Nurses have been influencing health policy at least since Florence Nightingale lobbied the British Parliament to educate and train nurses to serve in public workhouses. Dorothea Dix, Lavinia Dock, Lillian Wald and Margaret Sanger are part of a tradition of nurses using evidence, as well as their own field experiences to help shape policy, to improve health conditions in large populations. More recently, reports such as the Institute of Medicine's 2010 "Future of Nursing: Leading Change, Advancing Health" have stressed the benefits of having more nurses in policy positions. Nurses have served as heads of government agencies, including the Center for Medicare and Medicaid Services, and for powerful consumer groups such as AARP. They are holding leadership positions as health policy advocates, researchers, developers, administrators and evaluators. Today's nurses have a variety of paths to a health policy career, said Susan A. Chapman, PhD, RN, FAAN, professor at the University of California, San Francisco School of Nursing, and director of the master's program in health policy nursing there. Starting in 2002, UCSF began offering advanced degrees and a certification in health policy nursing. The programs represent one of a number of education opportunities for nurses specifically interested in becoming health policy specialists, according to the American Nurses Association. Some students in the UCSF program have planned on becoming health policy nurses from when they started nursing school, Chapman said. Others are there because they recognize that many of the clinical problems they encounter are the result of broken health systems. "They want to fix the system," said Ruth E. Malone, PhD, RN, FAAN, professor and chairwoman of the department of social and behavioral sciences at the UCSF School of Nursing and co-director of the health policy nursing program. "The kinds of nurses who are best at policy have broad interests. They are big picture people." For Leslie Dubbin, PhD, MS, RN, the connection to the big picture came during her work as a critical care nurse. On the same day, she saw two patients -- one a white man and the other a black woman -- who came to the hospital after suffering the same kind of heart attack. The man was successfully treated with an aggressive procedure, but the woman was treated more conservatively, Dubbin was told, because "black women didn't do as well' with the treatment the man received. On the day the man had recovered enough to be transferred out of the ICU, the woman died. "I still think about it to this day," said Dubbin, now chief program integration officer for ambulatory care at the San Francisco Department of Public Health. Why were treatments offered to some patients and not others? Why did African-American patients have poorer outcomes than whites? She wanted answers and she saw two paths -- doing clinical research to study disparities or looking at the environmental and social factors that put people in the hospital in the first place. The second route and a health policy nursing degree "seemed like a natural fit," she said.
Different directions
Students in health policy programs take courses in theory, research, communications and leadership. They learn about healthcare economics, caring for populations and global health. They need strong writing and critical thinking skills to be able to articulate and make a case for their ideas, Malone said. Dubbin had 20 years of experience in critical care and was working as an administrator at San Francisco General Hospital when she entered the UCSF master's in health policy nursing program in 2007. She eventually went on to get a PhD. The program requires students to complete a residency in a health policy setting such as a legislative office, advocacy group or professional organization office. Dubbin did her residency in Washington, D.C., with the National Association of Hospitals and Healthcare Systems. The organization was lobbying to keep intact disproportionate share payments for safety-net hospitals, who at the time were caring for large numbers of uninsured patients. As a nurse and administrator of a safety-net hospital, Dubbin was welcomed and her expertise was sought out by legislative aides and policymakers. "There was a sense that nursing is trusted and respected," she said. "It has a voice that needs to get listened to a lot more." Getting a position as a health policy nurse is not as simple as scanning a jobs website, Malone said. "You're not going to see an advertisement for a health policy nurse," she said. Nurses who want to work in health policy need to think hard about where their skills would be a good fit, she said. "Our graduates have gone in so many different directions." One got a position with the CDC in Rwanda, working in maternal child health and HIV prevention, she said. Another became a regent in the California university system. UCSF health policy nursing graduates have gone into high tech, biotech and advocacy institutions, Malone said. Some have returned or stayed in the facilities in which they were working, but in positions where they are able to use their policy skills to improve patient care. After Dubbin completed her PhD while continuing to work at SF General, she was approached and offered a job with the San Francisco public health department. As an integration officer for ambulatory care, her job is to ensure seamless transitions between various city health groups, such as primary care, jail care and mental health. A major project she now oversees is the creation of nursing wellness centers that will be part of new mixed-income housing complexes planned to replace some of San Francisco's poorest public housing projects. A goal of the centers, which include behavioral health and community liaisons, is to improve access and reduce health disparities for people long before they get to the hospital, she said. "I'm now looking at the 5,000-foot view" of healthcare. Cathryn Domrose is a staff writer. To comment, email [email protected].
