Recollections of the Flint water crisis are still vivid in the minds of many Americans. Responses to this crisis in the winter of 2014 needed to be swift and comprehensive. And while it may be hard to believe that access to clean, adequate, and equitable water in America remains at risk, advocates for environmental justice call for continued vigilance in ensuring access to safe and clean water. In this column, we discuss the need to ensure equitable access to this life sustaining resource through advocacy and legislative action with Katie Huffling, RN, MS, CNM, who is the executive director of the Alliance of Nurses for Healthy Environments.
Katie Huffling, RN, MS, CNM
Ms. Huffling, tell me a bit about yourself and how you became involved in addressing environmental health issues?
I trained as a nurse-midwife at the University of
Maryland School of Nursing. While there, I had the great fortune to meet Barbara Sattler and Brenda Afzal. They were leading the only environmental health center at a school of nursing in the country. Through their mentorship, I learned about the many ways that environmental toxicants could affect reproductive health and the health of the growing fetus. It is an area that many of us received little or no content on in nursing school, yet they can have significant negative health impacts across the lifespan. I became very passionate about environmental health issues and when the opportunity arose to work on this full time with the Alliance of Nurses for Healthy Environments, I jumped at the chance! We are the only national nursing organization focusing solely on the intersection of health and the environment. I now work with nurses and nursing organizations around the country on a number of environmental health issues such as climate change, clean air and water, toxic chemicals, and inclusion of environmental health into nursing curriculum.
Can you give me an example of an environmental health issue that is affecting health right now?
Clean water is one of the greatest public health advancements of the 20th century. As nurses, we recognize clean water is essential to health and a basic human right. It is also essential for providing nursing care. Nurses rely on water to wash their hands, give newborns their first baths, and is essential for the clean linens utilized throughout health care.
Here in the United States we have an expectation that when we turn on the tap clean, healthy water is going to come out. Unfortunately, for many throughout the country this is not the case. Every year, millions of Americans experience waterborne illnesses. Waterborne illnesses are caused by a variety of sources, including waterborne pathogens such as viruses or bacteria, human or animal waste, heavy metals such as lead or arsenic, or industrial pollutants. Certain populations may also be more likely to be exposed to unsafe drinking water, including low-income populations and some communities of color.
I know you have been a champion for environmental justice for some time now. What are some key legislative priorities with regard to clean and safe water?
To address a number of urgent clean water issues, the U.S. Environmental Protection Agency (EPA) proposed an update to the Clean Water Act, originally passed in 1972. The Clean Water Act needed to be updated due to the great expansion of knowledge regarding upstream sources of pollution. Researchers now understand how important protecting headwaters and other upstream water sources are to clean water downstream. There was also confusion concerning which waters were protected by the Clean Water Act. This followed two Supreme Court Decisions in 2001 and 2006, directly impacting the drinking water for 1 in 3 Americans.
In 2015, the EPA and the Army Corps of Engineers finalized the Clean Water Rule (CWR). This rule was only finalized after an intensive stakeholder process in which they held over 400 meetings and received over 1 million comments, 87% of which were in favor of the rule. The Clean Water Rule clarifies which “waters of the US” will be regulated under the Clean Water Act. These include traditional navigable waters, tributaries, a small number of waters that have a significant nexus to traditional navigable waters, interstate waters, or territorial seas, and also exempts certain waters such as puddles, ornamental ponds and rain gardens, and continues certain farm exemptions.
After the rule was finalized, a number of plaintiffs sued the EPA. The rule was suspended by the Sixth Circuit court until the outcome of these suits. This stay was overruled in February 2018. During this time the Trump Administration announced they were going to suspend the rule until 2020. This suspension was overruled by the courts in August and the CWR must now be enforced in 26 states.
The issues that the CWR addresses are very important to environmental justice communities. If the rule is repealed, low-income communities and communities of color—who already face disproportionate exposures from other environmental hazards—may be most impacted. These communities, along with rural communities, are more likely to have poor infrastructure that is not able to handle contaminants in the water. These communities also may not have the resources to upgrade their water systems. They may also be more likely to rely on well water that can be more susceptible to pollution from upstream sources.
Turning to implications for nursing, why and how can nurses get involved in addressing this issue?
The EPA has announced they plan to permanently repeal the CWR; however, this repeal has not been finalized yet. If they repeal this rule, the drinking water for over 117 million Americans could be negatively impacted. Once this official announcement occurs, the nursing voicing will be crucial to protecting this vital public health regulation. There are many ways nurses can be active in this policy arena:
Watch the new webinar from the Alliance of Nurses for Healthy Environments for one-hour free CE that reviews the CWR and provides opportunities for action (https://envirn.org/the-clean-water-rule).
Sign this petition to Acting Administrator Wheeler asking to him to keep the CWR in place.
Call your Senators and Congress people and ask them to support the CWR.
Engage your professional nursing organizations—write a newsletter article and ask them to write a letter to Acting Administrator Wheeler or to Congress. As the most trusted profession, when our nursing organizations actively engage on issues such as clean water, Congress listens.
The most vulnerable among us are harmed by dirty water. By actively engaging on clean water issues, nurses can help policymakers and the public make the connection that clean water is essential to health.
Are there additional resources we should be aware of?
The American Nurses Association’s Principles of Environmental Health for Nursing Practice with Implementation Strategies (which is available online here).
The Alliance frequently offers webinars (many with free CE) on a variety of environmental health topics. We’re free to join and if you sign up for our newsletter you will be notified of upcoming webinars and opportunities for action. To learn more, visit https://envirn.org.
Planting the health policy seed has become increasingly important to professional nursing organizations, nurse educators, and even nursing students who applaud the call for integrating health policy and advocacy content in today’s nursing curricula. As nursing students become acquainted with the policymaking process, they are also encouraged to familiarize themselves with the various professional and specialty nursing organizations who advocate on behalf of the nursing profession and the patients/consumers they serve.
Numerous nursing organizations including the American Nurses Association (ANA), National Council State Boards of Nursing (NCSBN), and National League for Nursing (NLN), to name a few, work to ensure that nursing’s voice is represented during policy discussions on issues that impact health care delivery, patient outcomes, nursing workforce development, and other issues of concern to the profession. These and other organizations advocate to ensure that students have financial support to attend nursing school, have access to loan repayment programs, and support to advance their nursing education and training. These organizations work diligently to help ensure that today’s nursing workforce is well prepared to meet the demands of providing high-quality health care services in an ever-changing complex and challenging health care environment.
Suzanne Miyamoto
In this article, we present information about the American Association of Colleges of Nursing (AACN) and share insights from AACN Chief Policy Officer Suzanne Miyamoto, PhD, FAAN, RN.
The American Association of Colleges of Nursing
Since 1969, AACN has been a leader in advancing nursing education, research, and faculty practice. Moreover, AACN serves as a national voice for baccalaureate and graduate nursing education. In addition to creating standards for designing and delivering quality nursing education programs, AACN represents over 810-member schools and colleges of nursing nationwide. The AACN has a Government Affairs Committee and a Health Policy Advisory Council that coordinate and spearhead several public policy initiatives and activities focused on advancing nursing education, research, and faculty practice. Currently, the association’s federal policy agenda focuses on four key areas: workforce, higher education, research, and models of care—all ongoing public policy imperatives.
Here, Miyamoto shares some insights about her organization and health policy advocacy.
Describe Your Role and the Role of the AACN in Preparing Today’s Nursing Students in Becoming Influential Advocates in the Health Policy Arena.
As Chief Policy Officer, I oversee AACN’s policy and advocacy work at the federal level working with all three branches of government. My role and that of our team can be described as strategist, lobbyist, and analyst. To ensure we meet the needs of our member organizations, the association has a Government Affairs Committee and Health Policy Advisory Council that provides guidance when we are reviewing legislative proposals or federal regulations. We want to ensure that what we support, oppose, or remain neutral on is in line with the experiences or challenges of our member institutions. AACN is in a unique position that we represent the schools of nursing, which includes the deans, faculty, and students. This requires our advocacy work to be nimble and abreast of the key issues Congress and the Administration are discussing. It is our role to not only develop the strategy but to educate and inform our membership on our position and why we take it. Information is the best offense and the best defense. That is why AACN fully supports all members of a nursing school to be engaged in our advocacy efforts. We have a grassroots network with other 11,000 students, faculty, and deans. This network has great potential to grow and offers real-time, advocacy opportunities.
What Are Some Top Priority Policy Issues Impacting the Profession and Health Care Today?
Some key issues impacting the profession today include
• Securing funding for Nursing Workforce Development Programs, Title VIII of the Public Health Service Act, National Institute of Nursing Research, National Health Service Corps, among others
• The Title VIII Nursing Workforce Reauthorization Act (H.R. 959, S. 1109)
• Health reform
• Deferred Action for Childhood Arrivals (DACA)
• Public Service Loan Forgiveness
• Opioid epidemic
What Can Students Do Within Their Area of Influence to Advocate for the Profession?
It is important that students stay informed of the issues. Students need to be active participants in their own learning. To understand what is happening at the federal level, a student must embrace the policy from multiple lens. It is not enough to read one source or one disciple. To truly garner the depth and breadth of the issue, the more voices, for and against, the better one’s understanding becomes. Securing a basic level of knowledge on an issue that may impact one’s education, research, or future practice is an excellent starting point.
Grassroots campaigns are central to any of our efforts. We can be more effective if we know how our national organizations are weighing in on issues. It’s also important to listen to all perspectives. Again, policy think tanks like the Center for American Progress or the Heritage Foundation may have different political viewpoints, but on some issues, they may see eye to eye. Their rationale for getting there may be different, but it is that difference that can help further an argument depending on the audience. Students can also join forces with faculty and others to reach out to legislators at the federal, state, and local level on issues important to nursing. Discussing issues with nursing faculty, who can serve as tremendous mentors for those interested in policy, can ignite a passion for this work in the future. That is how I came to seek a career in health policy and advocacy. It was the foresight of my faculty mentors who gave me the opportunities to succeed.
What Resources Are Available for Nursing Faculty Who Are Preparing the Next Generation of Health Policy Activists?
AACN established a Faculty Policy Think Tank that worked to prepare a set of recommendations for AACN’s Board of Directors on this exact question. The charge of the group was to inform and improve the state of health policy education in undergraduate and graduate education. The ultimate goal was to consider ways that will help create a generation of future nurses who understand the micro and macro drivers that impact policy—most importantly, how nurses in the future can continue to skillfully insert nursing expertise into policy discussions. The report was released in October 2017.
Turning to the continued need for policy advocacy at the student level, AACN also offers a three-day student policy summit open to undergraduate and graduate nursing students enrolled at AACN member institutions. The program helps to prepare students to engage in policy advocacy and the federal policymaking process. For more information, visit http://www.aacnnursing.org/Policy-Advocacy/Get-Involved/Student-Policy-Summit.
As mentioned earlier, AACN’s 2017–2018 Federal Policy Agenda is well suited to serve as a foundation for shaping policy discussions during online and classroom discussions as well as during virtual and/or actual lobby days. Students are encouraged to speak with their deans and faculty at their nursing programs to learn more about what’s happening within their institutions regarding public policy advocacy efforts that impact nursing education and nursing practice.
Seeking Federal Support for Nursing Workforce Development Programs: A Clarion Call for Continued Advocacy
Very central to this discussion is the need for ongoing advocacy to secure funding to support Title VIII programs. Title VIII programs are administered under the U.S. Department of Health and Human Services, Health Resources and Services Administration. The Nursing Workforce Development Program (Title VIII of the Public Health Service Act) continues to benefit countless numbers of nursing programs, practicing nurses, faculty, students, patients, and communities. In fact, numerous minority nurses continue to benefit from diversity grants because of Title VIII funding. During 2015–2016, the Nursing Workforce Diversity grants supported 7,337 students. Numerous other minority nurses, including minority nurse faculty, have received funding through this program to support their advanced nursing education or pay back student loans. To learn more about how Title VIII programs are making a difference for nursing students, practicing nurses, academic institutions, and communities at large, visit http://www.aacnnursing.org/Policy-Advocacy/Title-VIII-Community-Impact.
As a nursing student, speak with your faculty and professional organizations about how you can play a role in policy advocacy. Throughout nursing’s history, nurses have made a tremendous impact in advancing the profession and the delivery of health care by advocating for issues of importance to them. Developing your knowledge base about these and other issues impacting the profession is a great first step to becoming an influential advocate on behalf of the profession and the patients and communities you serve.
Increasingly, nursing students are being introduced to health policy and are encouraged to play an active role in some aspects of the policymaking process. Yes, I know, so much to do and so little time! However, opportunities to enhance one’s level of awareness and engagement regarding the policymaking process have never been greater. Planting the health policy seed has become important to professional nursing organizations, nurse educators, and even nursing students who applaud the push for integrating health policy and advocacy content in today’s nursing curricula.
Expected Competencies
Today’s nursing students must acquaint themselves with a number of policy issues that may impact their practice, the delivery of health care, and the profession of nursing. Nursing students are encouraged to develop increasing levels of knowledge, skills, and competencies related to health policy and advocacy commensurate with their advancing levels of nursing education. The American Association of Colleges of Nursing (AACN) has identified key health policy competencies to include in nursing curricula starting at the baccalaureate through the doctoral level. Nurse educators are encouraged to incorporate these competencies when designing and implementing health policy courses for nursing students across all levels of nursing.
Starting at the baccalaureate level, nursing students are introduced to aspects of health care policy, finance, and regulatory environments. Students at the master’s level are engaged in analyzing health policies and their impact on health care financing, practice, and health outcomes. Nurses at this level are expected to help interpret research findings as well as advocate for policies that will improve the health of the public and advance the profession of nursing. Building on these skills and competencies, students at the doctoral level are expected to acquire the necessary skills to demonstrate a higher level of involvement of leadership in developing policies, influencing policymakers, and assuming influential leadership responsibilities at the local, state, national, and/or international level.
Early on during nursing education, one should begin thinking about how legislation informs nursing practice and how public policies influence the health outcomes of the patients and communities that one serves. For example, funding for nursing education and research is an ongoing issue for the profession. This need requires ongoing and persuasive advocacy and communication with state and federal legislative officials. Each year, numerous organizations lobby at our nation’s capital to make the case for funding to support nursing education and research. In fact, increased funding levels for nursing education and research are, in part, attributed to the diligent advocacy by the nursing community and other stakeholders.
Opportunities for Policy Development
Recognizing the need to introduce nursing students to the policymaking process, the AACN hosts an annual Student Policy Summit. This three-day summit is open to nursing students enrolled at AACN member institutions and is designed to familiarize students with the policymaking process and nurses’ role in professional advocacy. Students journey to Washington, DC, to take a glimpse at the policymaking process at the federal level. Speak with your school and/or faculty to ensure that there is representation and support from your academic institution during the call for applications. For information about future offerings, I encourage you to visit the AACN’s website.
Recognizing the need to foster the policy development of its members, the National Black Nurses Association offers an annual Health Policy Institute at their annual meeting. Speakers with expertise and experience in the health policy arena have presented on topics, including health equity, prescription drug abuse, reproductive rights, and mental health, to name a few. Another example is the Oncology Nursing Society, which provides an online tutorial on the policymaking process and ways to become an effective patient advocate. Many nursing organizations hold virtual and in-person annual lobby days empowering its members to advocate on behalf of patients, communities, and the profession.
Be sure to check with your student, professional, and specialty organizations to see what opportunities they have to help supplement your classroom education. Volunteerism is yet another way to develop familiarity with the policymaking process and gain experience in advocacy. For me, I volunteered for a long time with the American Cancer Society and the Susan G. Komen for the Cure. These experiences enabled me to establish the linkage among practice, research, and patience advocacy. This in turn fueled my passion for learning more about the policymaking process and the various legislative initiatives informing the health and well-being of communities of color.
Current Legislation
Although numerous bills are introduced each year, only a small percentage will make it through the entire process, culminating in action at the executive level and signed by the President for passage. Similarly, numerous bills may be introduced or reauthorized that will have some implications for patients (e.g., reimbursement for care, increased access to care, support for clinical trials) or the profession of nursing (e.g., funding for nursing education and research). One bill that has implications for patients and the profession is the Nurse and Health Care Worker Protection Act of 2015 [H.R. 4266/S. 2408]. This piece of legislation was introduced by Representative John Conyers, Jr. (D-MI) and Senator Al Franken (D-MN) on December 16, 2015, during the 114th Congressional Session. This is the only national legislation that improves the quality of patient care and protects nurses and health care workers by addressing the safe handling of patients. To track the progression of this legislation, visit www.congress.gov.
During your nursing education or even in the workplace, stimulate some discussion and support around legislation and health policy issues and topics that have implications for nursing. Nursing in the 21st century demands that we take our rightful place at the table and advocate for patients and the profession. Developing the wherewithal to do so at the student level is an important first step.
In recent years, the relationship between oral health and overall wellness has teetered on the edge of public awareness. Now, the U.S. Department of Health and Human Services is launching an initiative aimed at making it a top priority. Eight HHS agencies, including the Office of Minority Health, the Administration for Children and Families, and the Surgeon General, are collaborating to support and expand oral health education and research. In particular, they hope to make oral health care services more widely available to underserved communities. Racial and ethnic minorities continue to be disproportionately affected by oral disease, and a significant facet of the initiative is working toward eliminating these disparities.
In April, Assistant Secretary for Health Dr. Howard Koh addressed the crowd at the National Oral Health Conference in St. Louis, Missouri, introducing them to the effort and its overall theme: Oral Health is Integral to Overall Health. Dr. Koh called the deficiencies in oral hygiene a “silent epidemic,” noting that 53 million people in the United States currently have untreated decay in their permanent teeth. Working with Dr. Koh in leading the initiative is Dr. Mary Wakefield, the Administrator of the Health Resources and Services Administration, in conjunction with the U.S. Public Health Service Oral Health Coordinating Committee.
Initiative goals and activities include creating campaigns that promote oral health and disease prevention and supporting oral health care professionals. Among individual agencies, the Indian Health Service will strengthen its Early Childhood Caries initiative, including monitoring childhood dental health through community health services and programs like Head Start. The Office of Minority Health plans to offer cultural competency training modules for dental health professionals, which will be available online. (The National Center for Research Resources will also provide Web-based tools for researchers.) And the Centers for Disease Control and Prevention plans to keep track of the overall state of oral health in the United States over the next few years, including the pervasiveness of oral diseases and patterns in dental health behavior. The Centers for Medicare and Medicaid Services, the Office of Women’s Health, and the Health Resources and Services Administration round out the team of collaborators, and each has their own contribution to the initiative.
The foundation of the effort is education, and program coordinators believe that by educating the masses regarding the importance of good oral hygiene and establishing healthy habits at a young age, they can stem the prevalence of tooth decay and oral diseases.
President Obama signed the historic Patient Protection and Affordable Care Act into law on March 23, 2010, and its first changes went into effect on July 1 of the same year. But signing that bill was just the beginning of a passionate national health care debate. Even one year later, the dust is far from settling.
One of the most politically divisive issues in the United States’ history, the Patient Protection and Affordable Care Act has been at the forefront of public and Congressional discourse practically from the moment it was written. Reforming the health care laws of the early 20th century has been a topic of discussion since the 1970s.
Yet, revisiting the Patient Protection and Affordable Care Act today is really just rehashing what was signed into law a year ago. Not much has actually changed, though those opposing the Act in the deeply divided Congress say it will change, and soon.
“Reforms under the Affordable Care Act have brought an end to some of the worst abuses of the insurance industry,” says the White House on its health care reform website, www.healthcare.gov.
Some of the more prominent facets of the reform include ending lifetime and some annual limits on care, allowing adults under age 26 to stay on their parents’ insurance plans, and forbidding insurance agents from denying care to children with preexisting conditions.
Regarding Medicare, almost 48 million of those receiving aid are eligible for free preventive care, including mammograms and colonoscopies, among other Medicare-specific reforms like prescription drug discounts.
The Act also takes into special consideration the disparities surrounding health care and minority populations. Minority Nursefrequently covers the lack of access to care and disproportionate incidences of disease, and the Patient Protection and Affordable Care Act outlines several initiatives to combat those inequalities.
Especially pertinent to low-income patients, the Act calls for subsidized preventive health care services like annual exams, immunizations, and cancer screenings for those falling into certain eligibility groups. It also invests in cultural competency and language training, chronic condition management teams, and community clinics, with a goal of doubling the number of patients those clinics can serve. The Act also provides funds for home care visits for pregnant women and new mothers, in an effort to stem the low birth weight and infant mortality epidemic affecting minorities.
Finally, by 2014, the Act will establish State-based Health Insurance Exchanges that will create a competitive health insurance marketplace and “guarantee that all people have a choice for quality, affordable health insurance even if a job loss, job switch, move, or illness occurs,” according to the U.S. Department of Health & Human Services.
Multiple parties have already questioned the Patient Protection and Affordable Care Act’s constitutionality, saying Congress does not have the power to require individuals to buy health insurance. The Obama administration has countered these claims, pointing to Congress’s Constitutional right to regulate interstate economic activity. The crux of the Act is fostering those State-based Health Insurance Exchanges, giving states flexibility in their implementation and giving individuals a choice that spans state borders. Surveys conducted by third parties, such as the Harvard School of Public Health, showed many Americans support the Act and many of its provisions, and that there is no swell of people hoping to have it repealed. Obama’s Congressional Budget Office also estimates the Act will eventually save money, reducing the deficit by $138 billion.
The White House, for its part, has tried to tout those functions of the Act that are already helping people, like the Medicare discounts and continued insurance coverage for young adults. However, though millions have already benefited from the law, most of the country has yet to feel its effects, making the continuation of these costly and sweeping changes seem pointless. The Act calls for more drastic health care overhauls through 2014, including many of the provisions directed toward reducing health disparities, but for the uninsured and underinsured, that can be a long wait.
Of course, speeding up the implementation of the Act isn’t an option, but voting during the 2012 election is. Nurses can support these changes (or refute them) with their vote. In the meantime, nurses can educate themselves, as the repercussions of the Act—whether it endures or is repealed—will be felt in communities and clinics, in juggernaut HMOs and small businesses, for years to come.
