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Nurses have a unique place in redesigning the future of healthcare, particularly after experiencing health policy failures with the coronavirus disease 2019 pandemic. Nurses consistently outperform other professions to enjoy a decades‐long reputation as the most trusted profession. Nevertheless, the nursing voice is missing at a public level; representation in governments and boardrooms negligible. While nurses carry out health policy, rarely are they involved informing policy. While substantial dialog on health system reform, regulatory changes, care coordination, and health information technology occurs, nursing's presence is absent. The barriers are many: a lack of political sophistication, family, and work demands limiting time, and a lack of confidence. Using the Yoder‐Wise Framework for Planned Policy Change, opportunities for engagement at each step in the process are made clear. Workplace opportunities provide entry‐level representation and exposure to the machinations of governance. Nursing professional associations provide similar opportunities. For many nurses, social media, while not without its risks, offers a familiar and accessible platform by which to engage patients, the public, and policymakers in planned, strategic steps to create policy change and improve healthcare for patients.
Keywords: action steps to policymaking, barriers to policymaking, COVIID‐19, executive roles, governance, health policy, nursing empowerment, nursing voice, patient advocacy, policymaking, politics, social media
Nurses in direct clinical practice have a long history of championing the needs and rights of their patients. Advocacy is at the heart of the nursing process, yet advocacy on a broader societal level by nurses is not as evident. Nurses are not timid about advocacy, often defending the rights of the patient even when that advocacy may be misaligned with the needs of others, including the nurse's employer. Nurses execute their advocacy responsibilities by developing clinical and emotional competency to complete a critical deliverable: safe, optimal patient care. 1 Nurses have the skills and courage, along with public respect for their work, to be involved and influential in health policy development. 2
According to the World Health Organization, “Health policy refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. An explicit health policy can achieve several things: it defines a vision for the future, which in turn helps to establish targets and points of reference for the short and medium‐term. It outlines priorities and the expected roles of different groups, and it builds consensus and informs people.” 3 The purpose of this article is to articulate the importance of clinical nurses' engagement in health policy and provide an overview of some barriers front line nurses may have regarding participation in health policy. A secondary aim is to provide some social media guidelines that nurses can use for engagement in health policy development. The use of the Yoder‐Wise Framework for Planned Policy Change 4 provides a model to frame the discussion and guide the policy interventions.
Nurses, particularly those engaged in direct clinical practice, are people of action who rarely take the time to view issues faced through a socio‐political lens. 5 Nurses may lack knowledge of the political process and have a limited understanding of how to leverage powerholders and thought leaders. Access to policymakers may be limited. All these skills are necessary to impact the development and ultimate passage of health legislation. If nurses consider becoming involved in the political process to advocate for policy, an absence of understanding about elected officials and their respective positions on health care may be a hindrance. The process is decidedly complicated and access to information mystifying. Researching pending health legislation and its implications present an overwhelming task that is fundamentally intimidating. Nurses need to be well informed and to have the capacity to speak with authority across every aspect of the health policy process.
Additionally, there are barriers related to traditional gender roles, expectations, and nursing's traditional voice in the development of health policy. Gender‐based roles can be a crucial factor in predetermining and shaping health systems, outcomes, and policy. Some of these roles include traditional childcare responsibilities, many nurses who are women face, along with potentially having to care for elderly parents. It would be challenging to achieve public policy targets without confronting outdated gender roles and gender inequality within and outside health systems. 6 The ability to speak with authority while navigating gender‐based role expectations and conflicts can be learned with education, experience, and mentoring.
The process of educating nursing students may have implications for understanding the absence of a maturing nursing voice. Nursing students progress more quickly when engaged by communities of practice. Nurse educators can develop, support, and orient novices into a culture to provide a sense of belonging. 7 To support nursing students in a culture of advocacy for health policy change, nursing curricula at both the undergraduate and graduate levels should include course work and, ideally, practical experiences in how nurses can influence health policy. 8
Front‐line nurses may believe it is impossible to create policy change at the national or even local level; many may think their role is too small to make a difference in health policy. However, the engagement front line nurses have with patients, and other healthcare professionals, make them ideal healthcare policy advocates. 9
The challenge for nurses is to find a way to engage in policymaking that is authentic to nursing's ancestry, values, and professional conscience. The role of a nurse mandates the ability to manage competing demands and the skills to problem‐solve to provide quality outcomes. Nurses are subject matter experts (SME) as they are an authority in a specific clinical area of practice. They have appropriate academic education and clinical expertize to serve as experts in sharing their knowledge with policymakers and others. 10 The knowledge nurses at the front‐line of patient care have related to their clinical practice should be shared with health policymakers. Nurses, when heard by powerbrokers, will add value to decision making around health system reform, regulatory changes, care coordination, and health information technology. As SMEs, the conundrum remains how best to leverage the well‐earned status as experts yet find forums that present a low risk‐low barrier to entry opportunities. Options are limitless. Taking on the role of SME, when combined with the Yoder‐Wise Planned Policy Framework 4 helps clinicians understand opportunities to become involved in policy change at different points in the policy process.
The Yoder‐Wise model 4 provides a framework for how front‐line nurses can use planned policy changes within the context of the coronavirus pandemic, a current example of uncertain and chaotic times (see Figure 1 ). This framework focuses on nine steps to help nurses better understand how to use their skills to plan and implement change, even under chaotic conditions, while recognizing the full scope of the process for an effective policy to be achieved. Each step in this process builds on and integrates with the other steps. When viewed as a whole, the steps in the policy framework outline the critical elements that need to be addressed for policy work to succeed. This framework applies beyond care sites to local, state, and federal organizations. For different settings, the players change, and the cycle may differ, but the process remains the same.
The framework for planned policy change
Using the coronavirus disease 2019 (COVID‐19) pandemic as an example, the first four steps of the model are illustrated in the discussion. The precipitator, step one in the framework, 4 was the novel coronavirus, severe acute respiratory syndrome coronavirus 2. Its sudden and widespread appearance created a crisis that undermined the ability of nurses to deliver safe, evidence‐based care to patients with the virus while maintaining their own personal safety. A critical point, step two in the framework, occurred as nurses and others at times did not have access to personal protective equipment (PPE) and ventilators for their patients. The apparent failure to adequately plan for the pandemic by health care institutions and government officials contributed significantly to the magnitude and urgency of the critical situation. The nurse's assessment, step three in the framework, encompassed the extent and impact the lack of PPE and other medical supplies and equipment had on the quality of care provided. In addition, nurses knew their health and the health of those around them was at risk.
The need for policy advocacy regarding the lack of PPE and the consequences of the hospital and public health unpreparedness is urgent. The remainder of this discussion reflects on how nurses can use a variety of avenues, including social media, to apply some other components of Yoder‐Wise's framework 4 for planned policy change.
Despite nursing's intrinsic involvement in the advocacy of the individual patient, the nursing voice is often not heard at a public level. Nursing's involvement in improving health and health care for all patients at a government level is but an extension of the advocacy work. The work is central to the nursing process. 11 The COVID‐19 pandemic unintentionally created an urgent need for nurses to advocate for changes in health policy.
Nurses represent approximately 50% of the global health workforce 12 ; however, nursing representation at the government and boardroom level is slim. 13 The importance of the nursing voice being heard cannot be overstated. Any other profession cannot replicate the situational knowledge of the healthcare needs of patients that this large workforce offers. Nurses and midwives penetrate geographical, societal, economic, and political landscapes that are immeasurably diverse. That kind of intelligence is essential to properly inform policymakers when making critical decisions about health system reform, regulatory changes, care coordination, and health information technology. Here, agendas are aligned: nurses want these key policy issues to be adequately addressed for their patients to achieve optimal health outcomes. Policymakers are acutely aware that these issues threaten their ability to deliver a sustainable and accessible healthcare delivery model. 14
The political landscape is perilous for policymakers. Delivering cost‐effective, accessible, yet sustainable health service to the voting public is a formidable challenge. Nursing should hold an exclusive place in this dialog, particularly now during the COVID‐19 pandemic. 15 At a time where there is rapidly declining trust with politicians and policymakers, 16 nurses have a unique opportunity to step into the void. Nurses, for decades, at least in the USA, have enjoyed consistent recognition as the most trusted profession in Gallup Polls. 5 The public inherently believes that nurses' moral compass protects them from conflicts of interest where fiscal, bureaucratic, or political incentives would otherwise cloud judgment. That decades‐long reputation withstands poor press in public opinion as isolated incidents, and this respect serves as our most bankable asset to leverage the nursing voice in policymaking.
Meaningful policy change can occur at the institutional level, where nurses are accustomed to functioning. Nurses' involvement in self‐governance within hospitals presents opportunities for staff nurses as well as others to participate in the clinical governance at a local level. 17 Clinical governance committees range from policy and procedure committees to infection control prevention and control committees to quality initiatives. These groups offer a unique opportunity for nurses to work with process, workload, personal commitments, and the power of their nursing voice within these conventions. Like any clinical skill, competency, or knowledge is gained as nurses progress from novice to expert clinicians. These committees offer fertile ground for the staff nurse to gain valuable experience in employing the Yoder‐Wise Model 4 to create health policy in their employment settings related to allocation and use of PPE.
Outside the employment setting, there are opportunities to gain confidence in effecting policy change. Nursing professional associations that align with clinical subspecialties are ideal for contributing to professional practice and leadership. Gaining competency around the roles within and the functions of professional associations closely aligns with the political process. Nurses can begin as a member contributing to online discussions, blogs, or social media interest groups sponsored by the association, then progress to active participation in any number of subcommittees, and finally run for office.
However, there are other opportunities far more accessible and intuitive to some. In the USA, fifty percent of the workforce are millennials, 18 many of whom have a unique set of characteristics that can change the playing field. Millennials want to understand the rationale behind organizational decisions. They want to be active participants of that process and have a desire to be engaged in social responsibility with less focus on profit and more focus on purpose. Most significantly, however, more than any other generation, millennials understand professional and social networks as opposed to the traditional hierarchy. 12
In an anonymous survey conducted in the USA of 366 health care workers, 97% owned an electronic device, with 87.9% reporting the use of social media. 19 Health care workers under the age of 40 were more involved in social media than those above the age of 40. Eighty‐eight percent of the nurses reported using social media. Nurses also encourage their patients to learn about their clinical conditions from reputable sources on social media. Millennials have matured with social media as a constant presence in their lives and understand the power of a network to leverage change. The COVID‐19 pandemic has presented an opportunity to hear nurses' voices at the policy table using social media.
Amid a COVID ‐19 pandemic, the need for nurses to engage in influencing public health policy is urgent. The report of staff having to care for coronavirus patients without adequate PPE is a failure of health policy. While many health care providers and administrators are voicing concerns, it seems their pleas for help go unheard. Nurses and other healthcare providers, along with their families, friends, and social networks, need to join in advocating for immediate changes in health policy, particularly the need to provide access to PPE and ventilators. Nurses can best articulate these needs based on their assessment of the critical situation and share their insights into possible solutions by leveraging the public trust they enjoy. Using Yoder‐Wise's 4 forth step planning, social media is one avenue for this advocacy.
Social media is both familiar and accessible for nurses. 20 Social media can be a place where millennial digital natives find their political voice. Few people would fail to recognize the incredible social activism created by hashtags, such as #MeToo that served to uncover women's shared stories of sexual harassment. Closer to our healthcare home, however, the viral 2014 #IceBucketChallenge aimed to raise essential funding for the USA Charity, the Amyotrophic Lateral Sclerosis (ALS) Foundation, by creating awareness about the denial of funding to ALS Researchers of US $1 million for an innovative project from the US government. 21
The #IceBucketChallenge resulted in over seventeen million people uploading over 10 billion videos viewed by over 440 million people internationally, leading to donations over US $220 million. While not an example of health policy, social activism illustrates how public engagement can support funding for such. It seems a similar strategy could be useful to advocate for appropriate health policy for the care of COVID‐19 patients.
Social media offers an ideal platform for engaging and impacting public policy with limited barriers to entry. It provides nurses a “nursery‐slope” for engaging with the public, informing policymakers, and building a brand about which they feel passionate. Nurses can bypass the bureaucracies of hierarchy. Arabi et al. 22 suggest that nurses can put into the public forum what they stand for, their values, and their message as it pertains to their capacity as health experts. The nurse can advocate for the change in health system reform, including care coordination and health information technology. Nurses, as experts, with the trust that comes with being a nurse, will begin to be recognized as a legitimate voice in public policy. As knowledgeable clinicians and skilled communicators, nurses are well‐positioned to influence readers, 22 whether they be patients, the public, or policymakers. The strategy can work with the current urgent needs created by the COVID‐19 pandemic. Nurses are now using social media to advocate for their patients as well as for themselves.
Social media engagement is not without its risks. A Chicago nurse filed a complaint alleging that she had been fired for warning colleagues via social media that the masks the hospital had provided were inadequate. 23 There are reports of nurses being told by their employers to not speak out about their working conditions and the shortage of PPE and ventilators. 24 While engaging in social media, nurses should be cognizant of their licensing body's regulations as well as aware of the nursing Code of Ethics 24 and the principles of evidence‐based practice. Situational knowledge of the nursing experience should not be underestimated, so offering a clinical example related to the needs of patients and providers related to COVID‐19 is what nurses can uniquely provide. Identifying information about patients is in direct violation of the Health Insurance Portability and Accountability Act Privacy Rule. 25 However, compelling stories of deidentified patients, settings, and conditions can be enormously persuasive.
An example of the use of social media and COVID‐19 was a picture of a nurse in Italy that showed the bruises on her face caused by wearing a protective mask. The photo revealed, in part, the emotional and physical effects of caring for COVID‐19 patients had on nurses. Another example is nurses taking to social media to speak out about the shortage of PPE. They are gathering around the hashtag #GetMePPE. 26
Owning our position as an expert means embracing the age‐old adage that we are not experts on everything. Beginning health policy advocacy work is a learning process, and we must be prepared to learn as we take our first steps. Those first steps of health policy advocacy may begin along different avenues: consumer groups, workplace settings, nursing organizations, mentor networks, or with elected officials. The steps should be organic and authentic to the individual: phone call, email, letter to the editor of a local newspaper, personalized note to an elected official (see Figure 2 ).
