Policy and Politics for Nurses and

Other Health Professionals: Advocacy

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 Contents vii

The Future Outlook: The Way Forward���������������������243 Baseline Information�������������������������������������������������������294

Conclusion�������������������������������������������������������������������������247 Challenges Facing the Community Hospitals�������298
Hospital Strategies in a Competitive Market���������301
Chapter 12 Medicaid and the Financing The ACA and The Rationalization of Hospital
of Care for Vulnerable Care ���������������������������������������������������������������������������������303
Populations: A Story of Healthcare Policy, Health Reform, and the
Misconceptions��������������������� 255 Role of Hospitals���������������������������������������������������������306

Introduction�����������������������������������������������������������������������256
Chapter 15 Enhanced Primary Care
Health Outcomes in the United States in
Relation to 10 Developed Nations�����������������������257
Roles for Nurses and Other
Populations Served by Original Medicaid �������������259
Professionals������������������������� 313
Original Medicaid Is Different Program in Why Primary Care? The Case for Change���������������315
50 States and Washington, DC�������������������������������260 Overtreatment, Overuse, Waste, and
Traditional Medicaid Costs and Variation Healthcare Harm���������������������������������������������������������315
by State���������������������������������������������������������������������������261 Support for Value-Based Care as a Bipartisan
ACA Medicaid�������������������������������������������������������������������265 Approach�����������������������������������������������������������������������317
Who Is Left Out�����������������������������������������������������������������266 How Payment Reform Shapes Needs and
Opportunities in Primary Care�������������������������������318
Health Insurance and the Health of
Vulnerable People�������������������������������������������������������267 What Skills Do Nurses Need in These
Advanced Primary Care Settings?�������������������������324
Chapter 13 Innovation for the Delivery Nursing Education�����������������������������������������������������������329
System of the Future: Medical Mental Health�������������������������������������������������������������������331
Homes, Accountable Care Dental Care�������������������������������������������������������������������������331
Organizations, and Bundled Conclusion�������������������������������������������������������������������������332
Payment Initiatives ������������� 279
Chapter 16 Physicians: It Is Increasingly
Introduction�����������������������������������������������������������������������280
about the Team��������������������� 341
The Innovation Center: Promoting Care
Delivery Models for the Future �����������������������������280 Medical Professionalism �����������������������������������������������342
Rationale for New Models��������������������������������������������281 Physician Supply: Who Are the Doctors?���������������343
The Four Major Healthcare Service Delivery How Are Physicians Practices Organized and
Models����������������������������������������������������������������������������281 Reimbursed?�����������������������������������������������������������������348
Conclusion�������������������������������������������������������������������������286 Physician Accountability�����������������������������������������������353
Medical Errors, Physician Practice,
and the Barriers to Quality Care�����������������������������356
Health Care and
SECTION 5  Overcoming the Barriers to Quality Care���������������356
Conclusion: Choices and Interests�����������������������������358
Provider and Care
Delivery289 Chapter 17 Health Information Technology
and the Intersection of Health
Chapter 14 Hospitals: Consolidation Policy ������������������������������������� 371
and Compression������������������� 291
Introduction�����������������������������������������������������������������������372
Hospitals’ Role within the Delivery System�����������292 Federal Origin and Influence in Development
Hospitals in a Historic Context�����������������������������������292 of HIT�������������������������������������������������������������������������������373
viii Contents
Nursing and Health Information Technology�������378
Nursing Terminology and the Data of
Nursing Care�����������������������������������������������������������������380
A National Action Plan: The Macro
Perspective on HIT�����������������������������������������������������381
Nursing and the Electronic Health Record:
The Micro Perspective on HIT���������������������������������382
Health IT: The Intersection of Data Security
and Health Policy �������������������������������������������������������383
Conclusion�������������������������������������������������������������������������391
Chapter 18 Political Power of Nurses:
Harnessing Our Values and
Voices������������������������������������� 403
Origins of the Nursing Profession �����������������������������405
Nursing Definitions: Past and Present ���������������������406
Nurses and Policy�������������������������������������������������������������407
The Nursing Workforce �������������������������������������������������413
Transforming the Care Delivery System�����������������415
Pathways to Nursing as a Career Choice�����������������416
Specialization and the Evolution of Nursing
Roles���������������������������������������������������������������������������������419
Current State of the Profession�����������������������������������419
Enhanced Nurse Licensure Compact�����������������������421
21st-Century Nursing: Evolving Roles
for Nurses�����������������������������������������������������������������������421
Policy as a Tool to Influence Nursing
Professionalism and Nursing ���������������������������������425
Conclusion�������������������������������������������������������������������������427
Legislative Resources�����������������������������������������������������427
Federal Agency Sites�������������������������������������������������������428
Other Related Sites���������������������������������������������������������429
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
© Anthony Krikorian/Shutterstock
Acknowledgments
It is with sincere appreciation and gratitude that
we would like to acknowledge the many individ-
uals, including family, friends, professional col-
leagues, and students, who have made this third
edition possible. Special thanks go to those pro-
fessional nurses who have gone before us pav-
ing the way by being stewards of the discipline,
advocates, and activists in promoting nursing,
public health, and policy. As the editors, we are
profoundly grateful to continue in their foot-
steps, fulfilling our promise to safeguard the
health of society and ensuring that future gen-
erations of nurses recognize how health and
public policy are instrumental to their educa-
tion and practice.
To my co-editors, Donna J. Middaugh and
Veronica D. Feeg, your enduring friendship, men-
torship, and insight have made this book possi-
ble. With your profound trust and unwavering
commitment, this third edition is offered in the
ongoing quest to ensure all nurses harness the
power within and bring their voices and values
to the bedside, boardroom, classroom, and halls
of Congress to promote policies that educate and
inform the public about what nursing is, not just
what nurses do.
We also would like to acknowledge the
superior oversight and dedication of Tricia
Plummer, our team administrator, who help
coordinate all the essential activities that made
this third edition such a seamless success. Tri-
cia, your professional skills and support were
greatly appreciated.
To my husband, Michael, whose love, pres-
ence, and encouragement has allowed me to fulfill
my professional hopes and dreams. Thank you
for making this such an exciting journey and
always believing all things are possible. To my
children, Nick, Lili, Kate, Luke, and JP, your joy
and love have fueled my energy and enthusiasm
to live my life by the words of Mahatma Gandhi:
“Keep your values positive because your values
become your destiny.” Always be positive and be
an example so that others may follow.
— Donna M. Nickitas
To my husband Robert and our son Rob-
ert Guy, who have awakened my soul and are
my inspiration in everything I do. They have
taught me to love unconditionally, enjoy life,
live with purpose, take risks, and strive for ex-
cellence. Robert Guy: You have become such
a compassionate, dedicated nurse! We are so
proud of you! Also, to the memory of my mother,
­Alpha Duff, a teacher, who taught me to never
stop learning.
— Donna J. Middaugh
To my husband Alan, you are my rock and
my enabler. You have always given me space to
do what makes me happy and wings to make me
soar into new endeavors without fear of failing.
You make the days easy for me to be produc-
tive in my own way. You give me understanding
when I’m unraveled; you give me comfort when
I need it most; you give me love in all you do.
To my daughter, Kelly, you are my sun and
the light of my life. You have become my teacher
and my sage with your wise guidance and words
ix
x Acknowledgments

of wisdom. You provide me with creative in-
spiration in my work by modeling it in yours.
To my mother, Mary, and in memory of my
dad, Americo “Red” DeCarolis, you both nur-
tured my passion for learning and supported
me unconditionally and financially throughout
my years in college. You may not have finished
high school but you always valued the impor-
tance of education.
— Veronica D. Feeg
© Anthony Krikorian/Shutterstock
Preface
Sally S. Cohen
Why this book? Why now? Nurses and other
health professionals have many textbooks on
health policy to choose from. Donna M. ­Nickitas,
Donna J. Middaugh, and Veronica D. Feeg’s third
edition of Policy and Politics for Nurses and Other
Health Professionals has distinct features that
make it a wise investment for faculty, ­students,
and others seeking concise, expert, and useful
information on how to understand and influ-
ence health policy.
First, the editors have carefully chosen the
most salient issues on government agendas and
not overwhelmed readers with the plethora of
all possible health policy issues around us. This
is critical in order to make health policy mean-
ingful to and within reach of students and cli-
nicians who can be quickly overwhelmed by the
world of health policy.
Second, this edition’s addition of case stud-
ies is of tremendous benefit. Based on decades
of teaching health policy at all levels of nurs-
ing education and to interdisciplinary and in-
terprofessional groups of students and faculty,
I am convinced that policy case studies are es-
sential. They offer faculty options for innovative
assignments and discussions that encourage stu-
dents to write or speak about health policy in a
nonjudgmental context. The case studies, which
are strategically placed within the chapters, of-
fer real-life scenarios. These scenarios typically
have more than one possible solution to a policy
problem. Case studies also: (a) facilitate discus-
sions about policy problems, (b) teach students
to articulate significant themes in health policy,
(c) require synthesis of valid evidence, and (d)
demonstrate the importance of political analy-
ses. The editors have wisely included more than
one case study in some chapters to demonstrate
how one policy can be applied to many differ-
ent situations or issues.
The third advantage of this text is that the
editors have a well-honed vision of what health
professionals need to know in an era of con-
tinually shifting public policy sands. Nickitas,
Middaugh, and Feeg’s third edition is based on
the premise that health professionals need to be
as nimble in government arenas as they are in
clinical settings. Moreover, they recognize that
this entails linking local, national, and global
health issues because of their inherent inter-
connectedness. With media and technology
enabling rapid dissemination of information, the
editors have provided content and case studies
that encourage effective communication using
online resources.
Some of these issues primarily apply to
individuals and populations with access to the In-
ternet and other technologies. Nurses and other
healthcare providers recognize that vast parts of
the world lack such resources. People in such
locales are struggling to find clean water, erad-
icate severe hunger, and prevent common and
new infectious diseases. Moreover, the geopolit-
ical terrain has become increasingly complex as
war, terrorism, and natural disasters strike across
the globe. The realities of climate change and en-
vironmental health risks make the sweeping dif-
ferences in allocation of resources between the
“haves” and “have nots” an ever-present challenge
for health professionals. These global challenges
are in contrast to other public health issues, in-
cluding the proliferation of noncommunicable
xi
xii Preface
conditions such as obesity, cardiac illness, and
mental health and behavioral problems (espe-
cially substance abuse and addictions).
Nickitas, Middaugh, and Feeg wisely ad-
dress the diversity of these issues by including
chapters on global and population health as in-
tegral to the text—and not as “add-ons” at the
end. By addressing poverty and other socioeco-
nomic causes of health problems, they acknow-
ledge the importance of health policy beyond
the doors of the clinic or hospital.
Similarly, they frame the chapter on physi-
cians as an issue of interprofessional teamwork,
instead of trying to present physicians or any
other professional as separate components of the
healthcare delivery system. By emphasizing the
importance of team care, they have minimized
the risk of readers engaging in the familiar and
useless “physician–nurse” games.
Will this text endure forever? No health
policy text can meet that challenge. However,
given the complexity of health policy and the
significant problems of teaching it to nurses and
health professionals, this third edition of Policy
and Politics for Nurses and Other Health Profes-
sionals can facilitate teaching and learning across
diverse settings and student populations. In the
health policy and education arenas, which can
be characterized by considerable disagreement
and little consensus as players vie for scarce re-
sources, this text is a winner and one that can
bring players together as they find common
ground in addressing the global and local issues
on which people’s lives and well-being depend.
© Anthony Krikorian/Shutterstock

Contributors
Nancy Aries, PhD Ellen Chesler
Professor of Social Policy Senior Fellow
School of Public Affairs Roosevelt Institute
Director of Baruch Honors Programs New York, New York
Baruch College
Barbara Cohen, PhD, RN
The City University of New York
Professor of Health Services
New York, New York
School of Health Studies
Steven Baumann, PhD, APRN-BC, RN Berkeley College
Professor New York, New York
Hunter College
Wesley Cook, DNP(c), APRN, FNP-BC, CPSN
Hunter-Bellevue School of Nursing
Nurse Practitioner
New York, New York
Washington, DC
Claudia J. Beverley, PhD, RN, FAAN
Brigitte Cypress, EdD, RN, CCRN
Professor (Secondary), Department of Health
Associate Professor
Policy and Management
East Stroudsburg University
Professor
Department of Nursing
College of Nursing
East Stroudsburg, Pennsylvania
Professor (Secondary)
College of Medicine Patricia Eckardt, PhD, RN
Director, Arkansas Aging Initiative, Donald Molloy College
W. Reynolds Institute on Aging Rockville Centre, New York
University of Arkansas for Medical Sciences
Veronica D. Feeg, PhD, RN, FAAN
Little Rock, Arkansas
Associate Dean and Director
Linda Bradley, MSN, MPH, PHCNS-BC PhD Program in Nursing
Assistant Professor Molloy College
New York City College of Technology The Barbara H. Hagan School of Nursing
Brooklyn, New York Rockville Centre, New York
Pennie Sessler Branden, PhD, CNM, RN, CNE Stephanie Ferguson, PhD, RN, FAAN, FNAP
Consulting Associate Professor
Barbara Caress
Stanford University
Senior Consultant
Stanford, California
Service Employees International Union
Founder, President, and Chief Executive Officer
New York, New York
Stephanie L. Ferguson Associates, LLC
Amherst, Virginia

xiii
xiv Contributors

Shirley Girouard, PhD, RN, FAAN Donna Middaugh, PhD, RN

Professor and Associate Dean Clinical Associate Professor
College of Nursing Associate Dean for Academic Programs
SUNY Downstate Medical Center Coordinator, Nursing Administration Masters
Brooklyn, New York Specialty
College of Nursing
Valerie Gruhn
University of Arkansas for Medical Sciences
Doctors Without Borders/Médecins Sans
Little Rock, Arkansas
Frontières
Geraldine Moore, EdD, RN
Joyce Hahn, PhD, RN, APRN-CNS, NEA-BC, FNAP
Molloy College
Associate Professor
Rockville Centre, New York
School of Nursing
George Washington University Lois Moylan, PhD, RN
Washington, DC Molloy College
Rockville Centre, New York
Christine Hancock
Director Donna M. Nickitas, PhD, RN, NEA-BC, CNE, FAAP, FAAN
C3 Collaborating for Health Dean and Professor
London, United Kingdom Rutgers University School of Nursing
Camden, New Jersey
Lauran Hardin, MSN, RN-BC, CNL
Editor, Nursing Economic$, The Journal for
Senior Director
Health Care Leaders
Cross-Continuum Transformation
Pitman, New Jersey
National Center for Complex Health and
Social Needs Betty Rambur, PhD, RN, FAAN
Camden Coalition of Healthcare Providers Routhier Endowed Chair for Practice
Camden, New Jersey Professor of Nursing
University of Rhode Island
Olga S. Kagan, PhD, RN
Kingston, Rhode Island
Eileen Levy, RN, PhP
Roby Roberston, PhD
Nurse Practitioner at NSLIJ
Professor Emeritus
Huntington Hospital
School of Public Affairs
Huntington, New York
University of Arkansas – Little Rock
Sandra B. Lewenson, EdD, RN, FAAN Little Rock, Arkansas
Professor
Yael Rosenstock
College of Health Professions
Director of Programming
Lienhard School of Nursing
Center for Ethnic, Racial, and Religious
Pace University
Understanding
Pleasantville, New York
CUNY
Jennifer E. Mannino New York, New York
Nancy Rudner, APRN
Professor of Nursing
George Washington University
Washington, DC
 Contributors xv

Janice A. Selekman, DNSc, RN, NCSN, FNASN Marie Truglio-Londrigan, PhD, RN

Professor Professor
School of Nursing College of Health Professions
University of Delaware Lienhard School of Nursing
Newark, Delaware Pace University
Pleasantville, New York
Brenda Helen Sheingold, PhD, MBA, BSN, FNAP
Assistant Professor Ralph Vogel, PhD, RN
Director Clinical Assistant Professor
Health Care Quality Graduate Programs College of Nursing
George Washington University University of Arkansas for Medical Sciences
Washington, DC Little Rock, Arkansas
Lisa Sundean, PhD, RN Helen Werner, PhD, RN
Assistant Professor Assistant Professor
Department of Nursing Program Coordinator, Upper Division
University of Massachusetts, Boston Monroe College School of Nursing
Boston, Massachusetts Monroe, New York
Joel Teitelbaum, LLM Sara Wilensky, PhD
Associate Professor Faculty
Department of Health Policy and Milken Institute School of Public Health
Management George Washington University
Milken Institute School of Public Health Washington, DC
George Washington University
Washington, DC
Anh Phuong Tran, BSN, RN-BC, ONC
Adult Health Nurse Practitioner
New York, New York
SECTION 1
Introduction
CHAPTER 1 Nursing’s History of Advocacy and Action
CHAPTER 2 Policy and Politics Explained
CHAPTER 3 A Policy Toolkit for Healthcare Providers
and Activists

© Anthony Krikorian/Shutterstock

1
CHAPTER 1
Nursing’s History
of Advocacy and Action
Sandra B. Lewenson and Donna M. Nickitas

OVERVIEW
The American Nurses Association (ANA) reminds nurses of the social contract between nurses and the
public that “reflects the profession’s long-standing core values and ethics, which provide grounding
for health care in society” (American Nurses Association [ANA], 2010, p. 10). The ANA Social Policy
Statement has articulated nursing’s social obligation since it was first published in 1980. Nurses turn
to this document to understand how nursing fulfills this obligation by providing ethical and culturally
competent care to individuals, families, communities, and populations. It also helps nurses explain their
role in the larger society, to new members of the profession, and to nurses already working in the field.
New position statements about inclusivity and diversity by the American Association of Colleges
of Nursing (AACN) (2017) and the American Academy of Nursing (AAN) (2016) contribute to a sense of
responsibility nurses share to fulfill the social obligation to society. The AACN (2017) states that “to have
equitable systems, all people should be treated fairly, unhampered by artificial barriers, stereotypes
or prejudices” (p. 173). It continues to address unconscious and conscious bias of which we as nurses
must be aware to make a change. Advocacy includes, and if not, should include, the notion of
inclusivity and diversity.
This chapter explores political advocacy in light of nursing’s role and responsibility to advocate for
and act on behalf of those for whom nurses have contracted to provide care. The first section of the
chapter explains why nurses need to know history to be effective advocates and why knowing history
matters to advocacy. It provides historical exemplars to highlight how history informs the profession
as it continues to invoke the social contract that nursing maintains with society. The second part of the
chapter examines a more contemporary look at nursing’s political advocacy efforts and what it means
for nurses, the profession, and the health of the public at large.

© Anthony Krikorian/Shutterstock

3
4 Chapter 1 Nursing’s History of Advocacy and Action
OBJECTIVES
■■ Discuss why nursing history is relevant to health policy and nursing advocacy and action.
■■ Explore historical exemplars that provide evidence of nursing’s ability to advocate for individuals,
families, communities, and populations.
■■ Analyze nursing’s role in how political advocacy impacts nurses, the profession, and the health
of the public at large.
▸▸ Nurses as Advocates
Although society reportedly trusts nurses to
work toward accomplishing the goals set forth
for them by the profession (ANA, 2010), nurses
may not be grounded in how they reached these
“long-standing core values” that the nursing pro-
fession developed over time. As nurses advocate
for their patients—whether seen as individu-
als, families, communities, or ­populations—
an understanding of nursing’s enduring and
long-standing values that are rooted in its his-
tory provide depth and breadth to their efforts.
To this end, it is important to know nursing’s
historical role in ensuring access to care; it is
important to know nursing’s contributions to-
ward patient quality and safety measures; it is
important to know how nursing interventions
changed over time in response to the context in
which nurses practiced; and it is important to
know how nurses and the profession adapted
to shifts in the social, political, economic, and
cultural environment (D’Antonio & L ­ ewenson,
2011). Fairman (2017) writes that “our past
shapes everything we do, whether we explicitly
acknowledge it or not” (p. xi).
Why Study Nursing History?
Historian and nurse educator Ellen Baer and col-
leagues respond to the question of why nursing
history should be studied:
Just as a nurse can make little progress
caring for or curing a patient’s presenting
problem without knowing the patient’s
physiological, psychological, and cultural
history so is it for a nurse trying to make
sense out of the persistent problems and
possibilities in nursing and health care.
To make right decisions in planning
nursing’s future in the context of our
complex health-care system, nurses
must know the history of the actions
being considered, the identities and
points of view of the major players, and
all the states that are at risk. These are
the lessons of history. (Baer, D’Antonio,
Rinker, & Lynaugh, 2001, p. 7)
Some lessons from the past that support
the understanding of political advocacy and
action can be learned by examining how Flor-
ence Nightingale influenced the development of
nursing education programs that started in 1873,
and led to what became known as the Modern
Nursing Movement. It began with the first three
United States Nightingale training schools: the
Bellevue Training School for Nurses in New York
City; the Boston Training School for Nurses at
Massachusetts General in Boston; and the Con-
necticut Training School in New Haven, Con-
necticut. Following the opening of these three
schools, hospitals around the country recog-
nized the value that student nurses bring to the
hospital because care could be provided at rela-
tively low cost and the hospital would have no
obligation to hire the nurses when they gradu-
ated. Nurses, after their training was complete,
would need to find work elsewhere, typically
in private duty or in the emerging field of pub-
lic health nursing.
Twenty years after the opening of these
schools of nursing, early nursing leaders

recognized the need to organize nurses to con-
trol the quality of practice and training as a way
to protect the public. Between 1893 and 1912,
four professional nursing organizations formed
to do just that: the National League for Nurses,
formed in 1893 (originally called the American
Society of Superintendents of Training Schools
for Nurses); the American Nurses Association,
started in 1896 (originally named the Nurses’
Associated Alumnae of the United States and
Canada); the National Association of Colored
Graduate Nurses, which formed to address ra-
cial bias in nursing and health care and was in
existence between 1908 and 1952; and finally, in
1912, the National Organization of Public Health
Nursing, formed to control practice and educa-
tional standards during the rising movement of
public health and public health nursing in the
United States. This organization ended in 1952
when the National League for Nursing assumed
its role (Lewenson, 1993).
Even before women in the United States
gained the vote in 1920, nurses sought legis-
lation that would define nursing practice, and
they advocated for the protection of the pub-
lic by prohibiting anyone who was not profes-
sionally trained from calling him- or herself a
nurse. This required convincing lawmakers, at
that time only men, to support nursing legisla-
tion; the nurses knew they could not vote into
law the early nurse practice acts. While nurses
struggled for statewide nursing registration, they
had to “fight battles against long hours of work
and opposition to nursing education” (­Lewenson,
1993, p. 171). To accomplish their goals, some
nurses, either individually or through the early
nursing organizations, began to support the
work of the suffragist movement and aligned
themselves with the larger women’s movement
of the early 1900s. Individual nursing leaders, like
public health pioneer Lillian Wald and nursing
suffragist Lavinia Dock, advocated for health-
care reforms in the community and the legisla-
tive arena. The professional organizations that
formed during this period did so to protect the
public from uneducated nurses and to develop
standards for nursing education and practice.
Nurses as Advocates 5
Although an in-depth history of this p
­ eriod
is beyond the scope of this chapter, it is im-
portant for nurses to understand that political
advocacy was part of the profession’s early iden-
tity. Political advocacy and action in nursing
are not new or innovative. Nurses have a­ lways
been political advocates for those in their care
(Lewenson, 2012). As a result, the early efforts
made by nurses and their professional orga-
nizations provide a narrative for and insight
into today’s advocacy efforts, where protection
of the public means ensuring a level of educa-
tion for all nurses, the development of quality
and safety standards, and the ability of nurses
to practice to the fullest extent of their educa-
tion, as recommended by an Institute of Med-
icine report (2010).
History Counts
Fairman and D’Antonio (2013) wrote, “history
counts in health policy debates” (p. 346). Bring-
ing a historical perspective to discussions about
health care deepens our understanding of the is-
sues by recognizing the evolution of ideas across
time. In the debate about control of the “newly”
minted medical homes of today, understanding
the roles of early public health nurses in provid-
ing primary healthcare services to individuals,
families, communities, and populations in both
urban and rural settings can trigger some use-
ful ideas or solutions about what to call the new
entity, who should finance it, and who should
lead it (Keeling & Lewenson, 2013).
The current debate centered on medical
homes provides such an example. The term was
first coined in the 1960s and defined a medical
model of care for chronically ill pediatric pa-
tients that looked at control issues, inter- and
­intradisciplinary issues of providing care, and
the financial aspects of care. Physicians led the
earlier medical home movement that has evolved
to mean “a model of primary care that is accessi-
ble, continuous, comprehensive, family-centered,
coordinated, compassionate and culturally ef-
fective” (American Academy of Pediatrics, 2002,
as cited in Keeling & Lewenson, 2013, p. 360).
6 Chapter 1 Nursing’s History of Advocacy and Action
Nurses use the words that define the medical
home of today to describe nursing’s work of
providing accessible, continuous, comprehen-
sive, family-centered, coordinated, compassion-
ate, and culturally effective care. Knowing the
history of nursing serves to highlight the pro-
fession’s strong contribution to health care in
the United States.
▸▸ Advocacy and Public
Health Nursing
Exploring some of the public health initiatives
that Wald established—the Henry Street Set-
tlement and the American Red Cross Town &
Country—offers excellent examples of how nurs-
ing, history, and political advocacy and action
intersect. By studying the work of those nurses
and nursing leaders within these settings, we
not only learn about the role nurses played in
primary health care (as described by Keeling &
­Lewenson, 2013), but we can also learn about
the healthcare advocacy that public health nurses
sought for those individuals, families, and com-
munities. We also learn about the unconscious
and conscious bias shared by society, includ-
ing nurses, towards black nurses and the sub-
sequent outcome that race played in healthcare
outcomes. The next section uses these two early
20th-century public health initiatives as exam-
ples of political advocacy by public health nurses.
Advocacy at Henry Street
Lillian Wald graduated from nurses’ training in
1891 from the 2-year diploma-based program
at New York Hospital in New York City. Within
2 years of graduating, she and her school friend
Mary Brewster recognized the overwhelming
healthcare needs of immigrant families living
in the overcrowded and unclean conditions of
the tenement houses on the Lower East Side of
New York City. Filled with a sense of social ob-
ligation to improve the health of society, Wald
and Brewster began the Henry Street Settlement
and found support for the venture from philan-
thropists and other nursing leaders. Wald’s work
expanded from just nine public health nurses
working in one settlement house that was estab-
lished in 1893 to more than 250 nurses working
throughout the New York City area in at least
seven different locations (Buhler-­Wilkerson,
2001; Keeling, 2007; Lewenson, 1993). The
Henry Street Settlement was one of the few pub-
lic health organizations to hire black nurses to
care for black patients (Pitt-Mosley, 1996). This
policy of inclusion did not exist in most health-
care settings, and discrimination was typically
the order of the day, whether in the north or
south or whether conscious or unconscious.
While caring for the families, Wald saw a
close relationship between the health of the pub-
lic and civil responsibility. In a speech she deliv-
ered in 1900 at the sixth annual meeting of the
American Society of Superintendents of Train-
ing Schools for Nurses, Wald said that “among
the many opportunities for civic and altruistic
work pressing on all sides nurses having superior
advantages in their practical training should not
rest content with being only nurses, but should
use their talents wherever possible in reform
and civic movements” (Wald, 1900, as cited in
­Birnbach & Lewenson, 1991, p. 318). In keep-
ing with her beliefs, Wald and her colleagues at
Henry Street introduced several legislative ini-
tiatives that would improve the health of chil-
dren, such as the introduction of nurses in public
schools (Wald, 1915). Wald (1915) described how
she advocated for hiring nurses in the local pub-
lic schools to decrease truancy rates, given that
children were sent home due to illness and lack
of treatment. As of 1897, physicians had only
recently been hired by the New York City De-
partment of Health to assess children in school.
Doctors sent children home from school when
any contagious illnesses were found. However,
this did not address some of the pressing health
issues because the physicians did not provide
treatment for conditions such as trachoma, a
contagious eye infection that plagued school-
age children at the time. Wald (1915) wrote
about her experience convincing legislators of

the value of assigning public health nurses in the
schools in her book The House on Henry Street.
In 1902, when a reform administration
came into power, the medical staff was reduced,
the physicians’ salary was increased to $100 per
month, and they were expected to work only
3 hours per day. The health commissioner or-
dered an examination of all public school pu-
pils and was horrified to learn of the prevalence
of trachoma. Thousands of children were sent
away from school because of this infection.
Where medical inspections were the most thor-
ough, the classrooms were empty. It was ironic
that Wald watched the children who had been
turned away from school playing with the chil-
dren they had been sent home to protect. Few
children received treatment, and it followed that
truancy was encouraged:
The time had come when it seemed right
to urge the addition of the nurse’s service
to that of the doctor. My colleagues
and I offered to show that with her
assistance few children would lose their
valuable school time and that it would
be possible to bring under treatment
those who needed it. . . . I exacted a
promise from several of the city officials
that if the experiment were successful,
they would use their influence to have
the nurse, like the doctor, paid from
public funds. Four schools from which
there had been the greatest number
of exclusions for medical causes were
selected, and an experienced nurse,
who possessed tact and initiative, was
chosen from the settlement staff to
make the demonstration. . . . Many of
the children needed only disinfectant
treatment of the eyes, collodion ap-
plied to ringworm, or instruction as
to cleanliness, and such were returned
at once to the class with a minimum
loss of precious school time. Where
more serious conditions existed the
nurse called at the home. (Wald, 1915,
pp. 51–52)
Advocacy and Public Health Nursing 7
Within 1 month, the experiment was deemed
successful, and an “enlightened Board of Esti-
mate and Apportionment voted $30,000 for the
employment of trained nurses, the first mu-
nicipalized school nurses in the world” (Wald,
1915, p. 53). School nursing continues to be a
concern for those interested in political advo-
cacy to improve the health of our young and
vulnerable populations. Historian Mary G­ ibson
(2017) writes that:
Today’s philosophy still reflects the pro-
tective and hopeful beliefs of leaders in
education of 100 years ago concerning
the influence of child health on our
nation’s future. . . therefore, keeping
children in school, healthy and ready
to learn, is a universal goal throughout
the United States. (p. 37)
Advocacy in the Town & Country
Wald’s advocacy extended to families living in
rural settings. One of the most compelling ex-
amples is the establishment of the American
Red Cross Rural Nursing Service (later known
as the Town & Country). As Keeling and Lewen-
son wrote (2013), this organization “served as
the point of contact for families in rural com-
munities where remoteness, isolation, and fewer
physicians and nurses created barriers to care”
(p. 362). Wald believed that the American Red
Cross—already organized to provide nursing ser-
vices during wartime and natural or manmade
disasters—was the right vehicle in which to or-
ganize public health nursing services throughout
the country during peacetime (Dock, Pickett,
Clement, Fox, & Van Meter, 1922; Keeling &
Lewenson, 2013). Through Wald’s influence,
philanthropists supported the implementation
of this new rural public health nursing service.
During the first year, criteria were established for
nurses who would collaborate with community
leaders, physicians, and families to provide both
curative and preventive health care in rural set-
tings. The requirements to become a rural pub-
lic health nurse were far reaching and included
8 Chapter 1 Nursing’s History of Advocacy and Action
pragmatic skills. Nurses were expected to ride
a bicycle or a horse, or drive a car so that they
could access their patients.
© fotorobs/Shutterstock
More important, and often difficult to find,
were nurses who had an education that prepared
them to negotiate and collaborate with others in
the community. Typical nurses’ training programs
did not provide these skills. It was determined that
a minimum of a 4-month education was needed
to prepare nurses to work independently in com-
munities across America (American Red Cross
Rural Nursing Service, 1912–1914). Educational
programs were established, like the one at Teach-
ers College in New York, in conjunction with the
Henry Street Settlement and the rural District
Nursing Service of Northern Westchester, soon
after the American Red Cross Rural Nursing Ser-
vice formed. By 1914, the new public health nurse
curriculum offered courses in sociology, munici-
pal and rural sanitation, and experiences in rural
and urban public health settings. These courses
were valuable for nurses who practiced in rural
settings because they did not have the same sup-
port systems as urban areas.
Black nurses faced barriers to attending
some of these early public health courses and,
as a result, contributed to few entering this ser-
vice. Frances Elliot Davis, a graduate of the Freed-
man’s School of Nursing in Washington, DC, did
attend the 4-month program at Teachers College
and was admitted as a Town & Country nurse in
1917. She was considered the first black nurse to
be admitted into the American Red Cross (Hine,
1989; Lewenson, 1993). Influenced by the return-
ing soldiers and the influenza pandemic in 1918,
Davis, along with other black nurses, were finally
accepted into the American Red Cross reserves
at the end of World War I. The bias of the mili-
tary and, subsequently, the American Red Cross,
reared itself in several ways. One of the most bla-
tant ways was the designation of race on each of
these nurses’ badges, separating them from their
white colleagues. Frances Elliot Davis received
her badge with the number 1-A inscribed on the
back. This was one way the Red Cross that served
as the gatekeeper into the Army Nurses Corps
could maintain the practice of segregated living
quarters and segregated health care. The National
Association of Colored Graduate nurses advo-
cated changes in these practices that eventually
ended by mid-20th century (Lewenson, 2017).
Wald’s advocacy extended to the use of me-
dia to show the public what a rural public health
nurse could do and to garner support for the
initiative. While she was at the third meeting
of the American Red Cross Committee on Ru-
ral ­Nursing—the committee established by the
American Red Cross in 1912 to develop the cri-
teria for the Town & Country—Wald suggested
that the committee “get in touch with the Publi-
cation Syndicate, and Rural Nursing written up
possible [sic] in story form for the Ladies’ Home
Journal and other popular magazines” (American
Red Cross Town & Country Nursing Service, 1913,
p. 2). At the same meeting, it was noted that Wald
and others supported establishing a relationship
with the Metropolitan Life Insurance Company
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