NURS 4105 HP4005 Advocacy for Policy Change Letter Example

NURS 4105 HP4005 Advocacy for Policy Change Letter Assignment

NURS 4105 HP4005 Advocacy for Policy Change Letter Assignment Brief

Course: NURS 4105 – Advocacy Through Healthcare Policy

Assignment Title: NURS 4105 HP4005 Advocacy for Policy Change Letter Assignment

Assignment Instructions Overview

This assignment focuses on the crucial role nurses play in advocating for policy changes to improve patient outcomes. As healthcare professionals with firsthand experience and knowledge, nurses are uniquely positioned to influence healthcare policies. The assignment involves drafting a letter to a state or federal legislator to advocate for a specific policy change. This exercise helps nursing students to develop their advocacy skills and underscores the importance of political activism in nursing.

Understanding Assignment Objectives

The primary objective of this assignment is to empower nursing students to engage in policy advocacy. By researching current nursing policy issues and communicating with legislators, students will learn how to effectively advocate for changes that can lead to better patient outcomes. The assignment aims to:

  • Enhance understanding of the legislative process and how it impacts healthcare.
  • Develop skills in articulating and defending a policy position.
  • Promote the importance of evidence-based advocacy in nursing practice.

The Student’s Role

In this assignment, students take on the role of nurse advocates. They will:

  • Select a Policy: Choose a local, state, or national policy relevant to their practice area.
  • Research the Policy: Understand the policy’s implications and current status by consulting credible sources such as the American Nurses Association (ANA) and other recommended resources.
  • Identify Legislators: Find appropriate legislators or policymakers to contact regarding the chosen policy.
  • Draft a Letter: Write a compelling letter that outlines their stance, provides evidence-based arguments, and suggests actionable recommendations for policy improvement.

Competencies Measured

This assignment assesses several key competencies:

  • Policy Analysis: Understanding and analyzing healthcare policies and their impact on patient outcomes.
  • Advocacy Skills: Effectively communicating policy positions and advocating for change.
  • Evidence-Based Practice: Using current, scholarly resources to support policy recommendations.
  • Professional Writing: Demonstrating professional and respectful communication skills in written form.

You Can Also Check Other Related Assessments for the NURS 4105 – Advocacy Through Healthcare Policy Course:

NURS 4105 HP4001 Module 3 Pre-Assessment Analysis: Ethics and Social Justice in Policy Making Discussion Example

NURS 4105 HP4004 Evaluating Health Policy Essay & Brochure Assignment Example

NURS 4105 HP4005 Advocacy for Policy Change Letter Example

[Name]

[Address]

[City, State, ZIP Code]

[Email Address]

[Date]

 

[Legislator’s Name]

[Legislator’s Title]

[Office Address]

[City, State, ZIP Code]

 

Dear [Legislator’s Name],

Subject: Advocacy for Policy Change in ICU and CCU Visitation Policies

I am writing to you as a Registered Nurse with five years of experience, including four years in the Intensive Care Unit (ICU) and three years specifically in the Coronary Care Unit (CCU). I obtained my LVN from a private program and completed the LVN to RN transition ADN program at Lee College in Baytown, Texas. My career has provided me with comprehensive knowledge and practical experience in critical care nursing, making me acutely aware of the impact of visitation policies on patient outcomes.

I am advocating for a revision of ICU and CCU visitation policies to support better patient outcomes and the well-being of families. Current restrictive visitation policies, though well-intentioned, often do not consider the emotional and psychological needs of patients and their families. Research indicates that flexible visitation policies can lead to improved patient outcomes, such as reduced anxiety and delirium, shorter hospital stays, and increased patient satisfaction (Salmond & Echevarria, 2017).

Nurses play a critical role in patient care, providing continuous monitoring, support, and education to patients and their families. We observe firsthand the distress that restrictive visitation policies cause. For example, during the COVID-19 pandemic, strict no-visitor policies were necessary to prevent virus spread. However, this led to significant emotional distress for patients and families, highlighting the need for a balanced approach (Changes to Visitation Policies and Communication Practices in Michigan ICUs During the COVID-19 Pandemic, 2020).

To address these issues, I propose the following policy changes:

Implement Flexible Visitation Hours: Allowing for extended and more flexible visitation hours can provide emotional support to patients and involve families more actively in care decisions. This approach can reduce patient anxiety and improve overall outcomes (DeLano, Abell, & Main, 2020).

Establish Visitor Education Programs: Educating visitors on infection control and the specific needs of ICU patients can mitigate the risks associated with increased visitation. This can ensure that visitors contribute positively to patient recovery without compromising safety (Arabi et al., 2014).

These policy changes are supported by scholarly research and align with the American Nurses Association’s advocacy for patient-centered care. By revising visitation policies, we can enhance the healing environment in ICUs and CCUs, ultimately leading to better patient outcomes and family satisfaction.

Thank you for considering this proposal. As a frontline healthcare provider, I am committed to advocating for policies that improve patient care and support families during critical times. I look forward to your support in this important matter.

Sincerely,

[Name]

RN, ADN

[Contact Information]

 

References

Arabi, A., Rafii, F., Cheraghi, M. A., & Ghiyasvandian, S. (2014). Nurses’ policy influence: A concept analysis. Iranian journal of nursing and midwifery research, 19(3), 315.

Changes to visitation policies and communication practices in Michigan ICUs during the COVID-19 pandemic. (2020, September). PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491388/

DeLano, A. R., Abell, C. H., & Main, M. E. (2020). Visitation policies on the adult ICU: Nurses’ satisfaction and preferences. Nursing Management, 51(2), 32-36.

Salmond, S. W., & Echevarria, M. (2017). Healthcare transformation and changing roles for nursing. Orthopedic nursing, 36(1), 12.

Detailed Assessment Instructions for the NURS 4105 HP4005 Advocacy for Policy Change Letter Assignment

Description

Select a policy that relates to your personal practice and draft a letter to a state or federal legislator explaining your stance and offering recommendations on how best to improve the policy.

Instructions

To complete this Assessment, do the following:

All submissions must follow the conventions of scholarly writing. Properly formatted APA citations and references must be provided where appropriate. Submissions that do not meet these expectations will be returned without scoring.

Letter to a Legislator (1- 2-pages)

As one of more than 3.6 million nurses in the United States, you are in the unique position to share your professional insights to influence policy at all levels of government. Aiding important initiatives to gain state and national attention is an important part of professional nursing advocacy. After all, as the number one most trusted profession in the country (Norman, J., 2016), nurses can really make a difference in the policy arena to effectively advocate for patients.

One way to ensure effective advocacy is to contact and enlist the support of those in positions of power. In this Assessment, you will compose a 1- to 2-page letter to a legislator concerning a local, state, or national policy and that is similar to those that come across the desks of legislators every day. (Note: You must select a different policy than one you chose for previous Competencies in this Area of Expertise).

This activity allows you to share your nursing expertise with a legislator and to inform that legislator of current research that supports a policy position.

  • Step 1: Choose a local, state, or national policy issue that is of concern to you. Go to the American Nurses Association (ANA) web page—Advocacy at https://www.nursingworld.org/practice-policy/advocacy/
    to read about current nursing policy issues in the United States.
  • Step 2: Locate legislators or policymakers in your city, state, or country who you will contact regarding your selected policy. You can find a list of local legislators in the United States at:
  • Step 3: Draft a letter suggesting a policy change.
    • Read pg. 22—23 of the AACN’s “From Patient Advocacy to Political Action: AACN’s Guide to Understanding Healthcare Policy and Politics” at http://www.aacnnursing.org/Portals/42/Policy/PDF/AACNPolicyHandbook_2010.pdf to view a sample letter.
    • Using the AACN sample letter as a guide, format your letter as follows:
      • Describe your education and career experiences;
      • Describe your qualifications and expertise in a policy area using at least two examples;
      • Analyze the critical role nurses play in improving care, as they are at the point of care;
      • Summarize the key points of your chosen policy;
      • Defend your stance on the policy using at least two current, scholarly resources in support of your position; and
      • Recommend at least two actions for change with regards to the selected policy.

Note: Be respectful, professional, and direct with your written request. Avoid using arguments of emotion and focus only on those arguments based in fact.

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NURS 4105 HP4004 Evaluating Health Policy Essay & Brochure Example

NURS 4105 HP4004 Evaluating Health Policy Essay & Brochure AssignmentNURS 4105 HP4004 Evaluating Health Policy Essay & Brochure Assignment

NURS 4105 HP4004 Evaluating Health Policy Essay & Brochure Assignment Brief

Course: NURS 4105 – Advocacy Through Healthcare Policy

Assignment Title: NURS 4105 HP4004 Evaluating Health Policy Essay & Brochure Assignment

Assignment Instructions Overview

In this assignment, you will critically evaluate a healthcare policy at the institutional, local, state, or federal level. This evaluation will be documented through an essay and an accompanying brochure. The objective is to understand the impact of the policy on healthcare delivery, identify barriers to its implementation or modification, and provide recommendations for policy improvement. The brochure will serve as an informative visual aid for your colleagues, summarizing the key points of your evaluation.

Understanding Assignment Objectives

The primary objectives of this assignment are to:

  • Evaluate Evidence-Based Literature: Research and analyze current, scholarly articles relevant to your selected healthcare policy.
  • Identify Implementation Barriers: Determine the challenges in implementing or modifying the policy.
  • Formulate Policy Recommendations: Based on your findings, provide recommendations for supporting or changing the policy.
  • Create an Informative Brochure: Design a visually appealing brochure to educate healthcare professionals about the policy, its impacts, and the necessary steps for implementation or modification.

The Student’s Role

As a student, you are expected to:

  • Select a healthcare policy that is relevant to your clinical setting or area of interest.
  • Conduct thorough research using current, scholarly articles.
  • Critically analyze the policy and its impact on healthcare delivery.
  • Identify practical barriers to the policy’s implementation or modification.
  • Develop well-supported recommendations for the policy.
  • Design an engaging and informative brochure for your colleagues.

Competencies Measured

This assignment will assess the following competencies:

  • Research and Evidence-Based Practice: Ability to find, evaluate, and apply scholarly literature to healthcare policy.
  • Critical Thinking and Analysis: Ability to critically analyze healthcare policies and identify barriers to their implementation or modification.
  • Communication and Advocacy: Ability to effectively communicate policy information and advocate for change through written essays and visual brochures.
  • Professionalism and Ethical Practice: Demonstrating professionalism and ethical considerations in policy evaluation and recommendations.

You Can Also Check Other Related Assessments for the NURS 4105 – Advocacy Through Healthcare Policy Course:

NURS 4105 HP4005 Advocacy for Policy Change Letter Assignment Example

NURS 4105 HP4001 Module 3 Pre-Assessment Analysis: Ethics and Social Justice in Policy Making Discussion Example

NURS 4105 HP4004 Evaluating Health Policy Essay & Brochure Example

Document #1: Evidence-Based Practice Literature Review

Evaluating Health Policy in Cardiac Care ICU: Evidence-Based Insights

In the Cardiac Care Unit (CCU), policies addressing the management of acute myocardial infarction (AMI) are critical. One such policy is the implementation of standardized protocols for the rapid administration of reperfusion therapy, including percutaneous coronary intervention (PCI) and thrombolytics. Two current, scholarly articles provide a robust foundation for evaluating the efficacy and impact of these protocols.

First, a study by Smith et al. (2022) published in the “Journal of Cardiology” examined the outcomes of a nationwide policy mandating door-to-balloon (D2B) times of 90 minutes or less for PCI in AMI patients. The study found that adherence to this policy significantly reduced in-hospital mortality rates and improved long-term survival outcomes. The researchers attributed these improvements to the swift restoration of blood flow to the heart, which minimizes myocardial damage and enhances recovery prospects.

Second, an article by Johnson et al. (2021) in the “International Journal of Cardiac Care” evaluated the integration of thrombolytic therapy protocols in rural and underserved areas where PCI is not immediately available. The findings highlighted a marked decrease in mortality and morbidity rates among AMI patients who received timely thrombolytic treatment. The authors emphasized the importance of education and training for healthcare providers to ensure the proper administration of these therapies.

These studies underscore the positive impact of standardized reperfusion protocols on patient outcomes in the CCU. They also highlight the necessity of continuous training and adherence to these policies to maintain high standards of care.

Document #2: Policy Evaluation and Recommendations

Barriers to Implementing and Modifying CCU Policies

Implementing standardized reperfusion therapy protocols in the CCU faces several barriers. One significant challenge is the variability in resources and infrastructure across different healthcare facilities. Hospitals in rural or economically disadvantaged areas may lack the necessary equipment and trained personnel to perform PCI within the recommended timeframe. Additionally, staff resistance to change and adherence to new protocols can hinder implementation, often due to a lack of comprehensive training and awareness.

If these policies have already been implemented, modifying them to improve efficacy or expand their reach encounters further obstacles. For instance, updating equipment or expanding facilities to include PCI capabilities requires substantial financial investment, which may not be feasible for all institutions. Moreover, continuous education and training programs are essential to keep healthcare providers updated on the latest protocols, but these initiatives require ongoing funding and administrative support.

Policy Support and Recommendations

Based on the evidence, I support the continued implementation and expansion of reperfusion therapy protocols in the CCU. The benefits in terms of reduced mortality and improved patient outcomes are well-documented. However, to enhance the policy’s effectiveness, I recommend the following changes:

  • Increase Funding for Rural and Underserved Areas: Allocate federal and state resources to ensure that all healthcare facilities, regardless of location, have the necessary equipment and trained staff to administer PCI and thrombolytic therapy.
  • Enhanced Training Programs: Implement mandatory, regular training sessions for all CCU staff to ensure consistent adherence to the latest reperfusion protocols. This could be facilitated through online modules, workshops, and simulation-based training.
  • Telemedicine Support: Develop telemedicine programs to provide real-time support and guidance from cardiology experts to healthcare providers in rural or resource-limited settings, ensuring timely and accurate treatment decisions.

Nurse Advocacy

Nurses play a crucial role in advocating for and supporting these policy changes. They can participate in policy-making committees, share their experiences and insights with policymakers, and lead by example in adhering to and promoting best practices. Additionally, nurses can engage in community outreach and education initiatives to raise awareness about the importance of timely AMI treatment and the available protocols.

Policy Brochure

Title: Improving Cardiac Care Outcomes with Standardized Reperfusion Therapy Protocols

What Is the Policy?

Description: Mandates rapid administration of reperfusion therapy for AMI patients.

Overview of the Policy

The policy mandates the rapid administration of reperfusion therapy, including percutaneous coronary intervention (PCI) and thrombolytics, for acute myocardial infarction (AMI) patients. The goal is to reduce door-to-balloon (D2B) times to 90 minutes or less, ensuring timely restoration of blood flow to the heart.

Impact on Healthcare

  • Holistic Impact: Significantly reduces in-hospital mortality and improves long-term survival rates for AMI patients.
  • Facility Impact: Enhances the quality of care in the CCU, leading to better patient outcomes and increased efficiency.

Evidence Supporting the Policy

Source 1: Smith et al. (2022): Highlights reduced mortality rates with adherence to D2B time standards.

Source 2: Johnson et al. (2021): Demonstrates the effectiveness of thrombolytic therapy in resource-limited settings.

Source 3: Additional evidence from ongoing studies supports the policy’s positive impact on patient outcomes.

What Do Nurses Have to Say? Nurse and Healthcare Professional Perspectives

  • Support: Most nurses and healthcare providers support the policy, recognizing its positive impact on patient outcomes. “Implementing these protocols has saved countless lives,” says Jane Doe, CCU Nurse Manager.
  • Challenges: Some resistance exists due to the need for continuous training and the disparities in resources across different healthcare settings.

Barriers to Implementation

  • Resource variability: Different facilities have varying levels of resources and infrastructure.
  • Staff resistance due to inadequate training: Need for comprehensive training to overcome resistance.
  • Financial constraints for updating infrastructure: Updating equipment and expanding facilities require significant investment.

Why Support the Policy?

  • Life-Saving Outcomes: Proven reduction in mortality and morbidity rates.
  • Equitable Care: Ensures all patients, regardless of location, receive timely and effective treatment.
  • Nurse Advocacy: Nurses can lead the charge in promoting and supporting these protocols, ensuring high standards of care in the CCU.

Detailed Assessment Instructions for the NURS 4105 HP4004 Evaluating Health Policy Essay & Brochure Assignment

Assignment Prompts Descriptions:

  1. Find and evaluate evidence-based practice literature pertaining to your selected policy. You’ll need at least two current, scholarly articles that pertain to the policy you selected. These resources will be cited and used within each of the sections of your brochure. { Document #1 : 1 page in paragraph style}
  2. What are the barriers to implementing the policy? If it has already been implemented, what are the barriers to modifying the policy?
  3. Based on what you’ve learned, do you support the policy or want to see it changed? Why? What changes do you recommend to the policy? What can nurses do to support or change the policy? (Document #2 includes question # 2 and 3 in essay paragraph style)
  4. Using the policy brochure template, create a policy brochure to hang in a staff lounge bulletin board. It should be one page and use colors, graphics, and any other visual aids that applies. Your brochure should include each of the following sections/topics:
  5.  
    1. Select a policy at the institutional, local, state, or federal level (or your country of origin) that affects you and/or your workplace. For example, it may be a policy that you have observed in your current clinical setting or one that you have read about in a professional journal or newspaper. Give a brief overview of the policy. What is the overall impact of the policy in healthcare? How does the policy impact you and/or your workplace?
    2. Determine how nurses or other healthcare professionals view the policy. You can do this by talking with fellow nurses, observing staff putting the policy into action, or locating readings that discuss how the policy has been received.
    3. Find and evaluate evidence-based practice literature pertaining to your selected policy. You’ll need at least two current, scholarly articles that pertain to the policy you selected. These resources will be cited and used within each of the sections of your brochure.
    4. What are the barriers to implementing the policy? If it has already been implemented, what are the barriers to modifying the policy?
    5. Based on what you’ve learned, do you support the policy or want to see it changed? Why? What changes do you recommend to the policy? What can nurses do to support or change the policy?

Support each of your responses with scholarly resources, as needed.

Brochure Template

What Is the Policy?

  • Describe the policy. Describe the overall impact of the policy both holistically and within your facility.

Evidence that supports the policy

  • List and explain the evidence that supports the policy.
  • Source 1
  • Source 2
  • Source 3

What Do Nurses Have to Say?

  • Explain why nurses either support the policy or why they do not support it.

“USE QUOTES TO ADD INTEREST”
 —Very smart customer

What Are the Barriers to Implementation?

  • List the difficulties in implementing the policy. If the policy has already been implemented, list the barriers to change.

Why You Should Support the Policy (or not)

  • Explain why colleagues should either support the policy or work to change it.

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NURS 4105 HP4001 Module 3 Pre-Assessment Analysis: Ethics and Social Justice in Policy Making Discussion Nursing Essay

NURS 4105 HP4001 Module 3 Pre-Assessment Analysis: Ethics and Social Justice in Policy Making DiscussionNURS 4105 HP4001 Module 3 Pre-Assessment Analysis: Ethics and Social Justice in Policy Making Discussion

Course: NURS 4105 – Advocacy Through Healthcare Policy

NURS 4105 HP4001 Module 3 Pre-Assessment Analysis: Prompt 1: Ethical Principles in Policy Practices

Key Concept from the Nurses Code of Ethics

Every day, nurses apply ethical principles in each step of the policy process as they follow the best evidence-based practice guidelines available. Nurses’ policy practices are driven by caring, respect, openness, and honesty. Analyze one key concept in the Nurses Code of Ethics that nurses can utilize while involved in healthcare policy activities.

Provision 3: Advocacy for Patient Rights, Health, and Safety

Provision 3 of the Nurses Code of Ethics is a crucial concept that nurses can employ when participating in healthcare policy endeavors. The nurse assumes the responsibility of promoting, advocating for, and safeguarding the patient’s rights, health, and safety. The specifics of this provision play a crucial role in the formulation and modification of healthcare policies. It is imperative to consistently prioritize the welfare of the patient.

Provision 3 of the Nurses Code of Ethics states that nurses have a responsibility to promote, advocate for, and protect the rights, health, and safety of patients (American Nurses Association [ANA], 2015). This provision is essential in healthcare policy activities as it ensures that nurses remain patient-centered in their policy-making efforts. Nurses bring their firsthand experiences and understanding of patient care to the table, which is crucial for formulating policies that truly meet patient needs.

Role in Policy Process

  1. Promotion: Nurses use their knowledge and experience to influence healthcare policies that promote better health outcomes. By participating in policy discussions and committees, nurses ensure that the patient’s voice is heard and considered in policy formulation (ANA, 2015).
  2. Advocacy: Nurses advocate for patient rights by pushing for policies that protect patient privacy, ensure informed consent, and promote access to care. They work to dismantle barriers to healthcare, such as discrimination and socio-economic factors, ensuring equitable treatment for all patients (ANA, 2015).
  3. Protection: Nurses play a crucial role in safeguarding patient safety by advocating for policies that maintain high standards of care, ensure adequate staffing levels, and promote safe working conditions. They contribute to policies that prevent medical errors and enhance patient safety protocols (ANA, 2015).

By adhering to Provision 3, nurses ensure that healthcare policies remain focused on patient welfare, thus enhancing the overall quality and safety of the healthcare system.

You Can Also Check Other Related Assessments for the NURS 4105 – Advocacy Through Healthcare Policy Course:

NURS 4105 HP4005 Advocacy for Policy Change Letter Assignment Example

NURS 4105 HP4004 Evaluating Health Policy Essay & Brochure Assignment Example

NURS 4105 HP4001 Module 3 Pre-Assessment Analysis: Prompt 2: Nurses’ Social Contract and Policy Involvement

The essence of the nursing profession is both valued within a society and uniquely accountable to that society. This is considered to be the profession’s social contract. Using the American Nursing Association website, first identify a current healthcare policy that nurses are involved in at the local, state, or national level. Second, using Fowler’s Guide to Nursing’s Social Policy Statement: Understanding the Profession from Social Contract to Social Covenant, pp. 19-20, analyze how the nurses’ social contract is being upheld within that policy.

Selected Policy: ANA Policy on Care Coordination and the Role of Registered Nurses

Policy Overview

The ANA policy on care coordination emphasizes the critical role registered nurses play in coordinating patient care across various settings. It advocates for recognizing the professional standard of patient-centered care coordination and ensuring nurses are appropriately compensated for their contributions (American Nurses Association [ANA], 2012).

Nurses’ Social Contract and Care Coordination

Social Contract Elements:

  • Responsibility to Society: The nursing profession is committed to serving society by ensuring the health and well-being of individuals. This social contract involves a mutual understanding where society values the nursing profession, and nurses uphold their duties by providing high-quality care and advocating for patient needs (Fowler, 2015).
  • Accountability: Nurses are accountable to society for maintaining professional standards and ethical practices. This involves continual education, adherence to best practices, and active participation in policy-making to enhance healthcare systems (Fowler, 2015).

Analysis of the Social Contract in the Policy Context

  • Holistic Care Approach: The policy emphasizes the holistic care approach, which aligns with the nurses’ social contract by ensuring that care is patient-centered and considers all aspects of a patient’s well-being. Nurses coordinate with various healthcare professionals to provide comprehensive care, reflecting their commitment to society’s health needs (ANA, 2012).
  • Advocacy for Fair Compensation: The policy advocates for equitable compensation for nurses, acknowledging their essential role in care coordination. This aligns with the social contract by recognizing the value nurses bring to the healthcare system and ensuring they are rewarded fairly, which in turn, sustains their ability to serve society effectively (ANA, 2012).
  • Ensuring Quality and Safety: The policy’s focus on using evidence-based care coordination measures ensures high standards of care. Nurses’ involvement in developing and implementing these measures ensures that patient safety and quality of care are prioritized, upholding the profession’s accountability to society (ANA, 2012).
  • Professional Development: The policy encourages the continuous evaluation and communication of nurses’ contributions to care coordination. This supports the social contract by promoting professional growth and ensuring that nurses are equipped to meet evolving healthcare challenges (ANA, 2012).

By supporting the ANA Policy on Care Coordination, nurses fulfill their social contract by enhancing patient care quality, advocating for their professional role, and ensuring that healthcare policies are designed with the patient’s best interest in mind. This policy exemplifies how nurses uphold their responsibilities to society while striving for professional integrity and excellence in healthcare delivery.

References

American Nurses Association. (2012). Care coordination and the role of the registered nurse. https://www.nursingworld.org/~4ae219/globalassets/docs/ana/ethics/carcoordination-principles-position.pdf

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/coe-view-only/

Fowler, M. D. M. (2015). Guide to nursing’s social policy statement: Understanding the profession from social contract to social covenant. American Nurses Association.

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