In nursing education, more attention needs to focus on students' political competence as health care providers in order to unite their future roles as professionals and as citizens (Rains & Barton-Kriese, 2001). To be politically competent, Rains and Barton-Kriese (2001) argued, students who graduate from nursing programs should be able to evaluate the nursing profession's role in decisions about health care policy, understand how the political arena and policy shape health care, be able to act as change agents for health policy through advocacy, and dedicate themselves to be politically active in health promotion. Nursing curricula should offer opportunities for students to develop these capacities. As politically competent nurses, they will then be able to participate in transforming health care at the local, state, and federal levels (American Nurses Association [ANA], 2015; Benton, Al Maaitah, & Gharaibeh, 2017).
Historically, undergraduate nursing curricula have included didactic learning activities related to public health policy, but usually they do not include hands-on opportunities for students to engage in the actual process of shaping public health policy at the institutional, state, or national level (Benton et al., 2017). In their integrative review of the literature on policy and political competence in nursing education, Benton et al. (2017) highlighted the importance of equipping future nurses to be prepared to be instruments for political change through increased awareness and experience of the political process. Potential teaching strategies include mock testimony and field trips to interact with legislators.
It is essential to incorporate nursing ethics in developing political competence in nursing education. Provision 3 of the ANA's Code of Ethics (2015) emphasizes advocacy: “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient” (p. 9). Provision 7 charges nurse educators with helping future nurses gain an understanding of the vital role that nurses have in the health of their patients and community through active participation in health policy (ANA, 2015). Patient advocacy extends beyond the patient's bedside, from the local to the national and global levels (Sathasivan, 2018; Sathasivan & Langston, 2018; Sathasivan & Le Vieuux, 2018; Sathasivan & Mumford, 2018). Through advocacy training, students can learn how to address social determinants of health—root causes of poor health and quality of life (Andermann, 2016). Critical to this advocacy is leadership, especially with respect to policies that influence patient care and outcomes. Although nursing curricula have historically emphasized leadership development, they have not focused on leadership in relation to political competence (Benton et al., 2017). With leadership skills obtained through advocacy training, nurses become better equipped to foster trusted relationships with community partners who have common health improvement goals for society (Butts & Rich, 2016).
Description of Public Health Policy Simulation
In the fall of 2013, faculty in public health nursing at the University of Texas at Austin collaborated with Texas Parent to Parent ( https://www.txp2p.org/), an advocacy organization for families of children with disabilities or chronic illnesses, in order to develop a public health policy simulation for students in the university's undergraduate and accelerated graduate nursing programs. Through this partnership, Texas Parent to Parent incorporated our nursing students in their advocacy training, which began in the spring of 2014. Since then, Texas Parent to Parent has continued to conduct advocacy training each semester for our public health nursing students.
The students' program involves a combination of classroom preparation provided by the nursing faculty in both the didactic and practicum sections of public health nursing, as well as Texas Parent to Parent's advocacy training, which consists of a simulation in which students give testimony at the State Capitol. Faculty in the didactic and practicum classes collaborate in preparing students for the simulation. In the didactic section, students receive an interactive lecture about policy, the policy-making process, and legislative testimony (oral and/or written). In the lecture, we present the concepts of evidence-based public health policy (Brownson, Baker, Deshpande, & Gillespie, 2017; Brownson, Chriqui, & Stamatakis, 2009; Marks, 2009) and health in all policies (Rudolph, Caplan, Ben-Moshe, & Dillon, 2013), so that students can understand the importance of advocacy based on evidence and also consider how policies outside the health care system have health implications that should be discussed during the policy-making cycle. We also introduce policy development and enforcement as a public health nursing intervention (Keller, Strohschein, Lia-Hoagberg, & Schaffer, 2004) and discuss how nurses can play a crucial role in influencing policy agendas. The lecture closes with an overview of the purpose and process of public testimony, including tips for effective presentation. Some examples of tips include use good eye contact and minimal reading from notes, know your audience, practice beforehand, respect decorum, and dress appropriately (Berndt, 2017).
Rather than providing students with detailed policy simulation scenarios and preselected bills, we require students to search for current and recent bills through the Texas legislature website and then select a bill of interest to them that relates to health or social determinants of health. In addition to looking at bills through the website, we encourage students to investigate other public health issues that may be future bills. This ensures that students are engaged in the topic and also provides them with an opportunity to become familiar with how to search for a bill. Examples of bill topics include mental health screenings in schools, increased independence for advanced practice RNs, and increased access to health care to reduce maternal mortality rates. After students have selected a bill or public health issue, they research the current data supporting their proposed plan of action in their testimony. The students are given written examples of oral testimonies that supplement the lecture's content. Students are required to identify their individual state senators and representatives and to present their 3-minute oral testimonies to faculty and peers. Some faculty require students to submit a video of testimony for peer and faculty feedback. These strategies facilitate subsequent revision of their testimony prior to the mock hearing at the State Capitol. Students are encouraged not only to provide statistics in their testimonies but also to incorporate personal experiences or anecdotes, because legislative staff have indicated that real-life stories can be persuasive (Haskins, 2018).
On the day of the mock hearing for public testimonies, students and faculty visit legislative offices where the students discuss their public health issues. Following the visits, students and faculty convene for the mock committee hearing, which is attended primarily by legislative staff, who hear the students' oral testimonies. Due to time constraints, students are randomly selected to present their testimony. After that, staff members provide constructive feedback. Staff also offer the opportunity for students to follow up with their legislators on their topics of interest.
After feedback from the legislative staff, faculty debrief with their students either immediately following the simulation or during the next scheduled practicum conference. The faculty use a structured debriefing technique that allows students to reflect on their experience. They ask open-ended questions about how the simulation impacted the students' cognitive, psychosocial, and affective domains (Coutinho, Martins, & Pereira, 2016). Examples of questions include:
- How do you think the simulation went?
- How did it make you feel?
- How will this experience impact the way you practice as a nurse?
Some faculty have students submit a written reflective journal of their experience.
Following the oral testimony simulation conducted during the spring 2018 semester, we surveyed the students for written feedback about their experiences. To assess their political competence (knowledge, ability, and confidence), we asked questions about the legislative process, advocacy for public health issues, communication with legislators, the role of nurses in public health policy, and the development and delivery of oral testimonies. In addition, the students were asked about the likelihood of their advocating for public health issues in the future. The majority reported that the oral testimony simulation was a positive experience, and it improved their political competence.
The students surveyed were from the undergraduate (n = 21) and accelerated graduate (n = 26) programs. Prior to the oral testimony simulation, the vast majority of students (87%) had little to no advocacy experience. Following the simulation, the surveys showed that 70% reported they were more knowledgeable about the legislative process; 91% were more knowledgeable about how to advocate for public health issues; 85% were more knowledgeable about how to communicate with legislators; 98% understood the purpose of advocating for public health issues; 91% understood the role of nurses in public health policy; 81% felt they were able to develop an oral testimony about a public health issue; 53% felt confident in their ability to speak to legislative leaders; 55% felt confident in their ability to give oral testimony to a hearing committee; and 66% were more likely to advocate for public health issues in the future.
The students also provided qualitative reflections on their biggest surprises about the simulation, what they liked about it, and what could be improved. The biggest surprises included how engaged and supportive the legislative staff were, how the activity was not as intimidating as they had expected, and how they enjoyed giving the testimony. Students' written feedback included the following quotes:
- The staffers that we spoke to were much more interested (or at least appeared to be) in what we had to say than I was expecting. They asked thoughtful questions that gave the impression they were engaged in what we were talking to them about. I appreciated it.
- Our legislatures [legislators] appear to be willing to hear from their citizens and value our opinions. I actually felt like I had a voice, so I was surprised at how accessible our state government is to the public.
- It was less intimidating than I thought it would be. It's like a shot—SO scary until it happens and then no big deal.
- How much I enjoyed researching and presenting on a topic I'm interested in. I thought I'd be much more nervous than I was.
Generally, the students' experiences were positive. The most frequent positive comments regarded preparation, advocacy, and direct application of the legislative process. The students also provided feedback on improvements to be made. The most frequent negative comments were related to providing more detailed information about expectations and the schedule of activities for the students' day at the State Capitol, the selection of students to present at the mock hearing, the provision of more time in the simulation schedule so that all students could present at the mock hearing, and the relevance of the simulation to the nursing curriculum. Examples of feedback included the following:
- I liked how it prepared me to speak about the topic. Rather than simply state an opinion, I actually had research to back my position. Additionally, I had to contemplate an issue that was important to me and articulate my concern. I feel that this activity not only gave me a procedural template to follow, it gave me confidence that I can give oral testimony moving forward. Outstanding!
- I wish that everyone got the chance to present. I felt that the conclusion [of] all my hard work and research was anti-climactic and I really resented that I didn't get to speak to the staffers about an issue that was important to me [during the mock hearing].
Impact on Nursing Practice
Learning through oral testimony has implications beyond a mere course assignment. This learning activity engages students in the core public health function of policy development and related essential health services, and it helps develop public health nursing competencies related to health policy (Quad Council Coalition [QCC], 2018). By preparing to speak on an issue at the State Capitol, students gain experience in identifying state policy issues relevant to the health of individuals, families, and groups (QCC, 2018, Competency 2A1). Meeting with representative or senator staff allows students to “provide information that will inform policy decisions” (QCC, 2018, Competency 2A4a, p. 16), which is part of informing and educating people about health issues. The activity also provides data for nursing education program accreditation.
Our school is accredited by the American Association of Colleges of Nursing (AACN), which requires that the baccalaureate curriculum incorporate the professional nursing standards and guidelines published by the Commission on Collegiate Nursing Education (2013). Our oral testimony simulation is directly related to baccalaureate nursing Essential V: Healthcare Policy, Finance, and Regulatory environments (AACN, 2008). Through this experience, students actively engage in examining legislative processes relevant to health and participate in a political process to influence health care policy.
Following our public health policy simulation, which included didactic preparation and hands-on advocacy practice, most students expressed being more knowledgeable about the legislative process, how to advocate for public health issues, and how to communicate with legislators. They had a greater understanding of the purpose of advocacy and the role of nurses in the public health policy arena. Students also felt confident in their ability to speak to legislative leaders, give an oral testimony to a hearing committee, and be more likely to advocate for public health issues in the future.
Future replications of the simulation may need to consider the logistics surrounding scheduling, tailoring the simulation according to resources, and addressing students' feedback. With respect to scheduling, faculty may need to adjust the simulation's schedule to offer more students the opportunity to present in front of a mock hearing committee. Some students felt that they had put in much time and effort but then were disappointed when they were not able to present their oral testimony in front of the mock hearing committee. However, as part of the simulation, all students were required to give their oral testimony in front of their peers and faculty during their clinical or lecture class. Additionally, faculty in nursing programs that are not located near a state capital may need to consider other outlets for students to deliver mock testimony such as city council. Finally, some faculty may want to consider providing their students with clear simulation scenarios. In our case, we have found that students appreciate the opportunity to select their own bill. Additionally, we prefer not to constrain the process with a predetermined simulation plan that contains possible responses and interactions that could occur during the testimony because we have access to legislative staffers who are well versed in responding to constituents. By allowing these interactions to emerge organically, we believe the students receive a more realistic experience.
On the basis of the resources available to them, faculty may expect to implement multiple iterations of the simulation in order to tailor it to their perspective programs. For example, early in our process of collaborating between didactic and practicum sections for our traditional baccalaureate nursing students, we tried giving students feedback on their practice testimony during the didactic class. This proved to be unmanageable due to the large class size, which was approximately 60 students. Consequently, we moved the practice testimony into the practicum sections, which have a smaller class size of 10 to 20 students. Then, faculty were able to provide adequate feedback.
Because faculty are tailoring the simulation, they may be incorporating students' feedback regarding their experience. For example, students said that they would prefer more detailed information about what to expect on their day at the State Capitol. For future simulations, we plan to provide explicit information through the electronic course management system. Faculty implementing this simulation should continue to highlight public health advocacy as a vital nursing role beyond the hospital and clinical setting. Furthermore, introducing public health policy early and threading it throughout the nursing curriculum can help create a culture dictating that public health policy is integral to nursing.
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