Advanced Nurses and Advocacy in Clinical and Community Settings – Pregnant BlackWomen in Orange County, North Carolina

A. The Difference in How an APN Advocates for an At-Risk Population in the
Community Versus an Individual Patient in the Clinical Setting Practice
Advocacy in nursing is an integral process grounded on the need to support communities,
patients, and their families to promote self-knowledge and “own” well-being. Ideally, advocacy
means supporting, championing, or recommending a specific policy or cause to build and
improve the target individual(s) skillsets, knowledge, and self-awareness about a specific health
issue and their proficiency in making informed decisions concerning their “own” health and
well-being. The target population can be patients at the bedside or at-risk populations at the
community level. The difference in the two settings also means that advanced professional
nurses must use different approaches when dealing with patients in clinical settings and at-risk
populations (often healthy individuals) in the community. The following are two major
differences between advocacy at the bedside and community settings.
The first difference is that an APN advocating for at-risk populations at the community
level works with the general public and other stakeholders in the community (schools and other
social institutions, community leaders, government agencies, not-for-profit organizations) to
identify social determinants of health (SDOH) and propose potential solutions for the general
population, especially at-risk individuals. The focus is on the social determinants of health
(access to healthcare, social support networks, employment, physical environment and
neighborhood, education, socioeconomic status), including how they affect the population’s
health. For example, an advanced practice nurse advocating for the maternal health of African
American pregnant women and young mothers would attempt to explore the issue from the

3
socioeconomic (poverty and household income) and healthcare (access to resources) lenses. A
nurse advocate attempting to champion equity in access might initiate a policy at the federal
level requiring Congress to provide more health subsidies to pregnant Black women, especially
those earning income below a certain federal poverty level.
However, at the bedside, the advanced professional nurse collaborates with patients, their
families, the management (hospital leaders and Boards of Directors), and practitioners from other
professionals (physicians, pharmacists, radiologists, and laboratory technicians) to champion
patient and clinician welfare and health. Advocacy falls within the clinical realm and includes
diagnosis, treatment, and prevention of diseases instead of advocating for preventing public
health policy policies. Nurse and patient education, creating standards and guidelines to improve
diagnosis and treatment, implementing ethical standards to reduce therapy distribution and
resource allocation, and organizational policies are often the focus of APN advocates. Taking the
example above, an advanced nurse professional trying to advocate for pregnant Black women in
maternity units might push for policies that reduce discrimination in resource access. The
proposed policy might prohibit clinicians from discriminating against Black women when
triaging pregnant mothers to cesarean surgical facilities.
The second difference is in the advocacy methods employed in the community and
bedside settings. Since the primary focus of community advocacy is on public health policies,
programs, and initiatives that benefit the entire community, more than often, advanced nurse
professionals leverage “grassroots” advocacy to encourage community members to acknowledge
their “own” issues and advocate for themselves by initiating policy changes at the local, state, or
federal levels. Grassroots advocacy focuses on mobilizing, organizing, and bringing the
community members, including at-risk populations, to advocate for themselves. The focus of

4
nurse advocates is to educate and inspire the public to contact their elected leaders to make
critical policy changes that affect their well-being and health (Loue, 2006). Advocacy at the
bedside does not require grassroots campaigns. Healthcare professionals are often largely
involved in advocating for the health and well-being of their patients by encouraging the
leadership to implement nursing professional standards and ethical principles to improve the
quality of care and patient safety.
B. How the Advanced Professional Nurse will Apply Two Evidence-Based Strategies to
Promote Interprofessional Collaboration Within an Advocacy Action Team (AAT)
i. Evidence-Based Strategies to Improve Interprofessional Collaboration
Advocacy Action Teams (AATs) are interdisciplinary groups comprising experts from
different professions and departments, human resources, accounting, nursing, medicine,
radiology, marketing, project management, and health information technology of informatics.
Since AATs bring together people from different philosophical, educational, cultural, religious,
and socioeconomic backgrounds, advanced professional nurses must always create ways to
improve communication and collaboration, ensuring that the group pulls together as a team
towards achieving shared goals. There is no better way to do this than implement evidence-based
approaches because of their perceived use of scientific evidence. Evidence-based approaches are
based on empirical evidence and have consistently improved the intended outcome (Li, Cao, &
Zhu, 2019).
An advanced professional nurse can roll out one strategy to improve interprofessional
collaboration with an AAT is a health information technology (health IT). Health IT refers to
health technology applied in healthcare organizations to support health information management
across computerized frameworks and systems. Evidence has shownthe ability of health IT

5
tofacilitate an open and secure sharing or exchange of health information (for example, patient
data like treatment history, labs, and demographic information) between providers (nurses,
pharmacists, physicians, lab technologists, and radiologists), quality monitors, payers, and
consumers (patients). Examples of health information technologies include telehealth,
ePrescribing systems, electronic medical records (EMRs) or electronic health records (EHRs),
computerized provider order entry (CPOE), wearable technology, and clinical decision support
systems. A plethora of studies have shown how leveraging the power of these technologies can
improve interprofessional communication and collaboration. This can enhancethe quality of care,
patient safety, and overall clinical and patient experiences (Alotaibi & Federico, 2017).
Building and enforcing a culture of open communication, transparency, and
accountability has also been shown by evidence to improve interprofessional collaboration and
participation (Bridges et al., 2011). Organizational culture refers to the practices, expectations,
values, customs, traditions, and behaviors that inform and guide actions within a group or
institution. A culture of transparency and accountability means that all messages within a team
are communicated openly, and all members are held accountable for their actions. The benefit of
embracing and enforcing this culture is its ability to build trust and strong bonds between
members. This can spur collaboration and member participation (Zajac et al., 2021).
ii. How to Apply the Two Evidence-Bases Strategies
After identifying the two evidence-based strategies discussed above (health IT and the
culture of transparency & accountability), advanced professional nurses can use the six-step EBP
process to identify and apply evidence to improve interprofessional collaboration with a
specified Advocacy Action Team. The six steps includeasking, searching, appraising,
integrating, evaluating, and publishing.

6
The advanced professional nurse develops an EBP research question in step one,
preferably PICOT-based. In this case, PICOT stands for population/patient, intervention,
comparison, outcome, and time(Akobeng, 2005). The PICOT question is intended to create more
structured, simpler, timebound, and answerable questions that research should address. For
example, the PICOT question for the first intervention might read: “can electronic health records,
compared to traditional methods alone, improve quality of care and patient safety within six
months?”
After formulating the research question and suggesting a few search strategies and
keywords, it is time for the nurse professional moves forward to collect the evidence to answer it.
There are multiple sources that a nurse can collect evidence from to answer the question,
including hospital and government databases for population-wide statistical data, reliable journal
databases like PubMed and CINAHL, books, and other non-scholarly sources like news articles
and anecdotal information. A nurse professional can use the following steps to conduct a
resource search: (1) generating relevant keywords, (2) choosing a bibliographic database, (3) and
running the search using Boolean terms like “OR” and “AND.”
The third step involves appraising the collected evidence. After retrieving articles and
other sources, the nurse professional evaluates their relevance, validity, applicability, and
usefulness to the research, writing, topic, course, or field. In this phase, the nurse ascertains that
the collected evidence supports and can answer the research question. A hierarchy of evidence
can assist the nurse professional in evaluating and ranking sources into levels(Akobeng, 2005).
In the fourth step, the nursing professional applies and integrates the evidence collected
with stakeholder wants/needsand experiences. Since the nurse had to generalize the population
(pregnant Black Women) to obtain relevant research articles in steps one and two, step four can

7
present a perfect opportunity to delve into the specific population and evaluate exactly how the
evidence-practice search can benefit it. Step four is also the phase the nurse professional works
to implement the suggested intervention/solution, primarily based on the research evidence
gathered (Akobeng, 2005).
After implementing the proposed strategy or intervention, the next step for the advanced
nurse professional is to evaluate its impact; how can it improve interprofessional collaboration.
For example, for an Advocacy Action Team working to improve literacy levels of Black
pregnant women, and the target is to enhance interprofessional collaboration among team
members drawn from the various professions using health IT like electronic health records
(EHRs), the evaluation will focus on how the technology has improved interprofessional
collaboration. Alternatively, an advanced professional nurse can measure population outcomes,
including literacy levels, to gauge whether the technology was effective.
Documenting and publishing the process and outcomes are the last steps of an EBP
process. This is the step the advanced nurse professional uses to share their research outcomes
with the hospital’s leadership (CEO, CNO, and the Board of Directors), potential sponsors,
fellow clinicians, and other stakeholders with a vested interest.
C. Analysis of the Data Validating the Issue Affecting an At-Risk Population
This CPE project examines inequity and discrimination against pregnant Black women in
Orange County, Chapel Hill, North Carolina. The discrimination is examined based on access to
quality and safe maternal resources in the county and state andon health outcomes, especially
low birth weight (baby born with a weight below 2,500 g or 5pounds, 8 ounces). For the
shortterm, the project targets to lower low birth weights among pregnant Black women in
Orange County through policy. For the long term, the target is to improve health literacy among

8
Black women through advocacy and building concern and interest in maternal health and well-
being, especially among young pregnant Black women.
Low birthweight is one of the major maternal health issues associated with an elevated
risk of infant mortality and multiple other long-term and short-term complications. North
Carolina is one of the low-income states with the highest low infant birthweights. In 2019, North
Carolina had an average low birth weight of 9.3, significantly higher than the national average
(8.3%) (America’s Health Rankings, 2019). Despite high levels of low birthweight in North
Carolina, evidence also shows how pregnant Black women are disproportionately affected across
counties, including Orange County. In 2017, the low birthweight among African American
women was 8.5%, compared to 5.2% among White women and 5.8% among Hispanic women
(Orange County’s Healthier Together, n.d.). This trend is also reflected at the national level
(Black women 11.6%; White women 5.9%; Hispanic Women 6.5%).
D. Characteristics of the At-Risk Population

Sex (female) is the first characteristic of the at-risk population. Sex is the physiological or
biological characteristic that defines humans as male or female. Different biological,
physiological, and physical features distinguish women, including breasts, menstrual cycle, and
childbearing ability. The second characteristic is race or skin color. This paper focuses on
African American women. The third and most important feature is pregnancy, a period or
condition of being pregnant, from fertilization to childbirth. However, this research will consider
both prepartum and postpartum periods. Age is another characteristic of the at-risk population.
Evidence suggests that young pregnant Black girls are at the greatest risk of low birth weight.
E. Social Determinants of Health Predisposing the At-Risk Population to the Health

Issue

9
Low literacy level, especially among pregnant Black women, is one of the major risk
factors or SDOH associated with low birthweight. Evidence suggests that prenatal education
positively influences a healthy lifestyle during pregnancy, assisting pregnant mothers to cope
with stress, avoid harmful chemicals/situations, identify warning symptoms/signs, support a
healthy diet, make early and appropriate preparations for labor and delivery, and transition
smoothly to postpartum care (Herval et al., 2019). Disinterest among Black women and a lack of
access to educational materials are factors associated with low literacy levels in the at-risk
population. High teenage or underage pregnancies can also be blamed for the low literacy levels
and low birthweights among Black women.
F. How the Current Policy is Insufficient in Addressing the SDOH Identified in Part E
Currently, no comprehensive programs, initiatives, or policies specifically aim to
improve health literacy of pregnant mothers and women, especially of African American descent
and other minority groups, in North Carolina, including Orange County. Also, there are no
specific state or local laws or programs targeting inequality in accessingprenatal and postnatal
resources. There are no comprehensive community-wide or statewide campaigns, initiatives, or
programs presently focused on improving maternal health literacy levels on a broader scale.
Pregnant mothers only depend on their primary care providers for guidance and counseling. This
often occurs when pregnant mothers visit maternal centers and clinics, usually during pregnancy.
The disadvantage of this approach is that poor pregnant women, especially young Black mothers
from impoverished families, might not be able to access maternal guidance and counseling
during their pregnancy due to a lack of funds.

G. Policy Proposal

10
I propose that North Carolina establish a statewide maternal program that focuses on
providing training, counseling, and clinical services to mothers, especially from low-income
neighborhoods, including African American women. The new program should have a maternal
clinic whereby pregnant mothers or women, in general, can visit to seek advice. The program
should also include an eHealth (telemedicine) program that allows women to videoconference
experts remotely at no cost or a subsidized price. A one-stop online website or database should
also be part of the program. The website should contain all materials (brochures, books, posters,
infographics, journals) about maternal health, providing women with information and data on all
areas of maternal care, prenatal and postnatal. A call center should also be incorporated into the
website, allowing users to dial or text for guidance.

1. How the Policy Proposal Could Impact the Health Issue
   A statewide maternal program will reduce low birthweights and other negative outcomes,
   including child mortalities, in Orange County and North Carolina. Providing clinical services to
   all pregnant women, irrespective of their socioeconomic power can positively improve maternal
   and child health outcomes. The proposed policy proposal will improve health access to quality
   and safe maternal resources in multiple ways, especially among traditionally disenfranchised
   women of African American descent and other minority communities. Firstly, a subsidized
   maternal clinic would ensure that pregnant women from low-income families gain access to
   cheaper and free maternal care services during pregnancy, childbirth, and postpartum. These
   services are currently elusive and responsible for the healthcare disparities between white women
   and mothers from minority communities in Orange County and North Carolina, ranging from
   prenatal/antenatal care to postnatal care. Prenatal care services include regular medical checkups
   that involve recommendations on maintaining a healthy lifestyle and access to information like

11
maternal physiological changes during pregnancy, prenatal nutrition (vitamins), and biological
changes. Antenatal care also includes services like prenatal diagnosis and screening.
The proposed maternal clinic will also provide pregnant women from low-income
families with low-cost or free delivery services during childbirth. These services include epidural
injections, counseling, postnatal services, and checks to ensure the mother and her baby are safe,
eat well, and respond appropriately. The proposed online portal, telehealth platform, and other
web-based services will make it easier for mothers to access prenatal and postnatal services,
especially counseling. These new services and resources will ensure that low-income and
impoverished pregnant mothers from minority communities gain access to quality and safe
services during and after birth.

2. How the Policy Will Address Diversity in the Population to Ensure Equitable
   Resource Distribution
   Implementing a state-funded and open-to-all program ensures that all women in North
   Carolina have access to equal resources and knowledge base. This will guarantee impartiality in
   access to maternal educational/clinical resources and health outcomes. The policy proposal will
   address diversity and ensure equitable distribution of maternal resources in multiple ways.
   Firstly, by providing low-cost and free services, the new maternal clinic and web-based service
   center will ensure disenfranchised pregnant women from low-income households, including
   African American and Latino communities, gain access to high quality and safe antenatal,
   delivery, and postnatal care resources, including counseling services, just like white women from
   high-income households. Secondly, the new resources and services will lower health disparity
   gaps among pregnant women in Orange County and North Carolina, including low birth weights.
3. How the Policy Upholds Two Provisions from the ANA Code of Ethics

12
The ANA Code of Ethics stipulates the moral obligations, values, and goals for nursing
professionals, including restoring, promoting, protecting, preventing illness, and alleviating
pain/suffering in patients, families, and communications. The code advocates for seven ethical
principles:integrity, fidelity, autonomy, accountability, justice, nonmaleficence, and beneficence.
Creating a statewide program that serves all women, regardless of their demographic differences
like race, age, socioeconomic status, religious background, and sexual orientation, upholds codes
four and nine. Code four requires that nurses practice with responsibility, accountability, and
authority for the nursing practice. They should also make decisions consistent with their
requirement to promote health and offer optimal care. Code nine requires nurses and the nursing
profession to maintain the integrity by integrating social justice principles into health policy and
nursing (Faubion, n.d.).

4. Potential Barriers in the State That Might Impede Implementation of the Policy
   Proposal
   Lack of funds and the human resource (experts) might hamper the ability of the state to
   move the policy paper from paper to practice. The state is operating on a tight budget, and rolling
   a free statewide program can be a huge challenge, considering the scale and scope of the project.
   H. Name and Title of the Policymaker with the Authority to Move the Policy Proposal

Forward and Rationale for the Selection

Valerie Foushee is the policymaker that can best push the policy proposal forward. As a
woman and representative for the 23 rd district (Chatham and Orange counties), Valerie
understands the maternal issues affecting women in Orange County and North Carolina. As an
African American woman, she also understands the inequities African Women face in a
historically prejudiced society against people of color.

13
I. Two Strategies I Will Use to Strengthen My Professional Practice as a Policy

Advocate

As an advanced professional nurse, learning about the policy process is one strategy I
might use to foster my professional practice and role as a policy advocate. The second strategy is
learning how to communicate effectively with the right people in authority to ensure my policy
proposals are communicated clearly and, thus, considered for debate in Congress.

14

References

Akobeng, A. K. (2005). Principles of evidence-based medicine. Archives of Disease in
Childhood, 90(8), 837-840. doi: 10.1136/adc.2005.071761
Alotaibi, Y. K., & Federico, F. (2019). The impact of health information technology on patient
safety. Saudi Medical Journal, 38(12), 1173-1180. doi: 10.15537/smj.2017.12.20631
America’s Health Rankings. (2019). Low birthweight in North Carolina.
https://www.americashealthrankings.org/explore/annual/measure/birthweight/state/NC
Bridges, D. R., Davidson, R. A., Odegard, P. S., Maki, I. V., &Tomkowiak, J. (2011).
Interprofessional collaboration: Three best practice models of interprofessional
education. Medical Education Online, 16(1). doi: 10.3402/meo.v16i0.6035
Faubion, D. (n.d.). The 9 nursing Code of Ethics (provisions + interpretive statements) – every
nurse must adhere to.https://www.nursingprocess.org/nursing-code-of-ethics-and-
interpretive-statements.html
Herval, A. M., Oliveira, D. P. D., Gomes, V. E., & Vargas, A. M. (2019). Health education
strategies targeting maternal and child health: A scoping review of educational
methodologies. Medicine (Baltimore), 98(26), e16174. doi:
10.1097/MD.0000000000016174
Li, S., Cao, M., & Zhu, X. (2019). Evidence-based practice. Medicine (Baltimore), 98(39),
e17209. doi: 10.1097/MD.0000000000017209
Loue, S. (2006). Community health advocacy. Journal of Epidemiology & Community Health
,60(6), 458-463. doi: 10.1136/jech.2004.023044

15
Orange County’s Healthier Together. (n.d.). Babies with low birth weight: Orange County.
https://www.ochealthiertogether.org/indicators/index/view?indicatorId=8893&localeId=267&co
mparisonId=7127
Zajac, S., Woods, A., Tannenbaum, S., Salas, E., Holladay, C. L. (2021). Overcoming challenges
to teamwork in healthcare: A team effectiveness framework and evidence-based
guidance. Frontiers in communication, 6. https://doi.org/10.3389/fcomm.2021.606445.