For anyone with half a soul (and that includes most all nurses I have ever known) the question to ourselves always arises at some point: “How can I be the most effective at helping to create some good in the world through what I do?” Is it through direct service, such as working as a nurse providing the best care to individual patients or to entire communities? Is it through active political engagement and advocacy, or even running for political office? Is it through more radical agitation for change, through activism of some type?

My students in the community health courses I teach are familiar with my college-aged daughter’s old collection of beanie babies. I throw the babies at students. (Margaret, if you’re reading this, no worries: no babies are lost or hurt in this class activity–and no students have been permanently injured either). I use the beanie babies in our first class as part of an enactment of sorts of the familiar parable of the babies in the river. (If it’s not familiar to you, here’s a link to my favorite version of this story by Steven Mayer, PhD of the Effective Communities Project: Saving Babies: Looking Upstream for Solutions. All of the versions I’ve seen mentioned in community/public health nursing texts are brief and insipid by comparison.)

I use the story to illustrate the pros and cons of direct service/patient care (pulling babies from the river, setting up more hospitals, ‘baby’ rehabilitation units, foster care homes–all sometimes referred to as ‘band-aide’ care ), versus the ‘upstream’ community-based nursing interventions of finding out how and why the babies got in the river to begin with and working with the community to prevent this from happening. As Dr. Mayer points out in his article, we need people to do both downstream and upstream work in order to save the babies. He also points out that our society puts more resources and emphasis on downstream ‘feel good’ efforts and not as much on the more politically-charged (and difficult to change) upstream measures that are threatening because they challenge the power structures of society. He states, “The term ‘social change’ is part of the same category of emotionally-laden terms as ‘racial equity,’ ‘social justice,’ advocacy,’ ‘activism,’ and ‘reform.'”

I mix the Babies in the River story with an excellent training module from the Bonner Curriculum/Bonner Foundation for community engagement in higher-education. The module is called “Bridging the Gap Between Service, Activism, and Politics.” It starts out with quotes by Mother Teresa (direct service,) Robert F. Kennedy (duh–politics–although for nursing/health care a quote from Lyndon B. Johnson would be more appropriate), and Martin Luther King, Jr. (activism). I ask them to work in groups of 3-4 and discuss the advantages and disadvantages of each ‘type’ of engagement, especially as it relates to health care. I also ask them to identify which of the three they personally feel most strongly drawn to and why. Not surprisingly, the vast majority strongly identify with direct service–although a strong (and vocal!) minority identify with activism. Only a few identify with politics. Of course, the vast majority of our nursing education focuses on direct service/care, and usually only gives passing (and cringing) reference to nurse engagement in politics and activism.

The ‘correct answer,’ if there is such a thing, is that we need nurses working in all three types of engagement and in both upstream and downstream health care efforts. In my own work I have found they are mutually reinforcing, and maintaining some direct patient/community care work informs and grounds my political and advocacy (and more upstream, out there activism) work. I am aware that there are many direct patient care nurses who would like to be more politically and advocacy/activist-engaged, but have legitimate fears of losing their jobs if they do so. Many activist nurses come from more privileged backgrounds and can ‘afford’ to stir things up. So how can we as nurses support and challenge each other to work for positive changes in our health care system?