Particularly in divisive political times, nursing professionals—like many of those in any number of other fields—might be tempted to put their heads down and work within their lanes, without paying much attention to the news and policy debates. But adopting an ostrich mentality with respect to health policy is not the modus operandi of the GW School of Nursing, where engaging with policy and advocating for improvements in the profession, and in healthcare more broadly, is pervasive.
In the health policy courses taught by Melissa Batchelor, director of the Center for Aging, Health, and Humanities at the Nursing School, she poses the question of how to better engage nurses in the policy process.
“Many nurses shy away from engaging in the policymaking process,” Batchelor said. “While you have to be aware of the politics in order to be effective, there are other ways we could advocate for things that are important to us as professionals.”
One need not run for political office to impact policy. Smaller things can still have outsized impacts, like contacting one’s representative. “The number of emails and phone calls are counted by each office,” Batchelor said. “So while it may not seem like a lot, contributing your voice to any given issue can add up.”
For Batchelor, policy engagement has involved educating through podcasting and encouraging nurses to engage with policymakers through news media and social media. Colleagues at the School of Nursing have approached policy from other directions. More autonomy for nurses and increasing paternal involvement in parenting are among the other priorities of the school’s faculty.
More Autonomy For Nurses
When Anthony “Tony” Roberson sees college students—the main age demographic of his practice—with attention-deficit/hyperactivity disorder, he can prescribe the first round of a medication such as Adderall. But state law requires that a physician see the patient on the subsequent visit.
“Why? We don’t know, but that’s how the law reads,” said Roberson, the new director of the psychiatric mental health nurse practitioner track at the GW School of Nursing, and an associate professor.
Roberson can then see the patient and prescribe up to three months’ worth of medication, but thereafter, the physician must step in again. However, in other situations, he can prescribe medications without adhering to similar requirements. “Now if I were to prescribe Zoloft for depression, or something else for bipolar disorder,” Roberson said, “that physician never has to see the patient. We never have to swap off back and forth.”
The key issue, he said, is the question of “full practice authority.” About half of U.S. states allow nurse practitioners to prescribe medicine without physician oversight—essentially having someone with an M.D. looking over their shoulders—while the other half does not. In the latter, the flow of care is disrupted, according to Roberson.
In his practice, Roberson’s collaborating physician trusts him and often tells him that she would have made exactly the same decisions that he did. She is equally perplexed as to why the system works this way. “We laugh about it. That’s how we get through it.”
When Roberson came to GW in 2019—first as a visiting professor, and then, starting in 2021, as associate professor—he knew that the university and the School of Nursing were well situated to lend their voice to policymaking. And since assuming directorship of the practitioner program in the beginning of August, he intends to focus even more heavily on impacting policy.
“We are really positioned well to be influential and make strides in terms of advanced practice nursing,” he said.
In the coming months and years, he will focus on two areas. First comes addressing access to care, which he knows is a complicated area, in which he may only make a dent. Data indicates there is a real dearth of psychiatric providers not only in rural areas, but also in very urban ones. Ten counties in North Carolina have no psychiatric providers who can prescribe medicine, he noted.
“It’s really quite bizarre,” he said. “It’s really quite a deficit.”
That’s one reason he thinks psych-nurses ought to have more autonomy. He also thinks that pay levels, which favor physicians over nurse practitioners, need to be rethought. “That’s an issue we have to consider, especially if we are going to recruit individuals into the profession or the specialty,” he said. “They want to be able to make a decent living based on what they are actually providing their patients.”
The second area is full practice authority, and the extra steps it creates when nurses need to have physicians essentially babysit their work. “Those steps build up over the course of a day, a week, a month, a year. Whereas if you eliminate those unnecessary steps, you are able to be more efficient in your practice,” Roberson said.
And he thinks there is a good chance that things can improve nationally, with GW at the forefront of pushing for change. “I am extremely hopeful. I was not 10 years ago, but I am now,” he said. “The momentum is there.”
“IT'S A DAD THING”
"We are really positioned well to be influential and make strides n terms of advanced practice nursing."
In the roughly three years (2019-22) that Y. Tony Yang, an endowed professor, served as executive director of the School of Nursing’s Center for Health Policy and Media Engagement, he was most proud of the high-profile speakers GW drew, which raised the center’s and the school’s visibility.
Those included Vice Admiral Jerome M. Adams, then the U.S. surgeon general; Victor J. Dzau, president of the National Academy of Medicine; U.S. Rep. Lauren Underwood (D-Ill.), one of three nurses serving in the House of Representatives; and Shannon N. Zenk, director of the National Institute of Nursing Research.
The school also established a highly visible health policy fellowship program within the center, which attracts international applicants, according to Yang. (A current fellow resides in Spain, for example.)
Yang, who came to GW in 2018, is currently co-investigator on a research grant awarded by the National Institute on Drug Abuse which funds five years of research (budgeted at $3.5 million) aiming to better understand regulatory efforts to minimize young adults’ use of marijuana in states where it is legal for recreational use.
“Our scientific premise builds on literature that indicates that licit drug retail marketing, both brick-and-mortar and online, target certain populations, for example young adults, racial or ethnic and sexual or gender minority groups, and the negative consequences of such retail on substance use in these groups,” Yang said.
Yang and Associate Professor Sherrie Flynt Wallington have completed a policy analysis, slated to appear in the esteemed, peer-reviewed journal Milbank Quarterly, titled “Paid Leave for Fathers: Policy, Practice, and Reform.” (Their analysis was done as part of a Robert Wood Johnson Foundation Interdisciplinary Research Leaders project entitled “It’s a Dad Thing.”)
A key point, Yang said, is that government policies securing paid leave for all parents, irrespective of gender, can both reduce structural inequality and promote fatherly parental engagement.
“Such policies are likely to be most effective when they secure full or almost full wage replacement, and when they provide incentives for fathers to take leave,” Yang said. “Organizations must also participate in the culture shift, providing workplaces that encourage paternity leave rather than reinforcing the ‘male breadwinner’ stigma.”
More broadly, Yang thinks that nurses—given how they outnumber others in the healthcare profession—ought to play a larger role creating health policy.
“There needs to be a greater effort to grow a cadre of nurses trained in health policy and help everyone in the nursing profession understand how nurses can effectively impact health policy,” he said. “Nurses have the potential to reshape the landscape of health equity over the next decade by expanding their roles, working in new settings and in new ways, and markedly expanding efforts to partner with communities and other sectors.”
The Only Socially-Accepted ISM
Batchelor sees ageism as a global problem, so much so that the World Health Organization launched a global campaign to combat ageism in 2021. She says that major societal changes are needed to realize systemic inclusivity and well-being among diverse groups of older adults. Her mission is to change the narrative around aging and influence the world to become more age-friendly.
“Regardless of race, gender, geographic location, or socioeconomic status,” Batchelor said, “older adults experience disparities, often exacerbated by structural factors that limit access to services and opportunities. Negative aging beliefs can decrease your life expectancy by nearly eight years; while positive aging beliefs can protect you from many chronic illnesses, including Alzheimer’s disease. Ageism’s negative health outcomes are compounded by racism and sexism; and structural ageism continues to be overlooked by society.”
Even birthday and greeting cards tend to reinforce negative stereotypes around aging, Batchelor added. “When you start to pay attention to it, you actually see ageism everywhere. As a society, we tend to not want to think about aging until we have to, but we should be doing a much better job teaching children, school-aged kids, and younger adults how to examine their beliefs around aging. How do you make sure they are positive?”
So what can be done to combat ageism?
Batchelor’s podcast, “This Is Getting Old: Moving Towards an Age-Friendly World,” is one tool she uses to educate the public, and the episodes focus on the aspects of healthy aging that are not yet in place. “That’s what’s really getting old—that we’re not ready,” she said.
She also uses social media and encourages other nurses to do the same. In August of 2022, a book she co-authored, “Social Media in Health Care: A Guide to Creating Your Professional Digital Presence” was published by SLACK Incorporated. She and her co-authors encourage healthcare providers to develop skills to communicate with audiences that are broader than traditional academic outlets.
"While you have to be aware of the politics in order to be effective, there are other ways we could advocate for things that are important to us as professionals."
She transfers this to the classroom by not only teaching students how to write traditional policy briefs, but to translate that information into infographics and/ or short videos to make it more engaging and have the potential to reach a much broader audience. She encourages students to follow nursing and policy leaders on social media to build their own professional networks and stay current on hot policy topics.
She noted that with four million registered nurses in the U.S., nurses are the largest percentage of healthcare workers. As a profession, nurses need to understand the basics of policymaking to advocate for, and advance the health of, our respective communities—for people of all ages.
Location, Location, Location
What makes the GW School of Nursing unique is that we are located blocks from the White House and in the midst of federal political activities,” said Richard Ricciardi, a couple of months into his new role as executive director of the school’s Center for Health Policy and Media Engagement and three-and-a-half-years into his GW tenure. “The School of Nursing is able to capitalize on a strong interest and investment in public policy engagement.”
The center is both strategic and operational, according to Ricciardi. Operationally, the center aligns itself with the school’s strong focus on policy and research. Its goal is to educate and engage students—undergraduates, graduates, and doctoral candidates—to be influential in local, state and federal policy initiatives.
“I won’t say it’s unique to our curriculum, but it’s very much a focus of our curriculum and a signature issue at GW,” Ricciardi said. “The center helps to facilitate the curricular activities, as well as engaging students and being involved with dynamic real-world activities external to the university.”
One focus is to increase policymakers’ understanding of the nursing profession. “Nursing can be confusing to the public, because we have multiple degrees and entry points,” Ricciardi said. “We have an associate or baccalaureate degree entry point. We have a master’s entry point. And in some schools, we have a DNP entry point. So, it’s important that nursing has a unified message to describe who nurses are and their value, what nurses do, and how nursing influences policy at all levels. At GW, we offer a DNP with a focus in health policy.
Ricciardi sees the center as a home for students and faculty to engage in policy related dialogue, facilitate networking, and to conduct research.
External work, including expanding upon the school’s and the university’s brand as a policy influencer, also falls under the center’s portfolio. Since the pandemic, the center has hosted webinar lectures on current, “hot” issues, with scientific and political controversy requiring debate. “We take a bipartisan approach if we are going to present a contentious topic,” Ricciardi said. “We will bring all sides to the table to engage in active debate and bring differing perspectives to inform the public.”
The center also hosts a health policy fellowship; currently, there are five interprofessional fellows. “It’s exciting work,” Ricciardi said. “And it is pretty unique. Not many nursing schools nationally are providing health policy fellowships to the external community.”
Partnerships between the center and 501(c)3s, -4s, and -5s whose missions align with the center’s also are an active part of influencing health policy. One example is the partnership with the American Organization for Nursing Leadership. “We are working with chief nursing officers to help strengthen the communication strategy for health systems and raise the voice of nurses in public discourse,” Ricciardi said.
"It is the kind of thing that we want these graduates to do to get in there and engage with state legislators or at the federal level and try to inform change."
“That’s a second goal of the center—media engagement,” he added. “Research has shown that nurses are infrequently used as media sources or subject matter experts in traditional and non-traditional media. We need to step up our game and engage with the media, since healthcare is a team sport and nurses are the largest workforce with much to contribute to policymakers and public discourse.
Ricciardi advises everyone in the nursing profession, whatever their inclination, to engage with policy and to become more media-savvy.
“First of all, every American has a civic duty—I would consider it your civic duty—to know what is going on, even if you begin your policy journey by getting involved in your local district,” Ricciardi said. “I understand that taking on and influencing national politics can be overwhelming. However, one place to begin is in your local district, by forming personal relationships with your community and elected officials, as well as joining coalitions.”
The reason Ricciardi got involved in policy was his realization that healthcare cannot be improved at the state or federal level unless nurses are formulating or implementing evidence-informed policy. “Since nurses are the largest healthcare workforce, we have much to gain and a great deal to lose if policies aren’t appropriately aligned with professional values, capabilities, and understanding of what the patients, the health systems, and society need,” he said. “In the end, patient care and outcomes suffer without policies that put the patient in the center of care and fully support the healthcare workforce and evidence-based care delivery.”
“To move toward universal healthcare and across-the-board access to care, and to minimize disparities,” Ricciardi added, “nursing is well positioned to lead policy efforts at local, state, and federal levels, and to improve the health and well-being of populations, to mitigate health inequities and improve access to quality care. I think it’s a professional responsibility for every nurse to be involved and lead.”
If one shies away from that, he said, “You’re putting the fate of the nursing profession in someone else’s hands, and that’s never a good thing.”
During the height of the pandemic, nurses were often portrayed in the media as heroes. However, they were infrequently called upon to serve as subject matter experts by the media. When reporters contact universities or health organizations seeking experts, they are often directed to physicians, not to knowledgeable nurses. “It’s an unfortunate phenomenon that has taken place over many years,” Ricciardi said. “My goal is to shift that paradigm so the media are more inclusive of nurses, both as part of the story and as leaders and scientists.”
Supporting New Moms
In addition to the forthcoming study on paid leave for fathers—her collaboration with Yang—Wallington is working on a suite of other things related to fatherhood, improving maternal outcomes and reducing maternal mortality in particular.
“This is not a traditional grant study. It’s more of a leadership-fellowship program,” said Wallington, associate professor of health disparities and oncology.
Wallington and colleagues are currently collecting data, but they already have a good sense that paid leave for expecting and new fathers makes an enormous difference in those fathers’ abilities to support expecting and new mothers. And Washington, D.C., has one of the highest maternal death rates in the county, so there is a lot of work to be done.
“As a researcher—and I’m a social-behavioral scientist—I didn’t really think a lot about how my research impacted policy, but I do now” Wallington said. “And I think that has been one great benefit of being in the School of Nursing, and working with Tony and being a member of the center. I am much more intentional about how my research impacts policy, and I think that’s a broader message especially to researchers.”
Particularly when thinking about social health determinants, one needs to think beyond the individual and look at broader structures that impact individuals. “Policy is one of those structural things that we have to look at,” Wallington said.
She advises other researchers—whether or not they are in nursing—to be more intentional about policy. “Policy is impacting some of these structures that we see, which lead to some of these disparate outcomes,” she said. “Part of a researcher’s responsibility is to have the broadest lens to look at those factors.”
Noticing a gap in the literature on fatherly roles in maternal health drove Wallington and her colleagues to try to better understand solutions that involve the father. (She noted that it’s been right for research to focus so heavily on mothers, but that shouldn’t mean ignoring fathers altogether.) Her team includes a policy researcher, a social-behavior researcher, and a community advocate.
“Many people don’t make that linkage and connection,” she said.
High-profile cases of fathers who noticed their wives in distress in delivery rooms but didn’t know how to raise the alarm, or did so too late and lost their wives, have begun to raise awareness that there is a need to better prepare and educate fathers and to understand their roles. Tennis star Serena Williams talked publicly about her very difficult pregnancy, for example.
“Some of it is bias. Some of it is racism. Some of it is training that healthcare professionals need,” Wallington said. And a lot of it is helping fathers feel more comfortable with their role as an extra pair of eyes and ears and advocates for mothers.
“It’s OK to take time off work,” Wallington said. “There is some literature that says that when fathers take paid time off, because their wife is expecting, to go to doctor’s appointments, that is frowned upon. We’ve got to change that culture to promote and encourage fathers to be involved all along.”
Students Leveraging For Change
A few years ago, the School of Nursing received a grant from the National Council of State Boards of Nursing to develop a master’s-level health policy certificate program. The council wanted to send people who work on different state boards of nursing to the program, because it wanted state board of nursing staff and elected members to have a better and broader knowledge of policy, said Mary Jean Schumann, associate professor of nursing.
Schumann wrote and implemented the grant and developed a 15-credit, five-course program. “We’ve offered it ever since,” she said. Cohorts start every August and number about half a dozen per year.
"There needs to be a greater effort to grow a cadre of nurses trained in health policy."
The school elevated those courses to the doctoral level (with more rigorous content and courses), to create a DNP policy track. “It all meshes with their other doctoral-level courses,” Schumann said. Like all DNP students, those in the policy track do capstone projects.
“What we do with them—and this is fairly new—is I sit down with them and figure out what they are passionate about,” Schumann said. “What is it that they see that they think needs to be changed, and how might they think about it? Who might be in their work environment that would be supportive of them? Is it at a state or federal level? They walk through that whole process as their defining project of the program.”
For a policy-focused capstone project, one alumna who graduated in May examined federal, state and district policies that drive school-based mental health. She interviewed school nurses in three states and pored over the policies and best practices in those states that might support them.
“She worked that up into a series of recommendations and did a national presentation at the American Public Health Association conference,” Schumann said. The student also presented a poster at a national conference and benefited from practicum experience with a lobbyist who works with the Maryland Nurses Association.
“A couple of legislators at the Maryland statehouse proposed a piece of legislation around having a minimum of one nurse in every school in the state, and she testified before the Maryland Senate and the Maryland House,” Schumann said. (The legislation did not pass, but Schumann is confident it will be reintroduced soon.)
“It is the kind of thing that we want these graduates to do—to get in there and engage with state legislators or at the federal level and try to inform change and leverage that change,” Schumann said. “Every nurse needs to be an advocate."