Journal of Nursing Education

Educational Innovations 

Strategies for Building Advocacy Skills Among Undergraduate and Graduate Nursing Students

Jill N. Peltzer, PhD, RN, APRN-CNS; Cynthia S. Teel, PhD, RN, FAAN; Elaine Frank-Ragan, PhD, RN; Heather V. Nelson-Brantley, BSN

Abstract

Background:

Nursing faculty are challenged to create learning experiences that both reflect the complexities of the current health care system and are relevant. Experiential learning opportunities should promote engagement in health care that extends beyond direct patient care to advocacy in larger systems.

Method:

To meet this challenge, faculty developed course assignments for students at baccalaureate, master's, and doctoral levels in which students worked with state Action Coalitions to implement the Institute of Medicine Future of Nursing report's eight recommendations. With faculty guidance, student teams developed and implemented projects or conducted research to assist the coalitions in their grassroots initiatives.

Results:

Students at all program levels reported high levels of satisfaction and engagement with these unique projects. Students reported understanding the importance of the Future of Nursing recommendations and intended to continue participating in statewide initiatives.

Conclusion:

Experiential learning opportunities at all program levels can engage students in learning more about advocacy, health care trends, and leadership. [J Nurs Educ. 2016;55(3):177–181.]

Abstract

Background:

Nursing faculty are challenged to create learning experiences that both reflect the complexities of the current health care system and are relevant. Experiential learning opportunities should promote engagement in health care that extends beyond direct patient care to advocacy in larger systems.

Method:

To meet this challenge, faculty developed course assignments for students at baccalaureate, master's, and doctoral levels in which students worked with state Action Coalitions to implement the Institute of Medicine Future of Nursing report's eight recommendations. With faculty guidance, student teams developed and implemented projects or conducted research to assist the coalitions in their grassroots initiatives.

Results:

Students at all program levels reported high levels of satisfaction and engagement with these unique projects. Students reported understanding the importance of the Future of Nursing recommendations and intended to continue participating in statewide initiatives.

Conclusion:

Experiential learning opportunities at all program levels can engage students in learning more about advocacy, health care trends, and leadership. [J Nurs Educ. 2016;55(3):177–181.]

Advocacy is an integral role of the nurse. Nurses are prepared to advocate for patients at the individual level to ensure quality outcomes. However, nurses are less prepared to advocate for the nursing profession to advance macrosystem-level changes to optimize population health. The Institute of Medicine's (IOM, 2010) Future of Nursing: Leading Change, Advancing Health report recommends that nurses advance health among diverse populations through academic progression, removing barriers to full scope of practice, and being leaders in the current dynamic, complex health care environment. Following release of the Future of Nursing report, the Robert Wood Johnson Foundation partnered with AARP to develop the Campaign for Action (Center to Champion Nursing in America, 2011), which provides a structure for fulfilling the eight recommendations addressed in the Future of Nursing report. As a key element of the overall Campaign for Action, Action Coalitions were established in all 50 states and Washington, DC. The Action Coalitions are grassroots initiatives involving nurses and nursing organizations from multiple settings to implement the Future of Nursing recommendations. In addition, the state Action Coalitions have sought the involvement of nurse champions (i.e., non-nurse partners) to increase the reach and visibility of the Action Coalitions. Each Action Coalition is unique, implementing projects and programs to address the recommendations within its state. All Action Coalitions are committed to the overarching goal of improving health at the individual, family, community, and population levels.

The Future of Nursing report, used as the template for nurses to be full partners in redesigning the current health care system, provides rich opportunities for faculty to design and implement course assignments that promote student involvement in the implementation of the recommendations. Involving students from all nursing education program levels (i.e., associate degree, RN-to-baccalaureate [BSN], BSN, and graduate) in state Action Coalitions builds professional identity and engages students in developing or enhancing leadership skills and competencies.

Nursing faculty are challenged to create learning experiences for students that reflect the complexities of the current health care system and broaden students' knowledge and application of advocacy. Experiential learning opportunities should promote engagement in health care that extends beyond direct patient care and microsystem-level activities and promote advocacy within larger systems to achieve optimal health outcomes among individuals, families, communities, and populations. To meet this challenge, faculty at the University of Kansas School of Nursing developed innovative learning projects for students in baccalaureate-, master's-, and doctoral-level courses. The purpose of this article is to describe the experiential learning projects that facilitated students' development of advocacy and leadership skills through engagement in grassroots initiatives.

Course projects were designed to meet four learning objectives:

  • Understand the implications from the Institute of Medicine's Future of Nursing (2010) report for the profession of nursing and, more broadly, quality patient services.
  • Advocate for the profession and for patients.
  • Experience the power of a grassroots movement in influencing the profession and the broader community.
  • Develop products to enhance state Action Coalition initiatives.

Faculty wondered whether immersion in state Action Coalition initiatives might creatively meet the course objectives and help prepare students for future nursing advocacy roles. Three concepts were identified as cross-cutting all program levels and projects: advocacy, current health care trends, and leadership. Faculty wanted students to expand basic advocacy efforts from focusing primarily on the individual to also focusing on the nursing profession. Working on Action Coalition projects provided opportunities for students to examine current health care trends, including the future of health care and nursing. Because nurses have leadership opportunities in all positions and settings, students had opportunities to build or enhance personal leadership skills and to differentiate among management skills and leadership identity, skills, and competencies. Faculty agreed to include the cross-cutting concepts in their respective assignments, with expectations that learning products would differ in complexity across the three program levels.

With faculty guidance, students developed and implemented projects, gathered data, or conducted research to assist the state Action Coalitions in their grassroots initiatives. In addition to instilling in the students the relevance of the Future of Nursing (IOM, 2010) recommendations, the learning activities promoted advocacy development and leadership and emphasized teamwork concepts that are integral to professional nursing practice, including interprofessional collaboration and supporting quality patient care. At each program level, students worked in teams in their respective courses to address the four learning objectives. Within the small groups, students self-identified leaders and the specific roles that facilitated engagement in grassroots initiatives through the state Action Coalition.

Valuing Action to Make Advocacy Real

Valuing Action to Make Advocacy Real is the theme that was used to articulate the application of the Future of Nursing (IOM, 2010) report recommendations in the authors' health care system, using the cross-cutting concepts that were identified by faculty as essential for all students to experience. Students worked with the Action Coalitions to develop, refine, implement, or evaluate projects and programs that addressed the four key messages of the Future of Nursing report. As a means to understand nursing's current and future responsibilities in a complex health care environment, students enrolled in selected BSN professional development, master's research project, and doctoral leadership courses were required to read the Future of Nursing report. Faculty used diverse learning activities in each class to assess students' knowledge of the report, such as in-class or online discussions and student reflection and question guides for each section of the report. Students received state-specific information about Action Coalition initiatives in Kansas or Missouri designed to address the key Future of Nursing recommendations. Because the University of Kansas School of Nursing is situated in a city that borders two states, students in the BSN program could choose to work with either the Kansas or the Missouri Action Coalition. Including both Action Coalitions provided opportunities for BSN students to learn about and become involved in advocacy and leadership efforts in the state where they anticipated working after graduation. Master's students worked with the Kansas Action Coalition because their faculty mentors are active participants in the Kansas Action Coalition. The doctoral student teams could choose to work with either the Kansas Action Coalition or the Missouri Action Coalition.

Baccalaureate Program

In the baccalaureate curriculum, students build from individual perceptions and identity formation within nursing, to a more broad understanding of the issues that affect nursing as a profession. The final BSN professional development course focuses on navigating the profession and challenges students to become involved in enhancing the profession. Students are encouraged to engage in political processes and professional organizations; to articulate how nursing practice is based on the concepts of excellence, lifelong learning, and professional growth; and to demonstrate an appreciation of contemporary issues in nursing and their impact on current clinical nursing practice. In this final course, BSN students are challenged to understand action as key to advocacy.

The faculty-approved BSN student projects in working with the Action Coalitions included (a) supporting the full scope of practice initiatives by examining the literature regarding patient outcomes between states with full scope of practice and states with limited scope of practice, (b) promoting seamless academic progression by identifying common and disparate prerequisites for state RN-to-BSN programs, and (c) optimizing engagement of nurses and non-nurses in Action Coalitions by assisting with development of Action Coalition Web sites. Since the inception of these action projects, the Action Coalition action and advocacy assignment continues to be refined. The assignment now also includes development of a proposal of the semester's work and a requirement for direct interaction with and guidance from professional nurse leaders within the Kansas and Missouri Action Coalitions (Table).

Valuing Action to Make Advocacy Real Project Exemplars

Table:

Valuing Action to Make Advocacy Real Project Exemplars

The faculty have found that the Action Coalition action and advocacy assignment successfully instills in students an understanding of advocacy, particularly the importance of advocating for one's profession. In postproject evaluations, students reported that before they joined the project teams, their perception of nursing was limited to interactions with patients. After participating in the action project, students reported an expanded view of nursing, including the importance of advocacy at the systems level. Students correctly identified current health care issues, such as the implementation of the Patient Protection and Affordable Care Act (2010), the need for more primary care providers, and the imperative to remove barriers to scope of practice. Students also reported a better understanding of leadership and how all nurses are or should be leaders in every role and setting. Faculty evaluated the project as being helpful in expanding student appreciation for the role of advocacy in practice.

Master's Program

In the master's program, students are required to take a research-focused course. After course completion, students work with a faculty mentor on a research project. Students typically select a mentor with whom they share a common research interest. Although not all faculty projects are connected with an Action Coalition, many faculty projects are involved in the Kansas Action Coalition efforts. Students enrolled in the research project course increasingly are involved in the work of the Kansas Action Coalition because of joining faculty projects.

As part of their research project work, eight master's students helped to conduct a qualitative research project focusing on Future of Nursing (IOM, 2010) report recommendation #4: Increasing the proportion of nurses with a BSN to 80% by 2020. Students analyzed trends such as how educational goals may affect practice, nursing roles, and professional identity. While interviewing nurses across multiple settings about academic progression, the student teams found that navigating academic progression was a primary theme. Although many study participants wanted to advance their education, significant barriers challenged them to reconsider academic progression. These barriers include conflicts between family and work time commitments and financial barriers that were not offset by potential advancement after completion of additional formal education. In considering academic progression from the associate to the baccalaureate level, study participants reported needing more time and money and also needing support and mentorship. Through the process of participating in interviews and data analysis, the master's students experienced professional and community advocacy based on how the IOM's (2010) 80/20 recommendation was interpreted by a variety of individuals.

Other examples of action projects for building advocacy skills include master's students partnering with a BSN student group to co-create a Match.com®-type of mentoring Web site, in which nurses interested in being mentored to acquire leadership skills are paired with nurses who are interested in leadership mentoring. The master's students also evaluated other Action Coalition partnerships with non-nursing organizations. Students interviewed key Action Coalition members to provide information to the Kansas Action Coalition about the role of nurse champions (non-nurses) in other Action Coalitions. This activity provided guidance to the Kansas Action Coalition on developing expectations and roles for the Action Coalition and the nurse champions to develop a partnership that meets the needs of all. Master's students also assisted with data analysis for several descriptive studies completed by the Kansas Action Coalition to establish baseline data about the nursing workforce, leadership roles, and cultural competency (Table).

Students experienced leadership by participating in team research and projects, with roles as team leader and team member. Students reported a better understanding of how to advocate for the profession. Students also observed how current health care trends can influence nursing roles, shape the current health care system, and, ultimately, influence health outcomes. On the basis of their observation of student performance during the projects and on the sophistication of the students' written products at the end of the project, faculty evaluated this emphasis on building advocacy skills in the context of the master's research project as helpful in expanding student appreciation for the role of advocacy in practice and in helping students develop advocacy skills in practice.

Doctoral Program

All Doctor of Philosophy and Doctor of Nursing Practice program students are required to take a doctoral leadership course that includes the following course objectives: examine entry-level role expectations for nurses with doctorates; apply organizational and leadership theories to enhance professional mastery; and create the conditions necessary for social change, using principles of collaboration. At the doctoral level, emphasis for the Action Coalition project is focused on advocacy for the profession, leadership, and complex change in the current health care system (i.e., advanced knowledge of health care trends). Working in teams, students are asked to identify a recommendation from the Future of Nursing (IOM, 2010) report that they believe will profoundly impact the profession and their careers. Doctoral student teams write a proposal identifying the selected recommendation, the plan for advancing the recommendation, the rationale for project choice, and the audience they will influence. In this leadership course, most of the doctoral students are experienced nurses, yet many have had little or no experience sharing their nursing accomplishments. Many students are uncomfortable promoting their role. Indeed, helping them understand the link between self-worth and the power they have to influence quality care is a major outcome of the action project. Acting as advocates for the profession and learning to influence or persuade others for good is foreign to many doctoral students.

Similar to the doctoral-level examples of student teams undertaking an action project with an Action Coalition, doctoral students in the leadership course chose to develop or expand on projects for the Kansas or Missouri Action Coalition. Students were guided on how to view the Future of Nursing recommendations as action plans to change the climate of health care. Some examples of doctoral students' action projects include creating a video for physicians explaining scope-of-practice issues and stressing the importance of patient-centered care; developing educational material targeting both currently practicing and future advanced practice RNs to work for change in state practice restrictions; and designing a brochure encouraging RN-to-BSN transition, which included educational and scholarship resources in Kansas (Table). By adopting a broader perspective about advocacy in practice, students gain a better understanding of population and professional advocacy . Population advocacy is the advocacy work for populations, either identified as a community bounded by geography, or a population of individuals with common characteristics, such as having a shared disease. Students experienced health care trends. Immersion in the Action Coalition through the multiple projects provided the opportunity for students to examine how multiple factors influence trends in health care and how trends changed or evolved over time. They also analyzed practice, education, and leadership issues within the context of personal goals; acquired skills for understanding themselves as leaders; and worked actively with Action Coalitions to change the current health care agenda. Although doctoral student projects varied in topic and scope, they were consistent in addressing the recommendations toward meeting the key messages of the Future of Nursing (IOM, 2010) report and addressing advocacy and leadership skill development. The doctoral faculty evaluated the action project emphasis as being successful in expanding student knowledge about and appreciation for advocacy in practice.

Results of the Program Implementation

Students at all program levels reported high levels of satisfaction and engagement with these unique projects through informal discussions with faculty during class discussions, online discussions, in-person meetings, and written course evaluations. Through these same methods, BSN, master's, and doctoral students reported understanding the importance of the Future of Nursing (IOM, 2010) recommendations, and they expressed intent to continue participating in statewide initiatives to follow the recommendations. Students also conveyed an appreciation of the grassroots initiatives necessary to advocate for nursing as a profession and for optimizing health outcomes at all levels—individual, family, community, and populations. Student projects supported the state Action Coalition initiatives, and students across educational levels were fully engaged in furthering the profession of nursing. Students actively addressed the complexities of the ever-evolving health care system through projects that had personal meaning and were relevant to their daily nursing practice and educational endeavors.

Students were evaluated on their Action Coalition project assignments, using assignment rubrics to ensure that they fulfilled the assignment guidelines in each program-level course. Faculty also evaluated whether the assignments addressed the broad objectives developed by faculty, which were to:

  • Understand the implications of the IOM's (2010) Future of Nursing report for the profession of nursing and, more broadly, quality patient services.
  • Advocate for the profession and for patients.
  • Experience the power of a grassroots movement in influencing the profession and the broader community.
  • Develop products to enhance state Action Coalition initiatives.

In both the BSN and doctoral courses, the student groups were evaluated on the development of project proposals, creation of a product to present, completion of peer evaluations, and submission of a reflective essay. Overall, faculty have been satisfied with the quality of the work developed by both the BSN and doctoral student groups. Since their inception, the action assignment guidelines have been revised to address student issues related to team assignments. In the BSN professional development course, the student team members self-select a specific team role with specific responsibilities. In the master's research course, the students and faculty co-create the specific research project objectives, which are used for the student evaluation. In this course, they do not develop a project proposal, always create a product, or typically work in a team; therefore, team member evaluations are not a component of the course assignment. They work primarily on a component of a larger project, such as data collection or a review of the literature. Master's students enrolled in the research course work closely with their faculty mentor on the project to successfully meet the project objectives. Faculty have also been satisfied with the quality of work developed by the master's students.

In addition, students reported meeting the course objectives within the specific BSN, master's, and doctoral courses through their involvement in the Action Coalitions and also meeting program-level objectives. Students in the prelicensure program complete an academic–professional portfolio in the same professional development course, with one component focusing on the nine BSN program objectives and how the student met each objective. Many students stated that this project supported their achievement of BSN program objectives, including demonstrating professionalism in their attitudes and behaviors, as well as demonstrating leadership in the evaluation of outcomes, improvement of care, and advancement of nursing practice.

After participating in research projects for the Kansas Action Coalition, students in the master's program explained how they met the course objectives and the master's program-level objectives during their final comprehensive oral examination for the master's program. In the examination, these students clearly articulated the steps needed to influence health policy and health care delivery systems (i.e., they understood and appreciated the importance of advocacy). The students also demonstrated professional values in their respective advanced nursing roles.

Students in the doctoral leadership course articulated how the action assignment helped them to meet course-level objectives and the doctoral program-level objectives. The doctoral students noted that participation in this project helped in developing their leadership skills to influence health care systems and influence health care policy. These perceptions were confirmed by faculty during the students' final oral comprehensive examinations.

Conclusion

Experiential learning opportunities at all program levels can engage students in learning more about advocacy, health care trends, and leadership. More specifically, by partnering with state Action Coalitions, faculty can support student learning through the theme Valuing Action to Make Advocacy Real. Student projects were oriented toward action—that is, facilitating student application of course content to statewide initiatives and involving students in grassroots movements. Project participation can instill a sense of ownership in redesigning the current health care system. Overall, students reported a greater appreciation of the concepts of advocacy, trending, and leadership by participating in these action projects. Faculty confirmed these student impressions.

Students at undergraduate and graduate levels can gain vital skills through involvement with grassroots initiatives. Partnerships with state Action Coalitions can provide interesting and unique opportunities for student engagement and learning. As faculty continue action-oriented Action Coalition projects, quantitative measures will be used to more objectively evaluate student learning outcomes and students' perceptions about course assignments that involve the Future of Nursing (IOM, 2010) recommendations and partnership with state Action Coalitions. Faculty may also assess for opportunities for intraprofessional collaboration among the three program levels, with teams of BSN, master's, and doctoral students working on an Action Coalition project.

Involving students with Action Coalitions for learning about advocacy, trending, and leadership resulted in many positive outcomes. Involving students in state Action Coalition projects can help students to realize the relevance of the Future of Nursing (IOM, 2010) report recommendations while also enhancing their advocacy skills. These action-focused projects are continuing to be developed. These creative learning experiences can help students across all program levels develop the advocacy and leadership skills that are needed for advancing the nursing profession, as recommended in the Future of Nursing report.

References

  • Center to Champion Nursing in America. (2011). Campaign history. Retrieved from http://campaignforaction.org/about-us/campaign-history
  • Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.
  • Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 et seq. (2010).

Valuing Action to Make Advocacy Real Project Exemplars

Program LevelAdvocacyHealth Care TrendsLeadership
BaccalaureateStudents developed an information brochure and poster to advocate for the need for advanced practice nurses (APRNs) to have full practice authority in the state. These advocacy products provided critical information for individuals in the state and education for the students involved in the project.Students developed a survey to collect data regarding school nurses' familiarity with Healthy People 2020 (http://www.healthypeople.gov/). Based on these findings, students developed a series of four educational videos that were then linked to the state Action Coalition, the state nurses' association, and public schools' Web sites.Students worked with a graduate student to develop a mentoring social site to pair nurses looking for mentorship with nurse leaders looking to mentor. Students developed a list of mentor and mentee qualifications and expectations. Students also created a list of tips for successful mentoring based on a literature review, as well as an evaluation form.
Master'sStudents assisted with a qualitative study about the impressions of academic progression among associate degree nursing faculty and public health and school health nurses. Students advocated for a more educated nursing workforce, identifying the factors that influence academic progression and the strategies to minimize barriers.A student conducted a literature review of interprofessional education and concluded that students from all health disciplines must be educated together to function as effective interprofessional teams. Interprofessional collaboration is increasingly being recognized as necessary to achieve optimal patient outcomes.A student worked with faculty and baccalaureate students to develop a mentoring social site, where nurses could be paired as mentor and mentee to help develop nurse leaders. Students also created a list of tips for successful mentoring based on a literature review, as well as an evaluation form.
DoctoralStudents developed a video highlighting the corporate value added when nurses are collaborative partners. This advocacy project included an executive-level explanation of the multitude of benefits that nurses offer in executive discussions due to their in-depth knowledge across interdisciplinary care models, while using systems and team thinking.Students produced a video highlighting the health care trend of patient-centered care. The video encouraged the transformation of the current health care structure to one that maximizes nurses' knowledge, skills, and roles, most notably among APRNs. Physician resistance to the APRN role expansion limits APRNs' ability to ensure patient-entered care. The project stressed the need for collaboration versus competition.Students created an online infographic encouraging nurses to recognize their leadership capabilities and become active in professional organizations. With the theme Take Action—Nurses Decide for Nurses, the students encouraged the powerful influence of the combined voices of nursing to lead change in health care.
Authors

Dr. Peltzer is Assistant Professor, Dr. Teel is Professor and Associate Dean, Graduate Studies, Dr. Frank-Ragan is Clinical Associate Professor, and Ms. Nelson-Brantley is Clinical Instructor, University of Kansas School of Nursing, Kansas City, Kansas.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jill N. Peltzer, PhD, RN, APRN-CNS, Assistant Professor, University of Kansas School of Nursing, 3901 Rainbow Boulevard, Mailstop 4043, Kansas City, KS 66160; e-mail: jpeltzer2@kumc.edu.

Received: February 20, 2015

Accepted: January 05, 2016

10.3928/01484834-20160216-11

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