From these posts, Capps has focused on Medicare reform, the nursing shortage, cancer, mental health, energy policy, the environment, and telecommunications issues. She also serves on the influential House Budget Committee where she takes an active role in promoting fiscally responsible spending priorities for the annual federal budget. Representative Capps is also the founder and co-chair of the Congressional Nursing Caucus, a non-partisan forum for the discussion of issues that impact the nursing profession. The Nursing Caucus allows members of Congress an open forum to address issues affecting the nursing community. 

Communicating with Legislators

Each year, legislators at both the state and federal levels must wade through hundreds of bills that cover a broad range of issues. It is impossible for them to be knowledgeable about all issues and to completely understand each bill. This is where advocates can wield a lot of power by helping their own legislators to evaluate an issue and determine how they will ultimately vote on that issue.

Each year, legislators at both the state and federal levels must wade through hundreds of bills that cover a broad range of issues.

The effective advocate will work to develop communication skills in order to convince others to listen and gain the perceptions of others. Repeated contacts with legislators and their staffs made in a straightforward manner greatly increase the likelihood that the information one provides will be heard and understood, and perhaps influence their decisions.

When dealing directly with policy makers, advocates must be informed, be concise, and be clear about what they want. Writing a well crafted letter, sending emails, leaving a written summary of your issue with staff, sending thank-you notes, and inviting the legislator to visit your workplace are all ways to get one’s legislators to consider one as an expert on health care and nursing issues and to make contact when they need information related to nursing and health care. One state legislator stated, "The nurses in my home district made me aware of the impact this legislation would have on patients." By utilizing the nurse’s information the nurse provided, the legislator was able to reconsider her position on several pieces of pending legislation and supported bills relevant to nursing practice. To review some techniques for working with policy makers go to Hill Basics: Visiting Capitol Hill and Making Your Voice Heard in Congress .

The legislative arena is a highly competitive environment where there are no guarantees of success for even the most reasonable proposal. At times decision makers have an invested interest in maintaining the status quo. Political advocacy can at times be discouraging when facts or research are discredited or agendas are challenged. It is wise to anticipate these types of setbacks and to be prepared with an appropriate response.


...all nurses are touched by the policy and politics of the health care system...Nurses need to be a strong voice actively advocating for positive change.

Whether they acknowledge it or not, all nurses are touched by the policy and politics of health care system and the impact the policies, legislation, and regulations developed in those arenas have on the way they practice their profession (Holmes & Gastaldo, 2002). Many special interest groups involved in health care actively participate in the development of health care policy by providing critical information legislators need to make decisions. Nurses cannot afford to remain in the background or added as an after thought to the policy and legislative arenas. As the largest single group of health care providers, nurses have the potential to successfully advocate from a diverse power base; and they and have a unique perspective on health care policies and expertise to share with power brokers. Nurses need to be a strong voice actively advocating for positive change. Nurses strengthen their power base when they network with nursing colleagues and other supporters to build consensus on important issues.

As the health care system continues to change, more and more nurses are choosing to take on the advocacy role, working to get health care policies which reflect nursing’s perspective implemented. However, without a sound understanding of the legislative process, policy advocates run the risk of having their message wasted by working with the wrong people or at the wrong time. There are multiple ways to advocate for nursing, ranging from simply making a phone call or writing a letter to expressing your opinion on an issue of importance, all the way to running for office yourself. Even the busiest professionals can find convenient ways to advocate for a better health care system. For the neophyte and the more experienced there are many resources (such as the websites listed below) available to nurse policy advocates who want to learn more about how to make a difference in key health care issues using legislative and policy processes and working within the political arena.

Websites for Health Policy and Political Activists

Agency for Healthcare Research and Quality:

American Nurses Association:

Centers for Medicare and Medicaid Services:

Commonwealth Fund:

Department of Health and Human Services:

For Public Employees: Being an Advocate from the Inside:

Institute of Medicine:

Library of Congress’s Thomas website:

International Council of Nurses:

National Council of State Legislatures:

RN Activist Kit:

United States House of Representatives:

United States Senate:


Sheila Abood, PhD, RN

Sheila A. Abood is currently Associate Director for Government Affairs at the American Nurses Association (ANA) with responsibilities for regulatory issues and for lobbying regulatory agencies on issues that have an impact on the nursing profession. In addition, she serves as the editor of Capitol Update, ANA's monthly electronic legislative newsletter and also as a Senior Associate Editor for the peer reviewed journal Policy, Politics, and Nursing Practice. Prior to her work at ANA, she served as Director of Government Affairs at the Michigan Nurses Association where she planned, promoted, and implemented the association's legislative program for eight years. She earned a MS in Nursing Health Services Administration from the University of Michigan and a PhD in Nursing from George Mason University.


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© 2007 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2007

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