Strategies and Tactics for Successful Legislation to Remove Barriers to APRN Practice and Care July 17,2012

Susan Reinhard, PhD, RN, FAAN Senior Vice President & Director, AARP Public Policy Institute; Chief Strategist, Center to Champion Nursing in America Susan Reinhard Thank you for joining us for today’s webinar on I’m Susan Reinhard, Senior Vice President & Director, AARP Public Policy Institute; Chief Strategist, Center to Champion Nursing in America. Before we go further, I wanted to mention that we are recording today’s webinar, so if you miss a section or would like to pass it on to a colleague, you can find the recording by going to  www.championnursing.org/events. I also want to let you know, in advance, that we intend to leave some time for questions from those on the phone after the presentation. So if you have a question, write it down or hold on to it and you will have an opportunity to ask it after the presentation. www.championnursing.org/events 2

Institute of Medicine Report High-quality, patient-centered health care for all will require a transformation of the health care delivery system Susan Reinhard As all of you know, In October 2010, the Institute of Medicine released a landmark report that outlines a blueprint for transforming the nursing profession to enhance the quality and value of U.S. health care in ways that meet future needs of diverse populations. The first of the eight recommendations made in the report is to remove scope of practice barriers to that “advanced practice registered nurses should be able to practice to the full extent of their education and training”. One of the most-viewed online reports in IOM history 3

The IOM Report : Key Messages and Recommendations Key message #1 Nurses should practice to the full extent of their education and training Recommendation 1: Remove scope-of-practice barriers For state legislatures: Reform scope-of-practice regulations to conform to the National Council of State Boards of Nursing Model Nursing Practice Act Susan Reinhard You are all familiar with the IOM Report’s key message and recommendation # 1. Today we are specifically discussing legislative change. 4

Practice 5 Susan Reinhard This is our famous CCNA map – which we adapted from Linda Pearson’s work – and titled it “Restrictive Collaboration Requirements by State” These requirements for physician collabobarriers to nurse practitioner care. You may notice that this slide has been updated from the version which appeared on page 99 of The Future of Nursing: Leading Change, Advancing Health to reflect NORTH DAKOTA’s successful legislation to remove the written collaborative agreement. It is now my privilege to introduce Connie Kalanek and Billie Madler. Constance B. Kalanek, PhD, RN, FRE, is the Executive Director, North Dakota Board of Nursing. Dr. Kalanek is also a member of the Advanced Practice Registered Nurse Committee of the National Council of State Boards of Nursing. Billie Madler, DNP, FNP, is the director of the Graduate Program, University of Mary and is also Past President, North Dakota Nurse Practitioner Association   5

North Dakota’s Legislation SB 2148 A bill to remove the regulatory requirement for APRNs to have a physician signed affidavit on file with the Board of Nursing Passed overwhelmingly Made effective August 1st, 2011 Link to SB 2148 Madler, B. M., Kalanek, C. B, Rising, C. (2012). An incremental regulatory approach to implementing the APRN consensus model. Journal of Nursing Regulation, 3(20), 11-15 Billie SB 2148 was introduced to the North Dakota Senate Health and Human Services committee on January 6th of 2011 and heard in that committee on January 18th. This committee gave a do pass recommendation on January 27th, 2011 and passed the Senate floor the following day. The bill was heard in the House committee on February 23rd, 2011 and given a do pass recommendation. On March 17th, SB 2148 passed the House floor vote and was signed by the Governor on March 31st. 6

Prescriptive Privileges Billie Requirements for collaboration regarding prescriptive privileges was the only regulatory barrier APRNs faced in ND. Prior to successful passage of SB 2148 nurse practitioners were required to have on file with the North Dakota Board of Nursing a physician signed affidavit. This affidavit identified who the nurse practitioner’s collaborative physician partner was. NPs in ND would not be granted prescriptive authority without have this documentation of a collaborative physician.

State Dynamics: Pre-Legislation State demographics Rural, geographically sparse Conservative Culture of hierarchy Communication and networks Incremental Legislative Efforts Connie North Dakota has a small population (672,591) in a large area (69,000 square miles) (U.S. Census Bureau, 2010). The state is prosperous because of the diversity of farming, oil, and gas industries. North Dakota also boasts a balanced budget with a surplus. However, the rural areas remain underserved: 60.8% of the population (U.S. Census Bureau, 2010) resides in rural communities, and 74% of physicians reside in the cities of Bismarck, Fargo, Grand Forks, Mandan, and West Fargo. Only 26% of physicians are in rural areas (Hart, Klug, & Peterson, 2012), though 40% of APRNs practice in rural areas (North Dakota Board of Nursing Database, 2012). Other environmental contexts perhaps unique to North Dakota that influenced the work of addressing regulatory barriers: Conservative state, culture of hierarchy, communication and networking….

Strategies and Tactics for Successful Legislation Preparedness NDNPA Partner with NDBON Stakeholders and opponents Billie Preparedness Move very quickly once the legislative session started. So, it was critical that nursing was well prepared in advance. Conversations within state NP professional organization (NDNPA) Consent from NDBON to move forward Initial conversations with stakeholders including leadership from healthcare organizations, other state and national professional groups (including AARP), ND Leadership Council, and discussion with North Dakota Board of Medical Examiners, and North Dakota Medical Association.

Strategies and Tactics for Successful Legislation Willingness

Strategies and Tactics for Successful Legislation Bill sponsor, bi-partisan co-sponsors Lobbyist Developing our story Communicating – Highlight local impact Engaging NPs Billie Strategies Selecting a well respective, veteran legislator that is knowledgeable and has a record of supporting health related legislation Securing a lobbyist that versed in healthcare regulatory environments and familiar to the legislative process and individual legislator Preparing succinct and consistent message that were meaningful and powerful – did this by communicating with NPs in the frontlines from all across the state. Providing real life examples of the barriers the current law created for NPs and the citizens from individual legislators districts. Gathering written support from professional organizations, special interest organizations, county commissions, healthcare administrators, and supporting physicians. Testimony planning – 4 NPs and 2 physicians who had a history of being collaborators with NPs and the NDBON. NPs testimony strategic –1 NP provided explanation of role and scope, 1 NP shared personal story of working in rural ND and her practice, 1 NP owned and operated her own clinic and reviewed documents of support, and 1 NP national publications/research and NP education. Others who testified in support were bill co-sponsors and a Representative who was a nurse practitioner. Communication was key. The core group of 4 NPs working on this piece of legislation were on the phone and email continually with NPs from across the state. They were encouraged, motivated, and empowered to participate in the effort. As a result, NPs all over, were mobilized. Many of these individuals spoke with their legislators. Several invited legislators to their clinics, some met face to face, all of them shared their passion for providing patient-centered care. In addition, the Representative who was a nurse practitioner provided insight to the legislators that needed additional education. She also fielded questions from her colleagues.

Consensus Model Implementation https://www.ncsbn.org/2567.htm NCSBN’s APRN Campaign for Consensus: State Progress toward Uniformity

Lessons Learned Billie and Connie It can be done!! Being present is good; Being visible is better, Being patient is necessary Focus on the message Be transparent Foster partnerships and cultivate relationships

Maryland’s 2010 Legislation Susan Reinhard will then introduce Susan Delean-Botkin and Hank Greenberg. Susan Delean-Botkin, MSN, CRNP, is Owner, Family Care of Easton, Maryland and the Past President, Nurse Practitioner Association of Maryland. Hank Greenberg, is State Director, AARP Maryland. In 2010, Hank was the Director of Advocacy for AARP Maryland Susan will mention the groups that supported the legislation. Hank will briefly mention AARP’s role. The 19 page written collaborative agreement was replaced by a one page attestation statement Legislation was jointly promulgated by the Maryland Coalition of Nurse Practitioners and the Nurse Practitioner Association of Maryland with the Board of Nursing Important for nurses to speak as one voice AARP Maryland added the consumer’s voice

Removing Barriers to APRN Practice and Care Learning Collaborative Themes in the Action Coalition Quarterly Reports (handout) AC leads submitted names of Recommendation 1 workgroup leads (handout) Monthly teleconferences planned Quarterly webinars New CCNA/CFA website will be launched in September. Susan Reinhard introduces Thank you Susan and Hank. I would now like to introduce Winifred Quinn, PhD, Director of Legislation and Campaign Operations, who will tell you about the Removing Barriers to APRN Practice and Care Learning Collaborative. 15

Questions? 16 Susan Reinhard Thank you Winifred. And I would also like to thank our North Dakota speakers Connie and Billie. All our speakers will be available for Q & A. I would now like to open the lines for Q&A Prompt the operator. While waiting for Audience Questions, Here are a few Susan R can pose to presenters: When we talk about “lessons learned” we don’t often describe how we learned from our mistakes. What “mistakes” could other states avoid? Talk about timing and when NOT to introduce legislation. 16

Campaign Resources Visit us on the Web http://thefutureofnursing.org http://championnursing.org Follow us on twitter www.twitter.com/futureofnursing http://twitter.com/championnursing Join us on Facebook http://facebook.com/futureofnursing http://www.facebook.com/championnursing Susan Reinhard The United States has the chance to transform its system and culture of health care, but only if all nurses – RNs and APRNs are able to practice the full extent of their education and training. Through efforts nationally and locally, the Campaign for Action aims to utilize the skills and potential of these women and men to effect sweeping change. We need all of you to join us. Together, let’s create a health care system that provides seamless, accessible, affordable and equitable quality care for every American. That concludes today’s webinar. Check us out on the web, follow us on twitter, or join us on Facebook! Thank you and goodbye. 17