HSOA Journal of Practical and Professional Nursing From Practical to Powerful: How a Nursing Student Health Policy Fellowship Transformed my Political, Professional and Patient Advocacy

Health policy education and engaging political opportunities are unfortunately rare in nursing. This article provides a Family Nurse Practitioner’s account of the impact of a novel experiential learning nurse advocacy health policy fellowship in Richmond, Virginia. Ad-ditionally, this commentary details imperative lessons gained in the transformation from unaware politically to becoming a professional asset. Moreover, this highlights how nurses can and should be active in legalizing improvements to promote patient and population health and wellness. A program whose mission is to increase the understanding of the role of the nurse as an advocate is detailed, supply-ing a new lens through which to view and change the profession of nursing while impacting citizen wellbeing and patient outcomes.

unprecedented 2014-2015 graduate level Virginia Nurse Advocacy Health Policy Fellowship (VNAHPF [HPF]) in Richmond, Virginia, I was a novice regarding political knowledge. My only exposure to this system was a high school civics class and a graduate nursing health policy course. Comparatively a 2010 study of 347 RNs indicated that 68.8% reported receiving no health policy instruction during their nursing education and 66.7% of RN participants who did receive health policy education rated it as poor [1]. Though I voted in several presidential elections, I did not know how to become politically astute on either a personal or professional level, possible outcomes of such or even what that would look like. I believed one of the only ways to advance the profession was through patient-centered care. I am now able to identify, connect and implement positive changes in my daily practice to improve patient and community wellbeing, along with professional practice resulting from the knowledge gained during the HPF.
Historically the role of the nurse has been viewed as secondary to that of their physician colleagues, a trend that may have begun when healthcare moved from the home to the hospital [2]. Exclusion in workplace advocacy and decision-making forums are synonymous with oppressed group behavior wherein the powerless nurse is silent and submissive when confronted with authority as being a "good nurse" is perceived as not challenging the system [3]. While nurses have been involved in improving patient healthcare since Florence Nightingale successfully lobbied the British Parliament to improve conditions for Crimean War soldiers, the profession has not collectively transformed healthcare [4]. Empowerment of nurses is therefore crucial in reducing stress, increasing job commitment and satisfaction [3], and provides opportunities to advance population health.
In addition, the quality of pre-registration practice learning experience is "highly influential on career choices at the point of registration" [5]. There is now a national precedence for nursing education and leadership in health policy and professional advocacy. This significant need for an "influence on public policy to improve population health " [6][7][8] advocates for including nurses in these fellowships, and assists aspiring practitioners in gaining these experiences, relationships and facilitates future active participation in coalitions and other health policy groups [9]. This further raises awareness and cements the urgent need for professional nursing voices "at the table" [7]. Moreover, it is through experience that health care providers develop key skills such as increased "accurate and creative" approaches and solutions [10], communication, teamwork and collaboration which are inordinately important in the policy arena [11].
This was the aim of the HPF, to increase an understanding of the role of the nurse as an advocate and to provide graduate nursing students with knowledge and opportunities to learn new advocacy skills. The specific program objectives included learning health policy terminology; meeting key stakeholders; comprehending how legislation is formulated; and determining how to personally make a difference for patient care, communities, and the nursing profession [12]. Therefore, much time was spent learning the policy setting and language, joining strategy sessions networking with key individuals and groups, such as the Brain Injury Association of Virginia the Virginia Athletic Trainers' Association and the Virginia Association of Community Services Boards, actively furthering the specific group's agendas, and attending health policy related sessions at the General Assembly. These experiences provided a new perspective through which to view and change the profession of nursing while affecting the health and wellness of our citizens. Moreover, the HPF is unique in that it creates interprofessional collaboration at our state's capitol.
My quest to instill change was ignited by faculty in my graduate nursing program. Recognizing a strong potential for leadership, these educators introduced me to the VNAHPF and I applied for this opportunity to learn to lead positive change as a nurse advocate. I was notified my acceptance in October 2014, with the majority of the time commitment falling between December 2014 and May 2015. Much of my early efforts were spent meeting with key stakeholders and developing strategies to promote favorable legislation during the session.
The session began in December 2014, with the reading and release of Governor McAuliffe's 2015 budget for the commonwealth of Virginia. This set the framework for the session goals, such as crafting new legislation or changing budget language, and commenced the formation of various coalitions with similar aims. As a fellow, I collected vast experiences through which to understand the legislative process and gained an understanding of how nurses can and should be active in legalizing improvements to promote patient and population health and wellness. In the three years since completing the health policy fellowship, I have acclimated into the role of an out-patient rheumatology Family Nurse Practitioner (FNP) for a large health system. As a result of the HPF, I integrate and apply the principles learned-including identifying stakeholders and their motivations, building a network of like-minded people, and knowing when to move an issue forward-into my current practice to improve patient care.
To quantify graduate students' advocacy aptitude the PAI was utilized by Primomo in a health policy course by Primomo and Bjorling in a study among undergraduate nursing students and Registered Nurses attending a state legislative day and also by Byrd et al., among 300 baccalaureate nursing students following a student-driven experiential health policy initiative [6,16,17]. Similarly the PAI was utilized pre and post an undergraduate interprofessional team based learning health policy advocacy exercise first with a pilot of 82 and followed by a larger study of 263 nursing, social work, and health administration/health sciences students [18]. Significant improvements were found in all studies regarding political astuteness scores following the activities. As these studies found, my PAI score improved significantly, from 6 to 31, as a result of the interactive health policy fellowship, indicating a progression from politically unaware to politically astute.
Four main themes permeated almost every exchange during the HPF: 1) Knowing the system; 2) Building relationships; 3) Power and influence; and 4) Unified message.

Knowing the system
The first step of the journey was cultivating general subject awareness. On my first day, I sat in on several meetings in the General Assembly Building (GAB) discussing topics including autism, brain injury and hemophilia. By the end of the day, I had hundreds of questions, met at least 50 new people from all political and advocacy levels, attended a Senate Finance and Education committee meeting, and realized that I had a steep learning curve ahead! However as the weeks passed, terminology such as "waiver redesign" and "passed by indefinitely" became readily understood and I began to form a basic working knowledge of the political environment and policymaking process.
Having never practiced health policy skills, I needed a refresher regarding how lawmaking blossoms from an idea to fruition as a passed bill (legislation).The gaps in my "common knowledge" led me to feel even more strongly about the need to strengthen civic engagement through experiential learning opportunities within nursing curricula. I initially found myself overwhelmed with feelings of ineptness until I became familiar with the legislative system and more comfortable with the language employed. Thus the first step in my pursuit towards political astuteness entailed knowing the system. This goal was accomplished by actively building upon an initial knowledge base with the help of my VNAHPF mentor and reinforcement provided by applicable real-life policy-geared practicum.
In rheumatology, considered to be one of the most ambiguous grey disciplines in which the "art of medicine" still applies, I have experienced many opportunities to apply the skills obtained as a health policy fellow. One example is choosing medications for treatment of Rheumatoid Arthritis (RA). In almost all cases this requires a "step wise" approach based on the patient's insurance plan and drug formulary. Aside from the patient and provider, stakeholders include the insurance company, Pharmacy Benefits Manager (PBM) or pharmacy and state and federal government. The significant decision of choosing medication is most often not left up to the provider or the patient dealing with the illness but rather dictated by insurance companies who make decisions based on deals as well as rebates and contracts with pharmaceutical companies and PBMs that change from one year to the next.
Providers and patients are typically required to use the appropriate Tier I drug on formulary. If this medication is not appropriate or efficacious, the patient/provider team must essentially gain permission via a prior authorization to use another by showing that the drug is medically necessary for that particular disease state. If this is denied providers must prescribe in the order of medications as approved which may not be the best course of treatment for the patient/ quality care. This continues until the patient has not responded to the appropriate number of medications to obtain the medication that would likely be the most beneficial to treat the illness and thus the ideal first choice.
The problem is often compounded in rarer diseases. For example, Autoimmune Retinopathy (AR) is an inflammatory eye disease often requiring immunosuppression for which there are no approved FDA indications for medication, unlike RA. In most cases, this condition requires fairly aggressive immunosuppression. Without it, the patient may lose their sight. Therefore, knowing the system in this case typically means that when I see a patient with AR, I already know that obtaining medication will be a challenge, particularly as I'm aware that my medications may have already been pre-selected.
NP programs prepare graduates for full prescriptive and practice authority with 23 states currently giving the NPs full practice authority without supervision or collaboration [19]. The health policy fellowship has been crucial to clarifying stakeholders, knowing the environment and my motivation to initiate change regarding prescriptions practice and promoting wellness in my patients. And as 2/3 of Americans will see a NP for their primary health care needs [20], it is imperative to understand how our role serves our patients both within and outside the office.

Building relationships
The second overarching theme emerged unexpectedly as I participated with board members and executive directors of the community behavioral health system in Virginia. In an interprofessional presentation from the fellowship mentor detailing how to be an effective advocate, I saw firsthand how even the participating successful executives still need reinforcement on the importance of forming and maintaining effective policy connections. I realized then that I could do this! Everything from procedures to terminology swiftly fell into place. I saw how policies made at the state level filter down and affect my practice all the time. For example, in my rheumatology practice, specialty tier and biologic drugs create financial burdens on patients as insurance companies deny or severely limit coverage. These exuberant costs, sometimes $10,000 per month, often prevent patients from taking their prescribed dosage in an attempt to 'make their medication last'. This does little, however, in managing the disease, creating a nowin situation for the patient. In practice when dealing with medicines difficult to obtain, knowing the stakeholders-including drug company representatives, appropriate insurer contacts and providers -is key. Familiarity with resources and contacts are important when pursuing many different avenues for obtaining medication coverage, whether through charity care, state funding, pharmacy rebates or insurance appeals. Thus knowing the stakeholders and building these relationships can be beneficial when trying to care for both rare diseases and diagnoses that necessitate costly interventions.
I was surprised and relieved to see policies in process designed to help alleviate these issues, such as patient assistance organizations lobbying for funding. For instance, the HPF mentor participated in a discussion with a representative of Patient Services, Inc. (PSI), a non-profit premium assistance organization that obtains funding from the state to help provide financial and social support to qualified patients of rare chronic diseases with unaffordable medical expenses [21]. PSI subsidizes the costs of health care premiums and provides pharmacy, treatment and Medicare part D co-pay assistance [21]. These costs are much less expensive to the commonwealth than paying for their total care, particularly if the patient is uninsured. This creates a win-win for the state, as their uninsured health care costs are reduced by the premium support that PSI gives to help pay for insurance for these individuals. Unfortunately, similar organizations supporting RA are quite rare, leaving my patients with fewer financial options to relieve these often-exuberant medical costs.
Another example of strategic and impactful alliance-building during the HPF involved a meeting with a delegate who serves on the House Appropriations Committee; the executive director of the brain injury advocacy organization; a public brain injury services provider; the fellowship mentor; and me. The meeting served two purposes: (1) to seek support from the delegate on restoring brain injury services funding in the current state budget; and (2) to apprise the delegate of ongoing communication issues with the state agency responsible for individual mental health services. Occasionally individuals with brain injuries have co-occurring mental illness conditions, and the brain injury advocates had been excluded from stakeholder meetings involving transformation of mental health services.
Due to an ongoing multi-year connection with advocates for brain injury services, the delegate understood the nature of the advocates' concerns of exclusion. He immediately volunteered to express his own concerns on their behalf to the director of the state mental health agency. Political astuteness was needed to understand who the key players were, when the meeting needed to take place, and what the most successful "ask" or "appeal" would be to the delegate. This reemphasizes how important political astuteness and forming continuing relationships with key policymakers are to health policy work.
To form these political ties, essential components are necessary. First, lawmakers who most wanted and solicited my perspectives were the ones within my own district. District legislators are crucial as they represent you, their constituent; thus, an accordance of mutual benefit exists [22]. Constituents usually have more power and influence with their district representative than any other legislators, and so should be the first connection on one's journey to becoming politically astute. In our state, legislators are regular people who are part time legislators and who may hold other full time jobs and are committed to improving laws for their constituency! Honing in on this reality increases personal and professional power, promoting collaboration and change.
Next, I made a point of meeting my own lawmakers in their home district. The fellowship mentor introduced me to representatives and their year round support staff who help guide the politicians by offering background on current issues. Gaining access to their staffers' contact information and maintaining community building opportunities are vital. After initially meeting my legislators and their staff, the next step was forming some connection with them. Following them on social media sites typically proved to be effective, as most have (multiple) accounts. These forums are often used to broadcast the issues each legislator is currently tackling, and allow sharing of thoughts regarding legislative issues impacting the very populations we serve. Finally, and most importantly, maintain this connection. Meet on a regular basis to discuss the issues that are important and why each is significant to them both personally and for those they represent. Persistence in relationship building and continued involvement are imperative aspects of actively engaging in the political process and essential leadership tools [22].
The VNAHPF allowed for unique insight into how nursing knowledge and practice are heavily influenced by policy. I now continually recognize effects of policy in my daily practice. Further, I grasped that if I wanted to assist with constructing future policies to improve my practice and the health care system for everyone, I would need to build rapport with key people who could translate my first-hand knowledge into policy. Surrounded by these connections and hearing strategic step-by-step mapping of how they formed and functioned, I finally understood the simplicity, yet significance, of nourishing these associations. I now serve on an advisory committee that impacts the prescribing practices of opioids locally and across the state health care system and is active in the Arthritis Foundation, which allows me to further understand and assist my patients. These relationships, built over the past two years, are a key connection between myself, patients with arthritis and their main concerns, as well as policy makers, healthcare administrators and clinicians within the health system that collectively move issues forward.

Power and influence
Key to powerful influence is understanding who has the power and influence to initiate change. At this level, one must hold onto personal beliefs and organizational goals while being willing to compromise in a way that either moves all parties' agendas forward or face waiting until public opinion is more attuned to one's specific goals [23]. This climate change, or impetus, may stem from a tragic event that raises public issue awareness or by interest and involvement from an influential position, and could take years or even decades [22,23].
An example of power and influence I experienced through the HPF examined youth head injury as one state legislator's personal interest in brain injury within the youth population heightened, influenced by a recent incident within his family. This particular policymaker also held a leadership position on a commission studying adolescent matters. In addition to questioning several key stakeholders regarding how the state is handling the current policies and needs, this enhanced awareness led to a decision to study head injury policies among student athletes. Clout is key to success. I realized I needed someone such as a seasoned health policy lobbyist to cohesively describe the surrounding issues and people involved. Knowing the written facts about an issue and building key relationships still did not provide sufficient knowledge to exert the type of power needed to be the "right person, at the right place, and at the right time" to impact a certain cause. Even when individuals are politically astute, they may need to seek guidance from someone who has seen how the "players" react to different scenarios.
As a provider, I want nothing more than to prescribe initially only the most helpful medications for my patients. When this is not possible, such as when a prior authorization is denied, I am now able to encourage and empower families to contact their senator and representatives, make appointments, and send letters along with me, as we are the voting constituency. Not only does this provide another avenue through which to support my patients, it furthers the political process, conversation and ultimately, change.
Other avenues of power include the "power of the pen," combining knowledge, relationships, and taking action to support a unified message. Social media presence should also be included as an influence cultivating strategy, including following representatives on Facebook or Twitter and joining special interest organizations. In addition, participating in clinical trials between drug companies and patients with the disease also increases one's ability to influence. This evidence, based upon well done clinical trials, when favorable, may lead to insurance companies having evidence that the medications are efficacious and may approve the medication for a broader population with FDA approvals. Coordination of strategic relationships is necessary between drug companies, appropriate clinicians, and the affected patient population. Moreover, the whole process depends on whether there may be a large enough patient population impacted that the company may benefit from financing the trial and eventually producing profit by having another indication for their medication and thus increasing its use.

Unified message
The final theme is providing a unified message. There is strength in numbers and "consistency in message" is crucial. Creating a unified message is most impacted by political engagement [23]. Additionally, ranking members of a group with a sound background of political astuteness is essential in crafting a message translatable to successful health policy legislation.
Again, reaching an agreement amenable to all parties may take years. This equates to persistence and timing, with the opportune message, in one unified voice. Compromise is critical, and may require sacrificing a long-term goal for a smaller short-term gain, often viewed as an incremental stepping-stone [22], a point best illustrated through recent Virginia discussions regarding the role of the Advanced Practice Registered Nurse (APRN). The different segments of this advocacy group include Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists and Certified Nurse Midwives. Currently, the APRN circle is considering whether to change the (nursing educational) objective from having all nurse practitioners obtain a Doctorate of Nursing Practice as the entry level degree into the field for achieving "full practice authority" in all 50 states [24].
This necessary unity cultivates a goal for all involved parties to rally behind while providing strength and momentum for the cause. One such movement is attempting to update the laws pertaining to APRNs to more closely align this group's legal medical rights with the NCSBN (National Council of State Boards of Nursing) consensus model [24]. Uniting interest groups such as this around a common goal involves establishing a common language and trust among the members. Witnessing the formulary stages of this process helped me understand persistent effort and time are needed to achieve the intended communication, organizational and legislative outcomes. This motivated me to join professional nursing associations with the ability to further support positive outcomes for my patients in daily practice.
Through my work on the opioids advisory committee, I am witness to a unified voice as a prevalent driving force assessing the right timing. The opioids epidemic and increasing number of drug overdoses mandates the need for change on multiple levels, from state and federal legislation, health system mandates and division policy changes to individual clinical practice changes and patients' behaviors surrounding opioids. Policy change is occurring due to powerful stakeholder participation and relationship building, a unified message, persistence, and current timing and political environment as several powerful groups and individuals demand change through a unified message, collaboration, persistence and dedication [22].

Conclusion
During my VNAHPF journey, I significantly improved my PAI score from "politically unaware" to "politically astute and an asset to the profession" [13] and identified systemic problems plaguing nursing practice and education. This would not have been possible without the HPF experience. One main structural problem within nursing is a lack of active political and civic engagement exercises incorporated into curricula. This can be changed by emphasizing active engagement in health policy courses at all levels and making mandatory experiential learning such as the VNAHPF. Faculty, mentors, and clinical leaders, therefore, must instill in nurses a desire to lead change and the background knowledge to do so effectively there by allowing each of us the ability to become a professional asset.
According to the American Nurses Association (ANA), nurses are the nation's most populous healthcare professionals, with one of the largest segments of the whole United States workforce, totaling over 3.6 million [25]. Nurses are thus in a unique position to effect change and promote population wellness through health policy initiatives impacting our patients, families and communities daily.
Nurses and nursing organizations are discovering paths to find their voices and the courage to incorporate themselves into influential public policy circles. Including nurses in health policy fellowships assists aspiring practitioners in gaining these experiences and relationships, and facilitates future contribution in coalitions and other health policy groups. These fellowships actively involve participants in the policy-making arena, further raising awareness and cementing the critical need for the profession of nursing's voice in the conversation [25].
Moreover, health care providers develop pivotal skills through experience including effective communication and collaboration which are inordinately important in the policy arena. Not only do these collective programs allow for visualizing the big picture, due to new trends incorporating multidisciplinary care teams, nurses and other Advanced Practice Providers (APP) are in an unprecedented position to find an equitable solution to lead in securing healthy common ground for all, such as through volunteering and occupying leadership roles typically filled by physicians.
As nursing professionals, our experiences, training, and relationships with our patients and communities can provide pivotal clout in educating legislators and other stakeholders on health policy needs and in leading change. The first step, and often the most difficult to overcome, is to get involved.

Recommendations for Nursing Practice to Improve Political Astuteness & Influence Policy
• Clearly improving political astuteness and the ability for nurses to influence policy begins with experiential health policy advocacy education. Finding teaching methods and experiences such as the HPF are critical to the development of knowledge, comfort level and engagement in the health policy making process • Another avenue for improving political astuteness and influencing health policy is to engage in professional associations. Most have a political advocacy arm and the power of coalition building to advance policy • Connect with your district and state legislators, and maintain a conversation. Those comprising the nursing profession have particularly valuable vantage points to share, with the ability to impact health care nationally • Lastly, seek out "Board" involvement. The best way to influence policy change is to be at the decision making table