Most nurses entering the profession probably don’t envision themselves having a seat at the table at health policy meetings with the president and first lady of the United States. Neither did Patricia Montoya, BSN, RN, MPA, whose nursing career led her to being appointed in 1994 by former President Bill Clinton to serve as a regional director for the U.S. Department of Health and Human Services (HHS).
"It was one of the toughest things I’ve ever done in my career," Montoya recalls. "It was indescribable. Hillary Clinton was someone who always had [health care for] children as a high priority."
What was it like working with Mrs. Clinton? "She was just like a regular person," says Montoya, "although I always felt awestruck and sometimes had to pinch myself that [it was really me going to these top-level federal meetings] to talk about issues or discuss any rollouts we were going to be doing on some of the initiatives. I just had the highest level of respect working with the first lady and president. It was an opportunity of a lifetime that I will always value and treasure."
During her appointment Montoya worked under Donna Shalala, the secretary of Health and Human Services under President Clinton. As a regional director, Montoya oversaw HHS activities in five states: New Mexico, Oklahoma, Louisiana, Texas and Arkansas.
"I helped coordinate activities among federal offices such as the Health Resources and Services Administration, the Administration for Children and Families, the Office of Aging and the Centers for Medicare and Medicaid Services. Essentially, I was Secretary Shalala’s representative [in that region]. I was also a liaison between [HHS] and the business community and elected officials in those states."
Whether they involve working for a federal agency such as the Centers for Disease Control and Prevention (CDC), a state health department, the legislative affairs department of a health care association or even running for political office, careers in health policy provide nurses of color with a unique opportunity to make a real impact in developing policies and programs that will improve the health of minority and disadvantaged populations.
According to the University of California, San Francisco (UCSF) School of Nursing, which offers graduate degree programs with a focus on health policy, "nurses with policy expertise are employed by health services research firms, hold elected or appointed office, or work in legislative and regulatory offices at the county, state and federal levels. Others work in the legislative or policy offices of HMOs, advocacy organizations or health care provider associations, and in policy and program planning at international government health organizations."
Careers in health policy can take nurses down many different paths—sometimes quite unexpectedly. Montoya, for example, was working as a school nurse in the 1980s when she was bitten by the policy bug.
"I realized that the decisions that were being made by the city council, school board, county commission, state legislature or Congress were directly impacting [health] programs I had developed for my young students and their families," she says. "I started getting involved, not only through the American Nurses Association (ANA), but also by getting involved in party politics. I worked at the community level with people who were running for office and people who got elected, educating them on health issues." She also earned a master’s degree in public administration.
Montoya’s combination of local community involvement, MPA degree and health policy work for the ANA earned her the national visibility which led to the opportunity for her appointment with the Clinton administration. Today she serves as the director of government relations and new business for the New Mexico Medical Review Association, a not-for-profit health care quality improvement organization.
Another nurse whose health policy career began at the community level is Lupita Salazar Letscher, BSN, RN, MN. The Oregon nurse says her interest in the field developed out of her experience working to increase access to quality health care for minorities by establishing community health centers.
"Policy began to present itself [as a career option] while I was working in planning and development and learning the process of opening a clinic in urban Portland to increase access to care," Letscher explains. "I fell in love with that work, and as a nurse I saw the benefit of serving as a patient advocate. I was already an advocate for my patients and their families [earlier in my career, when I was working in an ICU]. So extending that commitment to the wider community was natural."
In 2007, Letscher was selected to participate in the prestigious Robert Wood Johnson Health Policy Fellowships Program, which gives health care professionals from a variety of disciplines the opportunity to gain first-hand experience in health policy processes at the federal level. Sponsored by the Institute of Medicine, each year the non-partisan program sends a group of Fellows to Washington, D.C. for a one-year working experience in influential Congressional offices on Capitol Hill. Fellows are able to continue their health policy activities for up to two years after their Washington placement period.
"As Fellows, we went through a health policy boot camp [orientation] to become familiar with the ‘health care Olympians’—the experts, think tanks and key organizations," says Letscher, who is currently working in the office of Sen. John D. Rockefeller (D-W.Va.). "I’m enjoying being in Washington with my eight-year-old daughter. Most people who receive this fellowship are further along in their careers than I am." She notes that she is one of the youngest Fellows to participate in the program—a major accomplishment in her career.
Health policy wasn’t a planned career choice for either Montoya or Letscher. But today, a growing number of nursing school graduate programs are recognizing the need to formally prepare nurses to work in the policy arena.
Some programs are specifically targeted to minority nurses, such as the University of New Mexico (UNM) College of Nursing’s PhD Concentration in Health Policy program. Funded by a five-year, $4.8 million grant from the Robert Wood Johnson Foundation (RWJF), this program’s goal is to prepare Hispanic and Native American nurses to become leaders in minority health policy. Post-master’s students selected for the three-year program receive support in the form of tuition, living expenses and resources for computers, books and travel.
The program was launched in late 2007 within UNM’s existing PhD nursing program and complements the mission of the RWJF’s national Center for Health Policy, established at UNM in 2006. This interdisciplinary center has its own leadership and staffing as well as its own physical location on UNM’s main campus in Albuquerque. The PhD in Health Policy curriculum focuses on research, seminars, courses and interdisciplinary collaboration between the Center for Health Policy and the College of Nursing faculty and students.
"Our goal is to increase the number of nurses of color who have the knowledge and expertise to participate in health policy decisions at the state and national level," says the grant’s principal investigator, Marie Lobo, PhD, RN, FAAN, professor and graduate program director at the College of Nursing. "There is a [great need for more] nurses of color who are involved in health policy. [The purpose of our program] is to educate [minority] nurses who can represent their own communities and speak from their own experiences at the health policy table."
The UCSF School of Nursing, which serves an ethnically and culturally diverse student population, offers both MSN and PhD degree programs with a specialty in health policy, as well as a master’s entry (MEPN) option for students who have completed a baccalaurete degree in a non-nursing field.
"We really felt that there was a need for more nurses to be in policy positions," says Ruth Malone, PhD, RN, FAAN, co-director of the nursing school’s health policy graduate program. "Nurses have always been in policy positions, but typically they had to sort of learn by the seat of their pants and didn’t have any sort of formal training to help prepare them for those roles. So we felt that it would be helpful to have a program that really geared nurses toward this kind of role."
Malone cites an example that illustrates why it’s so important for nurses to be in health policy positions. "Our programs have summer internships that [place students] in a policy setting, such as in Washington, D.C., or Sacramento [California’s state capital]. One student who was interning in a legislative office was working with a legislative aide who was handling a health-related bill. The student was given a draft of the bill and was asked to review it. Our student realized that whoever had drafted this bill didn’t really appreciate the difference between a licensed practical nurse and a nurse practitioner—and obviously that’s a pretty significant difference. We think the kinds of hands-on, street-level experience that nurses with clinical practice experience can bring to a policy setting can make for better policymaking."
Jennie Solis, RN, MS, is a 2007 graduate of the UCSF School of Nursing’s health policy master’s program. After 10 years working as a bedside nurse, she was looking for new opportunities to further her career.
"I’ve always been interested in processes and looking at problems," says Solis. "Having worked in various [parts of the country], like New York and Nevada, I noticed that there were different diversity levels and differences in how nurses were treated. I had questions about nurse migration and how [foreign-educated immigrant nurses] adapted into the U.S. work environment. The health policy program fit my needs in terms of answering those questions and identifying problems."
Solis hopes to work abroad and says that her degree in health policy will help open doors for nonclinical work. "I hope to continue doing policy work having some input into nurse migration issues. But after completing the program, I also became interested in issues relating to quality improvement, such as improving the quality of health care provided to patients and the quality of training for nurses in general and quality work environments. I would prefer to go into the non-profit environment versus [working in a for-profit setting]."
By pursuing careers in health policy, nurses of color can bring their unique perspectives to critical issues affecting minority populations, such as racial and ethnic health disparities and health care for the uninsured.
"There are very few people of color going to the policymakers and representing positions that will positively impact [minority health outcomes]," says Lobo. "We need to improve people’s health so there are less disparities, and one of the ways that will happen is by changing policies—whether it’s changing the way health insurance is provided for children so that they’re getting preventive care, or changing how we encourage immunizations or how we fund prescription drugs for the elderly. There are a lot of different issues out there that need to be addressed."
What kind of skills and personal qualities do nurses need in order to be successful in a health policy career? Lobo believes nurses must have a passion to make things better for the communities they serve. "Having a willingness to speak to leaders is important. You must be able to speak to a senator or a secretary of health and be willing to put yourself out there and advocate for your position."
Minority nurses entering the policy arena can find career opportunities in many different settings, at the community, state, federal or even international level.
"One of our former students went to work for the CDC in Rwanda doing maternal/child HIV-prevention policy," says Malone. "Two other students were interested in clinical trials policy and technology reimbursement policies; they have both taken jobs with a private company working on those issues. They are involved in lobbying in Washington and Sacramento on technology reimbursement issues. We’ve had other students who have gotten involved in volunteer or part-time positions doing advocacy on issues that they were passionate about. A lot of our [health policy] students have gone on to the PhD program after completing the master’s program, because they get their appetites whetted and would really like to know more about research and develop those skills."
Minority nurses should also consider running for office. For example, U.S. Congresswoman Eddie Bernice Johnson, RN (D-Texas) began her career as a nurse before deciding to enter politics. She started by getting elected to the Texas state legislature, and she is currently serving her seventh term in the U.S. House of Representatives.
Letscher points out that nursing is one of America’s most trusted professions and that the public perceives nurses as having a great deal of credibility. "I would encourage all nurses to be engaged on a personal level by being an informed voter and getting involved in your local community issues, such as what your children are eating," she says. "For example, I testified on a nutrition bill here in Oregon to get rid of soda in schools. As nurses of color, we are representatives of a large and growing demographic. It’s very important for nurses to reflect the communities we take care of."
Malone sees a tremendous need for more minority nurses who can play leadership roles in shaping policy decision-making on health disparities issues, such as tobacco control. "I think we need more minority nurses working on tobacco issues, both in this country and globally," she asserts. "For example, African Americans have the worst tobacco-related health outcomes of any ethnic group [in this country]. We really need to be focusing on those populations where tobacco use is more concentrated, and that tends to be minority and poorer populations."
Malone notes that on a global level, tobacco companies are working very hard to get women of color to start smoking, especially in countries where women have not typically used tobacco products. The tobacco industry is bombarding these countries with heavy advertising and marketing that promotes smoking as a cool, Western thing to do.
"Access to care and HIV prevention are other huge [health disparity] issues," she adds. "There are so many different policy issues that could benefit from having more minority nurses at the table. Health policy is definitely an area where we can be much more powerful as nurses."