33.1: The Importance of Nurse Advocacy
By the end of this section, you should be able to:
- Examine the role of advocacy in promoting change and advancing a cause.
- Explain how nursing has historically been concerned with the social, emotional, and physical needs of people whose incomes are below the federal poverty threshold.
- Describe how the nurse advocate can advance public health and promote health equity through targeted social determinants.
Nursing is by far the largest health care profession in the United States, with over 4.6 million practicing registered nurses and 203,000 new positions created each year (American Association of Colleges of Nursing [AACN], 2023). There are many more nurses than physicians in the United States, but nurses are underrepresented in public health advocacy issues. However, given that nurses have been recognized as the most trusted profession in the United States for the past two decades (American Nurses Association [ANA], 2023b), they are well positioned to advocate for and protect clients’ civil rights, equality, health, and safety. Nurses are aware of the inequities in health care, especially among those most vulnerable. Nurses often translate health care to their clients and the public, as they possess the knowledge and skills to promote health using a compassionate approach to address health equity for all persons. Nurses educate clients on how to adapt their lifestyles to accommodate a host of health conditions. They effectively communicate the barriers to health in communities, coordinate effective health strategies, and educate persons and communities on methods to improve their health.
The Role of Nurse Advocates
Nurses can advocate for community-based changes that disrupt the barriers to equitable health care. According to the ANA (2023b), nurses advocate by promoting the rights, health, and safety of their clients. As advocates, nurses have historically championed a wide range of efforts to ensure that services, policies, and regulations meet the needs of individuals, families, and communities. Nurses promote justice, fairness, and equity in health care and address the social inequities that affect health. As discussed in Social Determinants Affecting Health Outcomes, the social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age (U.S. Department of Health & Human Services [HHS], 2020). These determinants often guide nursing practice and health policy development, as they overwhelmingly affect population health, well-being, and quality of life. The SDOH include access to safe housing, transportation, and neighborhoods; elimination of racism , discrimination , and violence; access to education, job opportunities, and adequate income; access to nutritious foods and physical activity; access to vaccination s and clean air and water; and elimination of linguistic barriers that limit literacy . For example, a family’s access to grocery stores with quality fresh foods improves overall nutrition.
In 2020, researchers measured the confidence of 768 Midwestern nurses in discussing the SDOH with their clients. In this study, nurses expressed that they were confident asking their clients about certain determinants of health, such as access to a primary health care provider (53.7 percent) and general access to health care (46.7 percent), but were less confident discussing income (50.4 percent), civic participation (48.8 percent), crime and violence (39.1 percent), utilities (38.8 percent), and interprofessional violence (34.8 percent).
This ignited a call for enhanced skill development in SDOH interviewing to improve the working knowledge of the SDOH. This skill development improved the nurses’ ability to advocate for their clients by establishing referrals for services that promote health access and delivery for their communities (Phillips et al., 2020).
In this video, Rear Admiral and Assistant Surgeon General Jonathan Mermin discusses why a focus on the SDOH improves health outcomes and promotes health equity.
Watch the video, and then respond to the following questions.
- What are the pillars of the social determinants of health?
- What wrap-around services would the nurse explore in order to improve health equity?
- When providing care to a population, what factors outside of the health care system impact the ability to maintain health?
Nurses’ ability to advocate for populations begins with an appropriate assessment. Several tools are available to identify the social determinants of health (Tiase et al., 2022), and although using this approach has shown some success (Buitron de la Vega et al., 2019), a universal approach to assessing the SDOH remains a challenge. In some areas, nurses now screen clients in primary care clinic settings and inpatient settings to determine what social barriers prevent them from maintaining or improving their health. This has led to an increase in community-based referrals and new roles for nurses as nurse navigators (Tiase et al., 2022).
The History of Nursing Advocacy
The history of nursing advocacy involves nurses advocating for client rights, well-being, dignity, and health care improvements. Nurses have historically leveraged their unique frontline position to drive positive change. Public health nurses have identified novel ways to protect children and vulnerable populations and continue to have a strong voice for social changes that promotes health. Today’s nurses stand on the shoulders of nurses who have made history by creating positive changes in their communities. Table 33.1 highlights a few of the many nursing leaders who have advocated for significant changes in public health.
| Nursing Leaders | Changes for Which They Advocated |
|---|---|
| Florence Nightingale |
|
| Dorothea Dix |
|
| Mary Eliza Mahoney |
|
| Sojourner Truth |
|
| Clara Barton |
|
| Lavinia Dock |
|
| Lillian Wald |
|
| Mary Breckinridge |
|
| Susie Walking Bear Yellowtail |
|
| Ruth Watson Lubic |
|
Nurses must address the social, emotional, and physical needs of people whose health needs are underrepresented. For example, in the 1960s, Loretta Ford witnessed that primary care in the underserved communities surrounding Denver, Colorado, was desperately lacking. Using innovative thinking, specialized instruction, and novel curriculum design, Ford launched the first nurse practitioner program in 1965. Today, the nurse practitioner model has become so successful in meeting the needs of clients, families, and communities that several advanced nursing programs and certifications have been created to address the social determinants of health at the master’s and doctoral levels.
In the current state of health care, nurse practitioners, clinical nurse specialists, certified nurse anesthetists, and certified nurse midwives work in advanced practice clinical roles in community specialty practices such as pediatrics, maternal and family health, gerontology, mental health, and perioperative care and in a broad spectrum of institutional roles. Whether in a role as a registered nurse (RN) or an advanced practice registered nurse (APRN), every nurse has an opportunity and obligation to advocate for persons whose social, emotional, and physical needs are unmet and for persons with incomes below the federal poverty threshold in targeted social programs and strategies. However, the shortage of adequate health care professionals continues to be the most profound in rural areas in the United States as well as underserved communities and in care for older adults. The Title VIII Nursing Workforce Reauthorization Act of 2019 was developed and supported by nursing organizations to help meet the accelerating need for nurses to serve in these communities. The Title VIII act provides funding to support the education of nurses at the undergraduate and graduate levels for nurses planning to practice in these areas of greatest need. The U.S. House of Representatives passed this act in 2019, and it is currently with the Senate (Title VIII Nursing Workforce Reauthorization Act of 2019, 2019).
Nurse Advocacy: Theory and Attributes
The role of client advocate was first introduced into the code of ethics by the International Council of Nurses in the 1970s and was subsequently adopted into the code of ethics of other nursing organizations, such as the ANA (Abbasinia et al., 2020; Kalaitzidis & Jewell, 2020). The defining attributes of nurse advocacy include safeguarding , apprising , valuing mediating, and championing social justice in health care (Abbasinia et al., 2020). To advocate for persons and populations, nurses safeguard their clients by preventing medical errors and calling out incompetency or misconduct by any health care team member. Apprising may involve providing clients with education about a diagnosis, treatment, or prognosis; identifying alternatives in a treatment plan and follow-up care; and maintaining privacy. Nurses must also maintain self-control in their communications with their clients by valuing clients’ autonomy when making health care decisions and understanding their considerations related to values, culture, beliefs, and preferences. Nurses may serve as liaisons for clients and families by communicating individual preferences to other health care team members. Nurses often confront policies or rules that create inequities in the delivery of health care services or resources (Abbasinia et al., 2020). In the community setting, nurses may strengthen partnerships, develop or participate in community action efforts, and develop healthy public policies (Iriarte-Roteta et al., 2020).
As an example of the nurse’s role as an advocate, consider LGBTQIA+ youth . Transgender and nonbinary youths are two to three times more likely to experience poor mental health outcomes such as depression, anxiety, and risk for suicidal ideation, suicide attempts, and self-harm than cisgender youth (Reisner et al., 2015). A report in 2021 revealed that when nurses provided educational workshops in health care facilities and schools on LGBTQIA+ topics (such as gender-affirming health care, inclusive sex education, sexual and gender diversity education, bullying , suicide prevention , safe spaces , and support groups), health inequities and discrimination in the health care system decreased (Medina-Martinez et al., 2021). Therefore, public health nurses can advocate for the LGBTQIA community by conducting mental health and substance use screening s and promoting a gender-affirming environment. Nurses should use appropriate pronouns and gender-affirming language and demonstrate compassionate listening without making assumptions. In a recent study of 104 transgender and nonbinary youth, the receipt of gender-affirming care, including puberty blockers and gender-affirming hormones, was associated with a 60 percent reduction in moderate or severe depression as well as a 73 percent reduction in suicidality over a 12-month follow-up period (Tordoff et al., 2022).
In this video, Sarah Rosso, the executive director of the Hugh Lane Wellness Foundation and mental health advocate and ally, explains how LGBTQIA+ cultural competence supports clients’ mental health.
Watch the video, and then respond to the following questions.
- Why does Sarah advocate for LGBTQIA+ cultural competency training among the community partners and organizations that work with their organization?
- How can communities reduce the impact of suicide on LGBTQIA+ youth?
- As a new nurse, how would you approach the issue of gender dysphoria among the youth in your community?