1. Lee, O. Danny PhD, APRN-CNS, CNE
  2. Dresser, Susan PhD, APRN-CNS, FCNS
  3. Fowler, Susan PhD, RN, CNRN, CRRN, FAHA
  4. Ford, Jeanna DNP, APRN, ACNS-BC, ACHPN, FPCN

Article Content

Clinical nurse specialists (CNSs) are an essential part of healthcare in the United States. Characteristics and competencies intrinsic to the role have enabled CNSs to make significant contributions toward the development of quality, cost-effective healthcare services.1-6 Advocacy is a core role competency and is exercised across all 3 spheres of impact.7 While nurses commonly advocate on behalf of individual patients, CNSs must also focus more broadly on legislative efforts aimed at reducing health inequities, removing barriers to advanced practice, and improving population health. Unfortunately, CNSs may not be politically skilled or actively engaged in legislative advocacy activities. The increasingly complex and competitive health policy landscape mandates that CNSs become professionally and politically skilled to successfully navigate the legislative waters.


First, the CNS is a nurse and as such should adhere to the American Nurses Association (2015) Code of Ethics.8 According to the Code of Ethics, nurses must advocate for the rights, health, and safety of patients. In addition, CNS graduates are expected to be competent in health policy as articulated in the American Association of Colleges of Nursing Essentials for the BSN, MSN, and DNP programs.9 Historically, nurses have been catalysts in advocating for healthcare reform since the early efforts of Florence Nightingale10 and were key activists in the move for women's voting rights 100 years ago.11


Advocacy is "the act or process of pleading for, supporting, or recommending a cause or course of action".8 Advocacy can take place at an individual level, by educating patients or consumers; an interpersonal level, by providing or securing resources for others that empowers them in attaining optimal health; an organizational or community level, by transforming the culture of care; and finally, at the policy level, by representing and speaking for consumers in policy and legislation driving access, protection, and justice. When nurses take actions consistent with the obligation to promote optimal health and care, they are acting as advocates. When nurses improve the ethical work setting that supports safe, quality healthcare, they are advocating for both the profession and its environment. In addition to providing direct care to patients, the CNS works to advance the profession of nursing through research, scholarly inquiry, and advocating for evidence-based practice. Furthermore, nurses demonstrate advocacy when they articulate the values of the profession and promote social justice in nursing and health policy.


In order to be effective political advocates, it is imperative that CNSs understand the process by which laws are created. Following the introduction of a bill by a member of Congress, there are 13 possible steps in the policymaking process12:


(1) Referral to committee


(2) Committee action occurs when the bill is put on the calendar and it is decided whether to send to a subcommittee or full committee. This is where bills may also die if they are not acted upon.


(3) Subcommittee review-research and hearings


(4) During the review, "mark up" means to make changes or amendments.


(5) Committee action to report a bill-decide if they want more research or approve the bill to the House or Senate.


(6) Publication of a written report-a full written report is produced that encompasses all studies, hearings, and position of the executive branch and committee members.


(7) Scheduling floor action means to put the bill on a calendar for debate-the House has several calendars, but the Senate has one.


(8) Debate occurs when members of the chamber are able to voice their opinion.


(9) Voting is required for passing the bill.


(10) If the bill passes, it is moved to the other Chamber where the process begins again from steps 1 through 9.


(11) If there are any differences between the bills from the two chambers, an ad hoc conference committee is formed to work out the differences. After the conference committee resolves any differences between the House and Senate versions of the bill, each chamber must vote again to approve the final bill text. Once each chamber has approved the bill, the legislation is sent to the President. If there is no agreement, then the bill dies.


(12) The President can sign the bill, and it becomes law; he can default on the bill for 10 days while Congress is in session, in which case the bill becomes law, or he can default on the bill after Congress adjourns and the bill dies. Finally, the President can veto the bill.


(13) Overriding the President's veto requires a two-thirds majority vote of both chambers of Congress.12



To succeed in political advocacy, the CNS needs to know how to use leadership skills to leverage relationships and motivate and influence others.13 The CNS needs to use networking opportunities to advantage. Use the power of your voice as well as the power of numbers within nursing to mobilize and advance issues important to the profession. Know who has the power and what is true and false, grounding yourself in the truth. When advocating, CNSs have to present themselves with calmness while using their voice to communicate the message. Agree to disagree, but avoid burning bridges. Advocacy skills cannot be used successfully without knowledge of the political arena. Sign up for the free Capital Beat eblast from the American Nurses Association; find your legislators, sign up for their email updates, and communicate with them; attend town hall meetings of your legislators; attend registered nurse advocacy days at your state or national capital through a professional nursing organization; visit the advocacy and policy tab on the National Association of Clinical Nurse Specialists website; and read the legislative and regulatory update in the Clinical Nurse Specialist-The Journal for Advanced Practice Nursing.




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