Stevens' article on health care access is a comprehensive discussion of an issue that is currently center stage on the national scene. Her article raises important questions about the centrality of this issue in the nursing community, specifically in practice, research, and theory. Stevens states in this article that nurses have not had ethical support to advocate for access to health care. Nurses do have ethical support and a moral mandate for such activity in the American Nurses Association' Code for Nurses (1976; 1985).
The Code for Nurses makes explicit nursing's goals and values, its moral obligations to patients and clients. One of the nurses' obligations is to work with other health professionals and citizens to promote efforts to meet the health needs of the public. More explicitly, the interpretive statements claim that nurses have obligations "to promote equitable access to nursing and health care for all people" and to actively participate in activities that ensure the availability and accessibility of high-quality health services to all persons with unmet health needs. These statements are unequivocal in support of an ethical obligation and mandate for nurses to be involved in health care access issues.
The first code approved by ANA in 1950 included the same broad obligation (Fowler, 1984). It says, in the spirit of the current code, that nurses should participate and share responsibility with others in promoting efforts to meet the public's health needs in local, state, national and international settings. Nursing has had this broad mandate, then, longer than the past decade. The mandate includes specific concerns for access to health care.
A bleak reality exists for nurses, nursing, and our proclaimed clients, according to Stevens. She signals a relative lack of action in significant parts of the nursing community with regard to this moral obligation. This moral obligation has existed for the last half of the 20th century in the code that is a public statement of what the profession considers to be its moral obligations and values. The Code for Nurses alone provides ethical support and a moral imperative for nurses to be involved in access to health care issues and related public policy. Yet, for the most part?with a few noteworthy exceptions?we continue to focus on issues of individual patient care in nursing and hold a mindset that nurses who work in arenas of public policy and politics have "left" nursing.
The focus of nurses and other health care providers on individual care is not surprising. There are several possible explanations for this focus. They include: (1) the first obligation mentioned in the Code which emphasizes respectful care of individuals, (2) the individual focus of much advocacy literature in nursing, (3) the traditional medical ethic that requires doing everything possible for the individual patient, (4) society's emphasis on individualism and individual freedom of choice, and (5) the bioethics literature's emphasis, until recently, on individual autonomy and rights. Even the stated commitments of community and public health nursing to the health of communities and populations at risk and to education dealing with participation in the legislative process and policy development have not been an effective counterbalance to a focus on the individual in health care and in our society. Such realities do not serve as justification for a continuing lack of attention to access issues in nursing practice, research, and theory development.
A recent counterpoint to the focus on individual client care in nursing is Nursing'sAgendaforHealth CareReform(American Nurses Association, 1991), endorsed by more than 50 nursing organizations. The Agenda is reflective of nursing's values and has profound implications for public policy development. It calls for immediate restructuring of health care in our country and proposes universal consumer access to a standard package of essential services to be delineated at the federal level. …