A Scoping Review of Legislative Advocacy Training in Healthcare Professional Education

To effectively support health advocacy efforts healthcare providers need to: 1) understand current legislative and regulatory systems in their communities; 2) learn how to effectively navigate established advocacy and policy processes; 3) educate legislators and administrative decision-makers about the complex healthcare system; and, 4) establish partnerships/coalitions that support community-guided change. The aim of this scoping review is to scope the published literature on political advocacy training programs offered to students in three healthcare provider disciplines (i.e., medical, nursing, and pharmacy). A final set of 41 articles are included. In the published literature, political advocacy training was more common in student nursing and medical programs than in pharmacy programs. Few interprofessional health advocacy student training programs were found, and most of these focused-on teaching advocacy from an academic medical-legal standpoint. [1] The intensity of and the training received in each program varied significantly.


Introduction
According to the World Health Organization, "Health policy refers to decisions, plans, and actions that are undertaken to achieve specific healthcare goals within a society. An explicit health policy can achieve several things: it defines a vision for the future, outlines priorities, and builds consensus and informs people." [2] Politics plays a critical role in health affairs and policy change. Advocacy, the "act or process of supporting a cause", involves policy action(s) aimed at reaching the selected goal. Health advocacy initiatives aim to protect, shape, and promote community health and wellbeing and are generally broken down into three main advocacy categories: (1) patient, (2) professional, and (3) political advocacy.
Patient advocacy focuses primarily on the role of healthcare professionals (HCPs) advocating directly for their patients' medical and health-related needs [3,4]. Professional advocacy refers to activities focused on the evolution of practice (e.g., scope of practice, rights and privileges, reimbursement structures). [5,6] Political advocacy refers primarily to individual HCPs or healthcare organization-level legislation and regulatory changes impacting professional scope of practice [6][7][8]. It is derived from a set of complex and dynamic processes, driven by belief systems, politics and regulations [6][7][8].
The legislative process is complex and daunting. Since translating information into policy and practice change is inherently political, HCPs must become skilled advocates. Professional organizations may provide a platform where HCPs can come together, become more involved within their profession, and work towards the goals of their profession. [9][10][11] Most currently available training materials, such as those provided by the American Association of Nurse Practitioners, [9] are focused on HCPs engaging with national decision-makers to support health policy changes identified by the professional organization. However, the needs of the professional organization may not align with the needs of the individual HCPs. Health policy impacts healthcare delivery, outcomes, inequities, and disparities. [3,4,7] In order to make a difference in their community, HCPs have a professional responsibility to effectively advocate for specific, individual-level, policy, and legislative change that addresses the unique health disparities and inequities afflicting their community.
Legislators and policy makers often enact politically-driven health policies that do not utilize available medical evidence or address the healthcare needs of their constituents. [11] In order for HCPs to effectively advocate for health policy change, especially those in underserved and rural communities, most require additional evidence-based, structured training to feel adequately prepared to address the systemic healthcare needs of their communities. [1] To effectively support change, HCPs need to: 1) understand legislative and regulatory systems; 2) learn how to effectively navigate advocacy and policy processes; 3) educate decision-makers so they have a better understanding of the complex healthcare system; and, 4) establish partnerships and coalitions that support positive community-guided change. HCPs need comprehensive training and support while they are students teaching them how to engage, inform, and collaborate with legislators and policy makers to address health policy gaps. [1,2,4,6] However, despite the need for healthcare policy, political advocacy and engagement are not part of most HCPs' curricula, necessitating they seek ad hoc training on their own. The aim of this scoping review is to determine the type and extent of political advocacy training that students of different HCP disciplines receive during their training.

Methods
We utilized a rapid scoping review approach in line with methods recommended by Tricco and et al. to establish the HCPadvocate scoping review protocol to "identify knowledge gaps, scope a body of literature, clarify concepts or to investigate research conduct." [12] Population of study For the purposes of this study, the population of interest was HCP students, students in the medical (i.e., physicians, physician assistant, and nurse practitioner), nursing (non-prescribing), and pharmacy fields. Post-graduate learners (e.g., residents and fellows) were excluded.

Intervention
We focused on training related to engaging in the legislative and/or policy-making processes with pertinent stakeholders (e.g., legislators, agency staff, etc.), and not patient advocacy. We sought literature on health advocacy training that had been integrated into a curriculum, as either a required or elective course, and excluded accounts of extracurricular training provided by student-run or external organizations. No comparator was required for included studies. Descriptive studies without outcomes and studies with any outcomes were included.

Data sources and search strategy
Through EBSCOhost, we searched the following databases from inception through November 16, 2021: CINAHL Complete, Education Research Complete, ERIC, Healthy Policy Reference Center, Health Source: Nursing/Academic Edition, and MEDLINE Complete. These were selected in order to conduct a broad and comprehensive search of the health literature. No limits were placed on date or country of origin. Key words and phrases comprising advocacy, legislation, regulations, or policy, and the study population were employed (see Appendix for exact terms). We supplemented our database literature search with a Google Scholar search performed on January 8, 2022 (see Appendix for exact terms); the first 500 results were screened for applicability. Finally, backwards citation tracking was performed for all included articles.

Study review and selection
Title/abstract citations were independently reviewed by two investigators. Full-text articles of citations that passed initial title/abstract screening were retrieved and reviewed by two investigators for inclusion. Discrepancies with citation screening or article inclusion were resolved with discussion and/or a third reviewer. Articles were included if they met the following criteria: were about a HCP student of interest (as defined above in the population of interest); discussed an advocacy education or training program (as defined above in the intervention); involved participation in the legislative, regulation, and/or policy process. Non-English language articles and programs that focused only on being a patient advocate were excluded.

Data extraction
Data from included articles were extracted by two investigators and organized using a Google Spreadsheet. The following data were collected: healthcare profession group; citation information (author, journal, publication year, article title); program description (goal/purpose); deliverables/outcomes; training type; number of students; duration of training; and intensity of the advocacy experience in the course (categorized as application, simulation, reflection, or didactic).

Results
The initial database search yielded 1,792 citations. After removing duplicates, 1,209 citations were screened and 140 full-text articles assessed for relevancy ( Figure 1). Forty-one articles met all inclusion criteria and were included in our review (Table 1).  Examines the theoretical underpinning of leadership knowledge, principles, skills, and competencies needed to lead interprofessional teams and healthcare system change to improve the health of society.
The student engages in a collaborative experience to apply leadership, health system, health economics, and policy Student interns were expected to research issues, support effective policy decision-making, attend and testify at relevant public hearing, develop a position paper on an issue, and present a verbal report.
Elective (n=7, 1 semester) Application [19] Innovations in the Public Policy Education of Nursing Students The project goal is to achieve core competency in public policy and the legislative processes through Integration of an innovative, curricula-wide, public policy initiative.
Involve students in the legislative process.
Students will draft an evidence-based newspaper article / letter to legislators, develop a fact sheet and present to legislators on lobby day Curriculum (n=45, 3 semesters) Application [40] Changes in Political Astuteness After a Health Systems and Policy Course Describe levels of political astuteness in graduate students at 1 university in the Pacific Northwest to determine if political astuteness changed after students completed a required 10-week graduate course in health systems and policy and to identify the specific changes that occurred.
Examine political astuteness in grad students before and after a required health policy course Teach students how to positively affect change while learning about the pharmacy practice regulatory and policy analysis processes.

Discussion
HCPs have a personal responsibility to ensure appropriate stewardship of public health dollars so that community health needs are met. When it comes to key issues, it is important that HCPs participate in discussions with legislators, as policy change is sometimes required to enact public health campaigns and to ensure that policy makers make evidence-based policy decisions that support the needs of constituents. However, not all HCP curricula prepare individuals to advocate for the health policy changes.

Provider differences
Political advocacy has long been emphasized in a number of nursing and medical programs. Training both within and across nursing programs has ranged from elective shadowing experiences participating directly in legislative events and advocacy initiatives to multi-year, integrated, didactic curriculum and practicum experiences that focus on translating nursing practice issues into regulation and/or statutory changes. Similar training differences were seen across identified medical school programs, ranging from a one-hour lecture introducing the concept of advocacy and the importance of social determinants of health, a one semester elective working with the national medical organization to help draft health legislation, and a year-long longitudinal policy and advocacy curriculum that involved a clinical, social justice-focused servicelearning project. Fewer advocacy training programs were found in the pharmacy curriculum, [34,39,41,55] and most were more didactic in nature and focused on teaching doctor of pharmacy students about the pharmacy regulatory and policy analysis processes and the development of advocacy skills. Lastly, the only interprofessional health advocacy, student training programs we found focused on teaching advocacy from an academic medicallegal standpoint. [1] There are a number of likely reasons for the increased number of training programs offered to HCP students, particularly those engaged in direct clinical practice, as they are more likely to be aware of the unmet health needs of their patients, have a broad understanding of the healthcare system, and recognize the importance of policy making to support practice guidelines that support improved patient outcomes. The commitment to and professional responsibility of HCPs is evident in the American Medical Association's (AMA), the American Nursing Association, and Oath of a Pharmacist. Activism, item 8 in the Declaration of Professional Responsibility: Medicine's Contract with Humanity, focuses on the "…social, economic, educational, and political changes that ameliorate suffering and contribute to human wellbeing [emphasis ours]". [22,23] In fact, the American Nursing Association believes legislative and political advocacy is no less important to advancing the profession of nursing than patient care. [22,23] It is the experiences of many practicing nurses that has motivated them to take on some form of an advocacy role; however, many nurses do not feel prepared to operate effectively in the legislative/advocacy setting, resulting in increased student training. [22,23] Moreover, in 2018, the American Society of Health System Pharmacy Statement on Advocacy as a Professional Obligation encouraged pharmacists to serve as advocates for the profession, [5] and spoke directly to the importance of preparing doctor of pharmacy students at several different levels, including standards incorporated in the Accreditation Council for Pharmacy Education (ACPE) standards, to advocate for change. [5] Intensity The intensity of each program, in terms of the amount of political advocacy content and the time allocated to the subject, whether it was an elective or required course, etc., varied significantly. While some courses explored political advocacy within the context of patient or community health advocacy, others included it in a policy or activism focused curriculum. This approach frames political advocacy as a natural outgrowth of HCPs' traditional role to improve their patients' health by learning about the social determinants of health, working closely with community organizations to further their goals, or championing particular health issues. For example, the program described by Chung et al. prepared medical trainees to be child health advocates [24]. Nannini and colleagues [25] reported a program designed to give physicians the skills and knowledge to effectively advocate on behalf of their patients and the general public, while the course described by Jones et al. sought to foster advocacy for vulnerable populations in RN-BSN students. [37] In contrast, programs focused on policy change were more generally focused on preparing students to appeal to legislators and regulators. For example, the program described by McGrew and colleagues taught medical student's organization and financing, decision-making, policy analysis, identification of leaders and special interest groups, advocacy, and communication with the media. [26] Smith et al. reported a course teaching pharmacy students how to effect change through learning about the pharmacy practice regulatory and policy analysis processes. [39] The programs varied widely in the degrees to which students were expected to participate in political advocacy during the course, from direct application of skills, to simulation of advocacy activities, to didactic content and outcomes (see Table  1). For example, while some had students engage in face-toface meetings with legislators; [1,13,[17][18][19][27][28]43,48,50,54] draft bills; [13,25,29,30] give public testimony; [31] or work with community organizations/advocacy groups, [16,21,31,32,51,52] other programs described a quasi-or total classroom learning experience in which students had to attend a town hall or city council meeting; [33,34] develop a proposal or public policy position paper; [14,[35][36][37][38][39]42,46,53] or complete academic work and sit for an exam or deliver a written final project. [15,17,20,26,[40][41][44][45]47,49,55] Interestingly, the variance in the amount of time devoted to advocacy training does not seem related to whether the class is an elective or a required course. For example, the month-long, required course described by Cha, et al. [14] teaches health policy, research methods, advocacy, and physician activism over the course of six to ten sessions lasting between 90 minutes and half a day. In contrast, another required course described by Marsh [44] and colleagues featured one 45-to 60-minute lecture and a discussion of advocacy. In contrast, an elective course described by Morris and colleagues lasted 12 weeks and had the students execute a social media advocacy campaign engaging elected officials and community-based organizations as part of the development and dissemination of evidence-based educational materials. [42] On the other end of the spectrum, Chung et al. described an elective course aimed at training medical trainees in child health advocacy, which lasted one month and resulted in a reflection paper. [24] Conclusion Political advocacy of HCPs refers to the set of complex and dynamic political and/or regulatory processes, impacting professional scope of practice. [6][7][8] In order to impact healthcare systems and practice, HCPs need to know how to advocate for necessary political changes in an environment with conflicting political agendas; however, these skills are not explicitly taught in all health profession programs. A number of medical and nursing programs provide some didactic and/or experiential health advocacy training; however, the training intensity and application varies both within and across curricula. In order for all HCPs to more effectively advocate for patients, we need to provide more consistent, extensive, and applicable political advocacy training in their academic programs to better prepare them to advocate for their communities and profession.