key: cord-0897055-docakluk
authors: Crowder, Sharron J.; Tanner, Andrea L.; Dawson, Martha A.; Felsman, Irene C.; Hassmiller, Susan B.; Miller, Lisa C.; Rinehard, Susan C.; Toney, Debra A.
title: Better together: Coalitions committed to advancing health equity
date: 2022-04-30
journal: Nurs Outlook
DOI: 10.1016/j.outlook.2022.02.013
sha: de585be8db260296d39594629422a1f523942cb8
doc_id: 897055
cord_uid: docakluk

The Future of Nursing 2020–2030 report identifies coalitions as a driving force for advancing health equity. Five coalitions provided insight into their accomplishments, lessons learned, and role in advancing health equity. The exemplar coalitions included Latinx Advocacy Team and Interdisciplinary Network for COVID-19, Black Coalition Against COVID, Camden Coalition, National Coalition of Ethnic Minority Nurse Associations, and The Future of Nursing: Campaign for Action. While all exemplar coalitions, credited relationship building and partnerships to their success, they used unique strategies for striving to meet their populations’ needs, whether the needs arose from COVID-19, racial and/or ethnic disparities, socioeconomic disparities, or other barriers to health. Research and policy implications for coalitions are discussed. Nurses play a critical role in every highlighted coalition and in the national effort to make health and health care more equitable.

Coalitions are influential organizations with purposeful, collective actions and voices. Coalitions have been identified as "a means of pooling the abilities, expertise and resources of numerous stakeholders to positively affect community health" (Granner & Sharpe, 2004, p. 514) . Today, more than ever, our nation needs the powerful actions and voices of coalitions to create a paradigm shift toward more equitable health care. Coalitions effective in shaping health behavior, realizing health outcomes, and addressing health inequities are purposefully built. Just as constructing a functional building requires time, money, resources, skills, and a collaborative effort among experts, the Future of Nursing 2020-2030 report emphasizes the same requirements for creating and maintaining a sustainable, effective coalition. A variety of factors serve as facilitators for coalition formation, including commonalities in critical need, purpose, geography and/or community of influence, ethnicity, and profession. Two critical needs are health equity and access to high quality health care, especially for those negatively impacted by social determinants of health. Recent thrusts for coalition formation have included such topics as reproductive justice to decrease inequitable birth-related morbidity and mortality (Bray & McLemore, 2021) and COVID-19 (Michener et al., 2020) . As evidenced by coalitions formed around both topics, coalitions can exist at the community, state, and national levels, but require a "hub" to coordinate activities and connect with stakeholders to increase coalition health equity capacity (Brown et al., 2019; Inzeo et al., 2019) .

Delving into the interworking of coalitions provides valuable insight about coordinating intersectional activities, addressing challenges, and creating effective strategies to promote change. Over the past two decades, a number of coalitions have approached community-level health concerns and health inequities. The Chicago Southeast Diabetes Community Action Coalition has been decreasing diabetes-related morbidity and mortality in Chicago's underserved neighborhoods (Giachello et al., 2003) . The Shape Up Under 5 committee of Somerville, MA has used a whole-of-community approach addressing early childhood obesity through internationally recognized social, environmental, and policy change to increase access to healthy food and physical activity (Korn et al., 2021) . What has been challenging has been determining what constitutes a successful coalition. A review of literature detailed six key principals of coalition-building that increase coalition effectiveness: (a) formal governance procedures, (b) strong leadership, (c) active member participation, (d) membership diversity, (e) inter-agency collaboration, and (f) group cohesiveness (Zakocs & Edwards, 2006) . Measuring the effect of a coalition on community health outcomes includes evaluating community changes, health or behavioral outcomes, and community capacity changes (Kegler et al., 2020) .

Nurses bring unique expertise and leadership skills that contribute to the health equity endeavors and outcomes of coalitions. This manuscript presents as exemplars five coalitions (see Table 1 ) including a description of their organizations and accomplishments, lessons learned, and roles in advancing the health equity agenda presented in the Future of Nursing 2020À2030 report. Representatives from the coalitions (Latinx Advocacy Team and Interdisciplinary Network for COVID-19 , Black Coalition Against COVID [BCAC] , Camden Coalition, National Coalition of Ethnic Minority Nurse Associations [NCEMNA] and The Future of Nursing: Campaign for Action [Campaign] ) provided details of real-world coalition work from their vantage points and in their own words. Following a summation of coalition contributions, research and policy implications are discussed.

Anticipating the increased health disparities and inequities that would emerge for the Latinx community during the COVID-19 pandemic in March 2020 (Rodriguez-Diaz et al., 2020; Rossen et al., 2021) , Duke University clinicians convened a diverse group of stakeholders to discuss a coordinated approach to address these issues. A formal name was given to the group- LATIN-19 (Martinez-Bianchi et al., 2021 ). An interdisciplinary executive team of Duke nursing and medicine faculty and two community-based professionals (a global management consultant and the director of Multilingual Resource Center at Durham Public Schools) leads the operations of Latin-19. The executive team meets weekly to discuss issues regarding communications, research initiatives, health profession student focused initiatives and to plan sustainable intervention strategies for the Latinx community. In addition, an elected advisory board of community stakeholders represents views of those outside the health system and advises the executive board.

In order to ensure sustainability of programs (den Broeder et al., 2021) and support community resilience initiatives (Fransen et al., 2021) beyond the COVID pandemic, the Latin-19 executive team developed two separate entities: a community based nonprofit corporation, and a hub for Latino health based in the Center for Population Health at Duke. These two entities work synergistically in an effort toward continued improvement of health equity for the Latinx community through advocacy, policy development, community based participatory research, and community outreach. The LATIN-19 executive team hosts weekly meetings via an online platform (Zoom) with an average of over 70 participants. Participants in meetings comprise an interdisciplinary, multisector coalition representing academic institutions, healthcare systems, public health departments, public school systems, community-based organizations, government, faith communities, and others. Nursing faculty are at the forefront of planning and implementing community-based research initiatives, training of community health workers, and community-based health promotion and prevention events, including testing, and vaccination events.

The LATIN-19 initiative has contributed to a notable decrease in COVID-19 cases in the Latinx population in Durham County. Latin-19 community-based testing and vaccination events have made a significant contribution to the increase in vaccination rates from 5% in March 2021 to 57% as of September 1, 2021, among Latinx residents (i.e., those who have received at least one dose of vaccine). The LATIN-19 executive team developed public service announcements, conducted media interviews geared to community education, and improved access in Spanish to the 211-state hotline information related to health and human services and resources in local communities. Additionally, the team obtained a commitment by the Duke University health system to implement a Spanish language version of the digital patient portal (MyChart) and increased the hospital's Spanish language signage. LATIN-19 members at the Duke Schools of Nursing and Medicine integrate COVID-19 response initiatives into medical Spanish courses, mentor several cross disciplinary and/or cross program research teams and provide training opportunities from undergraduate to postdoctoral levels.

Challenges at the service level included a lack of COVID-19 testing and vaccination sites in Latinx communities; lack of infrastructure for services to the Latinx community; a historical mistrust of health systems by the Latinx population; lack of adequate Spanish translations of official information regarding COVID-19 and the vaccine leading to misinformation spreading through social networks; and lack of access to care following positive diagnoses for COVID-19 (Njoku et al., 2021; Taylor et al., 2021) . Additional challenges related to delivery of care and rolling out community level programs included overextension of nurses and other health care workers at community, academic, and health system levels, leading to exhaustion from continuous volunteer effort; and a lack of recognition of Latinx health priorities within the university requiring considerable team effort to compete for grants to support community engagement.

Challenges in working with the community included building the trust of community organizations and maintaining sustainable partnerships; remaining vigilant in order to not overstep the authority of community led organizations; and competing for limited funding and other resources to support community level activities.

An effective strategy for overcoming a lack of information has been to remain constantly vigilant in tracking statistics for the Latinx community and subsequently following up with advocacy efforts, including phone calls to government officials, tweets, radio broadcasts, and the writing of opinion editorials for the press. Collaboration with community partners (including the County Health Department, Mayor's Hispanic/Latino Committee, Latino Community Credit Union, and Partnership for a Healthy Durham, and numerous community-based organizations) and support of local initiatives (such as community organization initiated pop-up clinics, community health worker trainings, and migrant farm worker outreach) has been key in the provision of consistent services to the community throughout the pandemic.

Advancing health equity requires a collaborative effort, across multisector groups. The LATIN-19 executive team recognizes that becoming trustworthy is vital in community engaged initiatives; this takes time and being present in the community. Nurses, and indeed all who work with vulnerable populations, must practice humility and vulnerability while listening deeply to questions and concerns of diverse community members when creating solutions together. Nursing is recognized as a highly visible and trusted profession, with a long history of leading at the frontline in public health emergency and response; the involvement of nurses in communicating public health information is an important strategy in approaching the lack of trust in marginalized communities (Guilamo-Ramos et al., 2021) . LATIN-19 0 s interactions have great influence on preparing the next generation of nurses and other health care professionals and the recruitment of a diverse workforce representative of the community served. Training the next generation of health equity pioneers is vital to ensuring a health workforce that is culturally and linguistically in tune with the Latinx community.

Long term goals for LATIN-19 include ensuring access to equitable, quality health care, increasing health literacy, and increasing community participation in research to enhance health outcomes for the Latinx population. These goals will only be achieved through collective leadership and trusting, collaborative partnerships and alliances that honor the voice of the Latinx community. Building and maintaining robust channels of communication with leaders in government as well as public and private health systems is essential in order to translate current needs,

N u r s O u t l o o k 0 0 ( 2 0 2 2 ) 1 À1 1 missed opportunities, and successes for the Latinx community into policy.

In order to share resources and maintain open collegial communication, LATIN-19 collaborates with the African American Covid Taskforce (AACT+, 2021), a group established at the onset of the pandemic to address specific needs of African Americans in the community. Members of LATIN-19 and AACT+ attend each other's weekly meetings, share lessons learned and support outreach efforts in the community. While many challenges are similar for these historically marginalized groups, each has its unique set of issues. Great care is taken to limit competition regarding funding sources and to maintain a collaborative relationship.

The BCAC was envisioned by Reed Tuckson, MD. During the AIDS epidemic, he was the Commissioner of Public Health in the District of Columbia. In March 2020, Dr. Tuckson convened leaders from the Historically Black Colleges and Universities (HBCU) medical schools and presidents from national organizations to form the BCAC. The coalition is a national health alliance of the four historical Black medical schools (Charles R. Drew University of Medicine and Science, Howard University College of Medicine, Meharry Medical College, and Morehouse School of Medicine); National Medical Association (NMA); National Black Nurses Association (NBNA); National Urban League, The Cobb Institute of the NMA, and BlackDoctor.org. "A Love Letter to Black America," the BCAC's first national press release, was published by convening leaders who felt compelled to acknowledge lived experiences as part of Black communities. Although comprised of health care providers, community advocates, scientists, and organizational leaders, the BCAC developed the love letter to express its connection to communities where coalition members were born, live, work, play, worship, and transcend life.

For the first time, the BCAC created a national cross-sectional, science-based platform to inform and address health issues in Black communities by those that looked like the faces in the community. The BCAC's goal is to be the defining voice and go-tosource for the Black community ensuring accurate information, correcting misinformation, and dispelling disinformation. The BCAC strategy for success is to support local community activities while engaging with national healthcare leaders and organizations, including government entities. The emerging evidence around COVID-19 clearly demonstrated disparities and negative outcomes in Black and Brown communities (Cuellar et al, 2020; Strickland et al., 2020; Washington & Cirilo, 2020) . Two of the HBCUs have medical schools and nursing programs with a very diverse student population. However, the NMA and the NBNA have members in all geographical areas and are capable of delivering robust grassroot action campaigns by building on existing partnerships with local community leaders to deliver BCAC's national agenda.

Key to BCAC's success is having organizations with a rich history of community service and engagement such as the Urban League, NMA BlackDoctor.org, and NBNA. These BCAC organizations are sought for their expertise and years of service. NBNA has a collaborative community health model that is designed to address health disparities and improve health outcomes in Blacks and other minority populations. The model is also grounded in the concept of community inclusion, social justice, human caring, and health care as a fundamental human right (Dawson, 2021) . NBNA was working in the community before the COVID pandemic, and the current saying is, "those Black Nurses are everywhere." Being everywhere is how to sustain a coalition, and more importantly build relationships. Nurses excel at both, which supports why nurses are the most trusted health professionals.

During its formative stage, the BCAC realized the strength in having similar, yet diverse groups, at the table to share resources: human capital, corporate contacts, fiscal support, and social media networks. Each organization added value and connections to support the coalition's intellectual and resource needs. BlackDoctor.org provided the technology this new coalition needed to reach the masses and act as the go-to social media site for those not wanting to visit medical, nursing, or other healthcare sites.

All co-convening members used their networks and reach to publish upcoming events.

The focus was continuous appraisal of the needs of the Black population across the country and quick dissemination of information and resources. Using collective human capital, BCAC increased its footprint and audience. Each group could also repost recorded events on their social media network. Coalition organizations with local chapters, such as NBNA, benefited from news outlets picking up a national story from the BCAC and connecting it to COVID-19-related events in the local community. This provided a valuable opportunity for local nurses to inform local conversations and communicate accurate data (Dawson, 2021) .

Another major outcome centered on sharing fiscal resources and contacts. For example, when CDC approached NBNA to provide a COVID-19 webinar, although financial support was available, the decision was made to shift this opportunity to the BCAC because of the technical support, speaker-ready bureau, and the network to promote events. Currently, the BCAC has achieved success because of the diverse, expansive expert network that is growing and changing to meet the needs of communities served in every state. Some of the partners include the Ad Council, Leading Age, Federal Drug Administration, American Red Cross, pharmaceutical organizations, faith-based entities, Robert Wood Johnson Foundation, Kellogg, Commonwealth, Kaiser Family Foundations, American Association of Retired Persons, Agency for Healthcare Research and Quality, National Dental Association, National Consumer League, National Council of Negro Women, MommiNation, American Hospital Association, Actor Equity, and other thoughtleaders and influencer groups. Each partner helped reach critical audiences to move the Black and Brown communities from passive hesitancy to active listening and decision-making. BlackDoctor.org served as the engine for conducting surveys and collecting data. Early data demonstrated a positive shift in the number of people that would take the vaccine or self-reported an increase in knowledge about COVID-19.

Through BCAC, many organizations came together for the unified goal of addressing health inequities and lack of credible information during the COVID-19 pandemic. However, each organization continues to focus on their own mission, vision, and endeavors that also addresses health inequity, disparities, and workforce diversity. For example, NBNA has a collaborative mentorship program for nursing students (student connect forum), early career nurses (under 40 Forum), and mentor-mentee matching mid-career and specialty focus groups. After years of underrepresentation in the nursing workforce, NBNA uses strategies to increase nursing workforce diversity. The Mini Nurse Academy, experiential program targets third through sixth grade students. Early engagement and enrichment activities prepare young students for health and science-based occupations, namely nursing. The program has been piloted with two elementary schools in the southeastern UnitedStates Other multisector approaches include interacting with community colleges, universities, sororities, and fraternities, boys' and girls' clubs, and faith-based organizations. Additionally, enrichment camps and pop-up nursing academies will be offered during summer breaks and other times. These strategies support the Future of Nursing 2020-2030 report's workforce diversity recommendations.

The BCAC and NBNA are looking beyond COVID-19. Both organizations are building and expanding relationships in health policy, clinical research, social justice, health equity, and other spaces focusing on increasing healthcare workforce diversity, improving access to care, and addressing social and political determinants of health. NBNA and the Cobb Institute of the NMA are collaborating on adult vaccination research, another outcome of the BCAC. NBNA has long supported and advanced efforts to increase immunizations and vaccination across the lifespan. Coalitions look to what are keys to success, and one identified key is that, in Black communities, the tasks of eliminating health disparities and improving health outcomes is larger than any one group; coalition-building and collaboration across boundaries are critical. To move the needle in addressing health inequities, the focus must center on a community asset-based engagement approach. That out of box approach requires building blocks to sustain community initiatives where people live work, play, worship, and transcend life. Therefore, the call to action is to address social and political policies that create conditions that lead to poor health outcomes and inequities. NBNA's position within the BCAC and ongoing activities demonstrates its' commitment to addressing health inequities and the Future of Nursing 2020-2030 report's recommendations.

The Camden Coalition of Healthcare Providers (Camden Coalition) addresses complex health care needs through several local, state, and national efforts. At the local level, the flagship Camden Core Model (Camden Coalition, 2021a) provides person-centered, trauma-informed care that improves patients' ability to manage their chronic health conditions, navigate the fragmented healthcare and social services systems, and achieve their individual goals for well-being. The coalition identifies patients with frequent hospital or emergency department admissions using real-time data from the Camden Coalition Health Information Exchange, (Camden Coalition, 2021b) and staff members meet patients at the hospital bedside or in a community setting to offer care coordination services. Enrolled patients receive a customized care plan and services from a community-based team of nurses, social workers, and community health workers for an average of 90 days.

The standardized methods and resources that nurses, and other team members, use in the Camden Core Model were eventually codified into a care planning toolkit. Knowledge of the techniques and practices that were more effective with patients, including methods for building authentic healing relationships with clients, evolved into what is now called COACH (Camden Coalition, 2021c). This five-part framework trains staff to problem-solve with patients to effectively manage their chronic health conditions and reduce preventable hospital admissions. Led by senior members of the nursing team, COACH trainings have been given to both teams and individuals at health systems large and small across the country. COACH trainers have subsequently transferred their subject matter expertise into a virtual course that will launch in 2022. Attendees will be able to earn CEUs upon completion of the virtual course.

In 2020, joining forces with state lawmakers and other partners, the Camden Coalition -along with Healthy Greater Newark ACO, Trenton Health Team, and the Health Coalition of Passaic County -became certified via state legislation as a Regional Health Hub (Camden Coalition, 2021d). Envisioned as a coalition of non-profit organizations dedicated to improving healthcare delivery and health outcomes for New Jerseyans, Regional Health Hubs join with consumers ARTICLE IN PRESS N u r s O u t l o o k 0 0 ( 2 0 2 2 ) 1 À1 1 and stakeholders to improve outcomes for Medicaid covered patients.

Camden Coalition launched The National Center for Complex Health and Social Needs (The National Center, 2021) to share experiences in the emerging field of complex care and highlight complex care innovations and breakthroughs across the country. The National Center serves as a professional home for individuals and organizations caring for people with complex health and social needs, uniting and amplifying their efforts to improve care nationwide. The National Center's Senior Advisor is Lauran Hardin, MSN, CNL, FNAP, FAAN. She provides consultation services for health systems adopting best practices from the field of complex care. She also guides institutions in the economic potential of stabilizing complex patients through retraining and/or redesigning existing resources in the healthcare system.

Camden Core Model care team members have extensive experience in Camden and similar communities, and many of the coalition's LPNs and community health workers come directly from these communities. In response to COVID-19, the Camden Coalition established "pop-up" testing sites in high-risk Camden neighborhoods that were staffed by Coalition nurses. As testing transitioned to vaccination, LPNs and community health workers provided vaccines while Coalition navigators connected participants with other social needs to available resources. These opportunities identified the need for better coordination among partners and a larger role for community-based organizations to leverage existing relationships for more equitable and patient-centered strategies.

Additional lessons learned were related to leveraging clients' trust in the organization and its partners. A mixed methods study design, which included a Camden community survey, was used to understand specific vaccine attitudes and insights. The results informed outreach and navigation efforts, and the development of both a COVID Community Ambassadors Program (Gomez & Kane, 2021) and vaccine confidence training for providers (Camden Coalition, 2021e). Camden Coalition nurses trained Community Ambassadors to address vaccine hesitancy with their friends, family, and peers. To increase vaccination rates for children 12 and older, Coalition nursing staff led efforts to recruit Youth Ambassadors and worked with the school district to staff vaccine events at schools. They also assisted locally owned pharmacies to provide much-needed staffing support to the city and county Departments of Health.

Additional lessons learned have been garnered through the integration of coalition effectiveness research. The results of a randomized control trial showed little variability in 180-day readmission rates between Camden Core Model clients and other patients receiving standard care, but there was an increase in a variable important to participants-access to public benefits (Finkelstein et al., 2020) . Furthermore, qualitative data from the study provided insight into the complexity of clients' needs, clients' experiences with health systems, and the importance of building authentic relationships with clients. Coalition nursing staff played a significant role during the course of the RCT, both as interventionists and leaders of care teams.

The Camden Coalition joined with partners to address inequities in maternal health outcomes, access to cancer screening and treatment, challenges in access to healthy food, connections between healthcare and the faith community, youth tobacco use prevention, school attendance, improvements to the built environment, and more.

The coalition created My Resource Pal, an online social services database of Camden area resources. The free site is accessible for both individuals looking for direct services for free or reduced cost as well as providers connecting patients to food, health, housing, transportation, employment services, and more. The coalition also participates with social services network Aunt Bertha to integrate My Resource Pal into the Health Information Exchange. This partnership allows providers to access social needs information, refer patients to local resources, and access past social services referrals for a more cohesive record of patients' social needs.

Camden Coalition also created ecosystems of care (Noonan, 2019) , both within Camden and across the country. Such ecosystems are co-designed with consumers and require connectivity and interdependence across sectors, professions, and fields. Furthermore, the Camden Coalition recognizes that the path to health equity will not be forged by a single organization or individual. Instead, through multi-sector, interdisciplinary coalitions working together to transform systems, they can serve individuals' and communities' needs.

The NCEMNA is the only coalition in the UnitedStates that represents the diverse needs of one million racial and/or ethnic minority nurses. NCEMNA is comprised of five national organizations (Asian American/Pacific Islander Nurses Association, National Alaska Native American Indian Nurses Association, National Association of Hispanic Nurses, NBNA and the Philippine Nurses Association of America ) with a commitment to advocating for equity and justice in health care as a unified voice in the UnitedStates.

In 1998, NCEMNA was introduced to the national health leadership and organization community with the initial directors (Dr. Betty Smith Williams, Dr. Bette Keltner, Dr. Kem Louie, Dr. Antonia Villarruel, and Ms. Lolita Compas) representing their organizations. The initial and continued activities of NCEMNA focus on eliminating racial and ethnic disparities and increasing the number of minority nurse researchers. NCEMNA leaders built on existing contacts with both private and public organizations. They identified areas of mutual concern and sought to establish partnerships. These included: Collaborative Workshops with the National Institute of Nursing Research to develop a research and training agenda related to eliminating health disparities and increasing the pipeline of minority nurse investigators, Symposia at the American Academy of Nursing, publication of five white papers on the status of ethnic minorities' health and recommendations for nursing research in Nursing Outlook, Biennial American Nurses Association presentation "Eliminating the Nursing Shortage: Ethnic Minority Nurses an Untapped Source," Aetna/NCEMNA Scholar Program, $50,000 Grant, and receipt of a $2.4 million National Institutes of Health, National Institute of General Medical Sciences 5-year grant for a program to increase ethnic nurse scientists.

The mission of NCEMNA is to "Be the unified body advocating for equity and justice in healthcare." The coalition's vision is "To be a leading voice and driving force for ethnic minority populations." Over the years, the NCEMNA mission has continuously pursued as the member associations act as a unified force advocating for equity and justice in nursing and health care for ethnic minority populations. The NCEMNA Board of Directors and its officers maintain active efforts to promote ethnic minority nurse leadership in areas of health policy, practice, education, and research and to implement leadership development and mentorship programs.

NCEMNA describes a number of accomplishments since its formation. To confront health care disparity and inequality in the U.S., NCEMNA focuses on advocacy and public awareness as well as strengthening collaboration and linkage among ethnic minority groups, other organizations, and stakeholders. NCEMNA has produced several position statements, articles, and panel presentations related to violence, racism, and COVID-19. NCEMNA is at the forefront for leading change through its representation on a number of alliances including Nurses on Boards Coalition, the Future of Nursing 2020-2030 report, National Commission on Racism in Nursing, and the Future of Nursing Equity, Diversity, and Inclusion Steering Committee.

NCEMNA uses its' partnerships, collaboration, and synergy to lead, inspire, and influence. NCEMNA strives to work together to realize the member organizations' shared goals and be successful in meeting the challenges of building a healthier community, free of racism, health disparities, and inequities that lead to poor outcomes. The coalition continues to use effective strategies to advocate for those initiatives that are important to NCEMNA. The coalition is the voice for the voiceless, those unheard, and underserved, for the purpose of advocating for policy change, resources, a diverse workforce, and cultural congruency.

There is a growing awareness that limited health-care coverage and lack of access are only part of the reason why health disparities exist. Many of the strongest predictors of health are social, economic, and environmental factors. Reducing disparities requires national leadership to engage a diverse array of stakeholders; facilitate coordination and alignment among federal departments, agencies, offices, and nonfederal partners; champion the implementation of effective policies and programs; and ensure accountability (Centers for Disease Control and Prevention, 2013). Therefore, NCEMNA collaborates on innovative engagement activities that take advantage of the expertise, proven track record and experience of the NCEMNA member associations. The member associations address disparities through advocacy, strategic multicultural approaches, community and provider engagement and technological advancement.

NCEMNA's established goals remain especially relevant for today's health equity challenges and include: (a) the development of a cadre of ethnic nurses reflecting the nation's diversity; (b) advocacy for culturally competent, accessible and affordable health care, (c) promotion of the professional and educational advancement of ethnic nurses, (d) education of consumers, health care professionals and policy makers on health issues of ethnic minority populations, (e) development of ethnic minority nurse leaders in areas of health policy, practice, education and research, and (f) endorsement of best practice models of nursing practice, education, and research for minority populations.

The Future of Nursing: Campaign for Action

In 2010, AARP Foundation and AARP, the nation's largest nonprofit, nonpartisan organization dedicated to helping people 50-plus seek and create wellness in all aspects of life, joined the Robert Wood Johnson Foundation (RWJF), the nation's largest philanthropy devoted to building a Culture of Health, to launch the Future of Nursing: Campaign for Action. The Campaign is a national initiative to ensure everyone in America can live a healthier life, supported by nurses as essential partners in providing care and promoting health equity and wellbeing. Guided by recommendations from a 2011 Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, the Campaign built a network of national and state coalitions comprised of leaders from nursing, health, business, education, and other sectors to strengthen the nursing profession (Campaign for Nursing, n.d.-aEditor: Note that this citation is not highlighted.). The Campaign has coalitions in nearly every state and the District of Columbia and is ARTICLE IN PRESS N u r s O u t l o o k 0 0 ( 2 0 2 2 ) 1 À1 1 coordinated by the Center to Champion Nursing in America, also an initiative of AARP Foundation, AARP, and RWJF. The Campaign is led by director Susan B. Hassmiller, PhD, RN, FAAN, at RWJF, and chief strategist, Susan C. Reinhard, PhD, RN, FAAN. The Campaign for Action has achieved many milestones including: (a) creation of a broad network of national and state coalitions that include more than 1,000 businesses, health organizations, hospital systems, insurers, private companies, and non-profit organizations; (b) modernization of state laws and regulations so nurses can practice to the top of their training and education, improving care for 84 million people in 24 states (up from 11) (Campaign for Action, 2021a, August 5); (c) placement of more than 10,000 nurses on boards or decision-making bodies (Nurses on Boards Coalition, 2021); and (d) diversifying the nursing workforce so that it more closely reflects the communities it serves. The percent of white nurses in the RN workforce declined about 6% from 2009 to 2019, while the percentage of Hispanic, Black, and Asian nurses in the RN workforce nudged upwards in that same time frame, increasing by 3.34%, 1.74%, and 1.12%, respectively. Additional promising data show the number of pre-licensure registered nursing school graduates from underrepresented groups increased by almost 80% in that same time frame (Campaign for Action, 2021b, September 18).

The Campaign credits its success to a number of key strategies. These strategies include the partnering and institutional commitment of three respected and powerful organizations, funding and fundraising technical assistance for state/local coalitions and relationship building through convenings, learning collaboratives and other programs. The Campaign also relates its success to the creation of simple, succinct "Campaign imperatives" that served as its North Star; messaging relevant not only to nurses but to a consumer and/or public audience; and the use of measurable short and medium-term dashboard goals to maintain the Campaign's focus.

The Campaign has learned many lessons through its nation-wide coalition building efforts. When the Campaign launched in 2010 to implement IOM recommendations, the work was focused on strengthening the nursing profession by advancing education, leadership, and scope of practice, among other recommendations. Much of the focus was on nurses and the nursing profession. It became important to change the narrative and speak about these issues in a way that made them relevant to anyone who has ever sought health care: nearly everyone. The Campaign carefully tracked its progress on more than two dozen national measures on a dashboard (Campaign for Action, 2021c, September 15) updated twice a year for all to see on its website. Finally, the Campaign also learned that it is often impossible to get everyone on board for new undertakings but going with a "coalition of the willing" is effective.

The Future of Nursing 2020-2030 report identified eight competencies essential for nurse leadership in achieving health equity, and one of them was "leading multisector partnerships" (National Academy of Medicine, 2021) . This is a central tenet to the Campaign's work, along with a commitment to working with diverse and broad-based partners to eliminate health disparities. Advancing health equity will require the involvement, ideas, and energy of people and organizations from every walk of life. The Campaign is poised to tap the thousands of organization partners from the past decade, as well as align endeavors with AARP, which shares the same priority of eliminating health disparities.

The Campaign identifies the health equity agenda as everyone's agenda, not owned by nurses or any individual sector. Influencing the health equity agenda requires thinking creatively, across sectors, state lines and political divides to eliminate health disparities, tackle institutional racism, and create a nation where all have a chance at wellness.

Communication and messaging strategies, partnerships with members of the community in need, responses to COVID-19, and funding streams vary among the five exemplar coalitions. While the coalitions differ in their approaches, their success is based upon understanding of, commitment to, and entrenchment in their population of interest. This steadfast commitment to their populations is also seen in the myriad of research strategies and policy initiatives employed to achieve their health equity goals. Whether face-to-face or virtual-only meetings, community COVID-19-focused or nursing-centric organizations, each coalition assesses their population's needs and meets them in innovative, relationship-building ways. An aspect needed for coalition sustainability is innovative sources of funding, whether funds are self-raised, government-supported, or contributed by foundations. Despite differences in their approach, these exemplar coalitions share a unified message of the profound influence of collaboration, which resonated in the language of each community coalition: (a) Latin-19, "long-term goals will only be achieved through collective leadership and trusting, collaborative partnerships and alliances that honor the voice of the Latinx community;" (b) BCAC, "in Black communities, the work of eliminating health disparities and improving health outcomes is larger than any one group; coalition-building and collaboration across boundaries are critical;" (c) Camden Coalition," the path to health equity will not be forged by a single organization or individual. Instead, through multi-sector, interdisciplinary coalitions working together to transform systems, they can serve individuals' and communities' needs." Furthermore, NCEMA and the Campaign identified as key roles their engagement with broad-based partners in order to advance health equity.

The Future of Nursing 2020-2030 report referred to coalitions as an "empirically based intervention," referencing a Disparities Leadership Program evaluation study involving coalition leaders of disparityeliminating stakeholders from 31 different states (Betancourt et al., 2017) . Unfortunately, evidence supporting the benefits of coalition activities historically lacked consistency in reporting coalition characteristics (Anderson et al., 2015) , use of valid and reliable tools to measure their effects (Granner & Sharpe, 2004) , and outcomes beyond coalition members' perceptions of desired behavior change (Zakocs & Edwards, 2006) . To be able to increase the rigor of coalition effectiveness research, future research questions must explore two critical questions: (a) whether the synergistic interaction of multiple sectors impact behavior and health outcomes and (b) if coalition activities alone or conjunction with other approaches are more effective than other approaches at impacting community change (Kegler et al., 2020) .

Beyond coalitions being the mechanism that addresses structural change toward health equity (Brown et al., 2019) , coalitions can partner with groups doing health equity and structural intervention research, serving as facilitators of community engagement in and trust of research. One example of coalition partnership in research is community-based participatory action research which is considered not only a research method but also a process and an outcome (Giachello et al., 2003) . Coalitions can also partner with academic and professional organizations for other research endeavors, including conducting research, recruiting participants, and supporting community members as leaders in research. When translating research into nursing practice, nurse leaders can connect with coalitions for mutually beneficial partnerships. In so doing, nurse leaders, researchers, and health care system partners should embrace the expertise coalitions espouse regarding their members, target populations, and communities. Providing nurse support for coalition health initiatives and including the voices of coalitions in health care delivery decisions that impact coalition-supported communities, is critical to advancing health equity.

Health policy and advocacy activities are fostered by bidirectional relationships between coalitions and policymakers. Coalitions as stakeholders can inform policies and provide the "lived experiences" as they engage with legislators and state and local officials to benefit their specific populations. Coalition members educate policy makers about critical issues such as the inequitable impact of COVID-19 on certain populations or the need for maternal postpartum coverage up to one year. The power of the people is seen as coalitions, especially those comprised of diverse groups, come together with collective voices to influence policy decisions. That reflects the power of many versus the power of one group. Such coalition efforts have influenced advancement of such federal legislation as the Black Maternal Health Momnibus Act (2021) and Maternal Health Quality Improvement Act (2021). Leaders of coalitions also engage in dialogue regarding the need for local, state, and federal funding. That advocacy can provide varied perspectives and the evidence for more informed policy decision making. On the other hand, the direction can change so policies cause coalitions to be created or inform coalition endeavors. We must continue to prepare nurses for critical roles in coalitions including being actively involved in policy arenas where decisions are made and conducting research. Coalitions that focus on the nursing profession are also critical in elevating the presence and voices of nurses in governmental and legislative environments. These advocacy efforts benefit not only nurses but the health equity of those they serve.

Building influential coalitions that improve health equity requires the use of innovative strategies at local, state, and national levels. Interwoven in the real-world coalition work presented are the critical roles nurses must assume if we are to create solutions for the health inequities that exist in our society. Nurses have opportunities to lead initiatives and collaborate with other organizations as we address the needs of communities, partner with coalitions for health equity and community engaged research, and advance health equity dialogue in policy arenas. Through the Future of Nursing 2020-2030 report, the call to action has once again been sounded for nurses to not just identify health inequities but to lead and contribute to improving health equity for the sake of our nation. 

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