Learning the Ropes of Policy, Politics, and Advocacy

Judith K. Leavitt, Mary W. Chaffee and Connie Vance

“I am not afraid of storms for I am learning how to sail my ship.”

—Louisa May Alcott

Every politically active person, from United States presidents to chief executive officers, learned the political and policy skills that catapulted them into positions of power and responsibility. Nurses are no different. Though one can learn about the policy process and political analysis through formal education, it is only through experience and practice that one can apply what has been learned. A most important catalyst in becoming involved is to find mentors—colleagues and friends who are politically savvy—to teach us, to believe in and support us and to celebrate our success and learn from our failures.

This chapter explores how to become involved through mentoring, education, and experience. Students new to politics as well as experienced nurses have unlimited ways to expand their knowledge and involvement. Whatever our experience, we improve our skills as we engage in the process. There are infinite causes and issues in health care to stimulate our interest if we want to become engaged. We need only decide how much energy and time we are willing to devote. Success in the world of policy and politics demands the strengths and skills that nurses possess. Working in the policy arena will open doors to opportunities where nurses can become significant participants and leaders. This book includes many stories about nurses who have done this. These stories can be inspirational and motivate others to become active in policy and politics.

Political Consciousness-Raising and Awareness: The “AHA” Moment

How does one get started? Many find that there is a defining moment when the old ways of reacting to issues of injustice, inequality, or powerlessness no longer work. It is the moment when a person realizes that an issue or problem is due to failures in the system. For instance, lack of support staff on an acute care unit may be related to decreased reimbursement rates rather than an uncaring hospital administration. Denial of care for a patient eligible to receive Medicaid or Medicare could be related to cuts in federal funding, rather than the patient’s need for care. Realizing that a problem may be due to a policy failure is a critical first step toward becoming part of the policy solution. This is political consciousness-raising and an “aha” moment. It is the adrenaline rush that urges, “Something must be done—and I need to become involved.”

Until that defining moment, nurses may feel frustrated, angry, or hopeless. When the “aha” hits, we begin to understand that we can and must influence those who make the laws and regulations that create the inequities. We recognize the personal nature of policy issues (“the political is personal”) Many health care problems require policy solutions, and advancing a solution requires skills that can be learned. When nurses accept that they are not at fault for the inadequacies of the health care system and instead believe that nursing can shape solutions, the profession itself becomes political. Nurses then become proactive rather than reactive. The result is that the individual nurse, as well as the profession, become empowered to act. Feeling empowered is essential to true advocacy.

Getting Started

Through interviews with 27 American nurses involved in health policy at the national, state, and local levels, Gebbie, Wakefield, and Kerfoot (2000) set out to discover how and why these activist nurses became involved. Their results corroborated what we knew anecdotally:

• The majority of respondents had parents, most often fathers, who were active in policy and politics and who created a mentoring, supportive environment.

• Many were raised to be independent and to believe in their capacity to accomplish what they wanted.

• High school provided a training ground in political socialization.

• Nursing education provided role modeling and mentoring by faculty, deans, and alumni as well as the opportunity to increase political awareness through courses in policy, political science, and economics.

• Clinical practice often provided strong role models, and experiences in public health and community health provided opportunities for political insights.

• Graduate education opened doors for many, through such avenues as the study of law, health economics, and health policy.

• Some had their consciousness raised gradually through work experiences that exposed them to public policy and the need to understand how to influence the process.

The nurses who were interviewed confirmed that there are multiple points of entry into the policy arena. Whether this chapter, this book, a course in policy and politics, or a conversation with a colleague is your first exposure, you have already started.

Political skills, such as how to be persuasive, how to identify and use power effectively, how to analyze barriers to goals, and how to mobilize people to work collectively, are all skills that can be learned. Nurses bring many skills to the political arena that are learned through education and further refined in clinical practice. Politics requires the kind of communication skills that nurses use to persuade an unwilling patient to get out of bed after abdominal surgery or a child to swallow an unpleasant-tasting medication. In addition, nurses, whether they realize it or not, are health care experts. Nurses can speak knowledgeably about what patients and communities need because they experience it firsthand.

Advocacy and Activism

Nurses are considered to be powerful advocates—but what exactly does this mean? Florence Nightingale saw nursing in all of its forms as advocacy—a “calling” that required nurses to look for and act in ways to be world citizens for the sake of human health (Dossey, Slanders, Beck, & Attewell, 2005). Advocacy is increasingly recognized as a component of professional nursing practice. Nursing education at the baccalaureate level is expected to produce nurses who “advocate for health care that is sensitive to the needs of patients” and who “advocate for professional standards of practice using organizational and political processes” (American Association of Colleges of Nursing, 1998, pp. 15-17). Nurses who have been educated at the master’s degree level are charged with assuming the role of advocate for consumers and the nursing profession as well as assuming the role of change agent in the health care system (American Association of Colleges of Nursing, 1996).

In the workplace, nurses work with patients to achieve mutual goals by advocating for the patient or for resources the patient needs. Outside the health system, nurses can be equally influential advocates. In the government, in professional associations, and in the community, nurses can use political skills to advocate for policies and change that will improve the health of populations (see Chapter 5).

The Role of Mentoring

At every stage of a nursing career—from student to novice to expert—mentor relationships are an essential element for professional success, socialization, and leadership development. In the traditional world of politics, the “old boys’ network” consisted of strong mentoring components. Gaining entry into the inner circle required the mentorship of political party leaders who served as sponsors, role models, and door openers to aspiring “politicians.” Nurses are discovering the necessity of receiving mentoring from a variety of leaders and peers at every career stage, particularly as they expand their influence from a clinical setting to policy and political involvement. For example, a nurse who has participated in lobbying elected representatives around an issue may need help learning the myriad rules of legislation particular to different legislative bodies. For instance, the two houses of Congress have different rules from most state legislatures. Knowing how to get bills passed requires understanding how to read legislative language and who can move legislation forward (see Chapters 64, 65, and 69). Mentors can guide others to learn about the processes and relationships.

A mentor or role model provides inspiration and encouragement to get involved, as well as coaching and tutoring in the nuts and bolts of political involvement. As explained by Kram (1983, 1985), mentoring has been compared to a dance relationship. The mentor is the dance teacher; the mentee is the pupil. The teacher supports, role models, guides, and critiques; the student/dancer seeks feedback, advice, and guidance and stays motivated to learn (Zauszniewski, 2009). It can be a long-term relationship as the dancer moves from acquiring knowledge and skills to refining and expanding learning. As with any other nursing skill, learning the political or policy process requires both theoretic and experiential knowledge.

In the nursing profession, the mentor model consists of both expert-novice and peer-peer partnerships. One example of developmental mentoring is the modeling of political behavior at lobby days in Congress or in state legislatures that are sponsored by nursing associations. At these events, nurse lobbyists and activists serve as mentor-guides and role models to nurses and students. They provide information and strategies and model effective behaviors while lobbying policymakers on specific legislation. These activists also provide the inspiration and vision for what can be done if nurses work together toward shared goals. This is real-life learning and it is a highly effective and practical way of developing political awareness and know-how. Check your state nurses association for lobby days.

Finding a Mentor

You can find a mentor, even if you don’t know someone personally. Begin with an idea of what you would like to learn or in what area of politics and policy you would like to be involved. Then identify people whom you have noticed, heard, or read about who are activists in your area of interest. Good sources for finding mentors are nursing associations, schools of nursing, clinical organizations, and local political organizations and campaigns. You may contact the person directly, via e-mail, by phone, or with a note, or you can ask someone who knows the individual to provide an introduction. Tell them what you want to learn and why you would like them to assist you. For instance, nurses can get involved in local political campaigns, where they are warmly welcomed, particularly if one identifies himself or herself as a nurse. The mentor may or may not be a nurse. The important criteria for a mentor are knowledge and an interest in you. Sometimes the mentor need only get you started; in other situations, a mentor becomes a lifelong friend and role model.

Collective Mentoring

Because the majority of nurses are newcomers to political and policy activism, every nurse should possess the mentality of being both a mentor and a protégé in the political process. Learning politics is not a solitary activity. This means that nurses should be on the lookout for mentors who can serve as their teachers and guides as they hone political and policy skills. Likewise, every nurse should assume responsibility for actively mentoring others as they refine their repertoire of skills and deepen their involvement. This reciprocal collective mentoring is extremely effective in expanding the political and power base of the profession and its members. Collective mentoring can occur in schools, clinical agencies, and professional associations. This means that wherever we practice, we can each refine our skills by seeking mentors and serving as mentors to others.

Inherent in this form of mentoring is the development of networks of persons who are active in policy and who take responsibility for expanding these networks. The nurses in these networks should develop strategies for mentoring political neophytes and for “claiming” nurses who may not be in traditional career paths (Gebbie et al., 2000). Organizational networks, including those in academic, clinical, and association settings, are a natural place to establish developmental mentoring activities. For example, politically active faculty members can network with political leaders in professional associations to provide undergraduate and graduate students with lobbying and leadership opportunities. Many state nursing associations are successfully reaching out to collectively mentor hundreds of nursing students through lobby days in national and state capitols. Nursing students and practicing nurses also have many opportunities to experience collective mentoring in learning the political ropes through relationships with leaders and peers in organizations such as the National Student Nurses Association, ANA, specialty and state nursing associations, and volunteer health-related organizations. In addition, local political parties, community organizations, and the offices of elected officials offer nurses opportunities to learn through mentored experiences. These organizations can offer numerous mentoring opportunities for involvement in lobbying, policy development, media contacts, fund-raising, and the political process in various venues.

Mentoring in policy development in any of the spheres also requires connections to knowledgeable leaders. In the workplace, one can learn from health professionals who serve as leaders on influential committees. For example, if you want to work on improving staffing systems, you would need to learn about the cost of staffing, the cost of bringing in temporary staff, and the budget allocation for staffing on the unit. A clinical unit manager should have that information and can help guide your learning. In addition, one would need to know how much Medicare and Medicaid allocates to particular types of patients (outside the control of the institution) and the acuity level of patients. By working with experienced and knowledgeable staff, one can learn how to put this information together, how to influence colleagues to support a proposed policy, and how to gain access to and support from organizational leaders.

Educational Opportunities

There are many ways to learn how to influence health policy; some will depend on your own learning style, where you live, and your interests. Whatever your educational and political goals, there is something for everyone—from continuing education programs to graduate programs in political science and policy, from workshops run by campaign organizations to fellowships and conferences. With a little effort and some help getting started, an exciting world of educational possibilities is available.

Is it really worth putting the time and energy into learning new skills? Can nurses make a difference? Absolutely—many nurses and professional nursing associations have profoundly influenced health policy through their political efforts. Nursing’s successful work is now being recognized by other professions as an example of how to be politically effective (see Chapter 85). The great success of nurse practitioners has been described as a model for how pharmacists can move their practices forward (O’Brien, 2003).