Analysis of MN’s Journey to Full Practice Authority:

What Worked & Why?

Mary L. Chesney, PhD, APRN, CPNP, FAAN

Clinical Associate Professor, U of MN School of Nursing

Co-Founder & Past President, MN APRN Coalition

Disclosure Statement

I do not have any contractual or financial conflicts of interest to disclose. I will not be endorsing any products or drugs during my presentation.

Presentation Objectives

• Describe the build-up to launching the 2013-14 legislative campaign for FPA in MN.

• Analyze key external factors and competing coalition factors that influenced legislators to favor FPA legislation in MN.

• Identify strategies and lessons learned.

May 13, 2014, St. Paul, MN

Today, Governor Mark Dayton signed into law a

bill that removes regulatory barriers for Advanced

Practice Registered Nurses (APRNs). The law

grants all four roles of APRNs autonomous

practice and removes the requirement for

physician oversight of APRN practice and

prescriptive authority.

Learning from Failures

“Those who cannot remember the past are condemned to repeat it.” (Santayana, 1905)

• Prior failed legislative attempts to gain APRN autonomy (1996, 1999, 2009)

• Building anew: Honest reflection – resolving differences – appreciation – setting egos aside

• Identified needs: • Infrastructure

• Unified external & internal communication plan

• Focus on MN Citizens – not us

Advocacy Coalition Framework (ACF)Sabatier & Jenkins-Smith, 1999

Relatively Stable Parameters

External Subsystem Events

Long-Term Coalition

Opportunity Structures

Policy Subsystem

Coal. A v. Coal. BResources ResourcesStrategies Strategies

Decisions byGovernment Authorities

Policy Outputs

Policy Impacts

Short-Term Constraints & Resources of

Subsystem Actors

Ultimate Goal APRN FPA

• National APRN Consensus Model • All 4 APRN roles

• 2nd Licensure as APRN

• Graduation from accredited graduate program

• National certification – Role & population focus

• Removal of two key barriers• Collaborative practice agreement with MD

• Written prescriptive agreement with MD

• Autonomous practice

• Autonomous prescribing

• Regulated solely by Board of Nursing

Strategic Plan

• Place citizens at heart of the problem

• Build broad, unified coalition infrastructure

• Build strong legislative relationships over time

• Use every opportunity to educate and build our case prior to legislative run

• Develop effective communication plan

• Hire lobbyists

• Draft & execute legislative plan

• Develop strong grassroots system

• Continuously broaden coalition & garner support

Problem Statement• MN has major, widespread primary care physician

shortages; unmet rural anesthesia & birthing needs

• All of MN APRNs are needed to address health care provider shortages and meet citizens’ healthcare needs

• Current barriers limit or prohibit all APRNs from practicing to fullest extent of education & training

• Therefore, barriers to APRN practice reduce citizens’ access to care & limits choice of provider

Guiding Principles

• All for one, one for all

• Speak with unified voice

• Speak truth & behave as credible, respected professionals

• Trust, communicate differences internally, NO SIDEBARS, NO RUMORS – go to source & check it out

• Do not allow opposition to divide & conquer

• It will take EVERYONE to move legislation –GRASSROOTS EFFORTS ARE KEY!

Disciplined Communication Plan

• Internal

• Continually inform – info updates

• Talking points – unified voice; stay on message

• Email blast system

• Social media presence

• External

• Disciplined legislative protocol (spokespersons, message)

• PR & press plan for nimble, rapid response

• Evidence-based fact sheets for legislators

Infrastructure

• Built entirely new coalition – MN APRN Coalition (Fall 2009 – early 2010)

• Mission & vision (2010)

• Incorporated in MN (Fall 2011)

• IRS 501c6 not-for-profit designation (2013)

• Dues & revenue generation structure

• Logo

• Website & FB page

• Lobby team

• Recruit members (2,000 of 6,100 joined)

The MN APRN Coalition is dedicated to improving patient access and choice to

safe, cost-effective health care by removing statutory, regulatory, and institutional

barriers that prevent APRNs from practicing to the fullest extent of their

education and training.

Mission Statement

Importance of Social Media

• Facebook

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Use Every Opportunity

• Secured seat on 2010 Legislative Access Commission Health Workforce Task Force

• 2012 Governor’s HC Reform Task Force

• Submitted written comments & testified in Access & workforce workgroup

• Enacting APRN Consensus Model to increase access to care was a recommendation in final report

Grassroots Plan

• Division of state into 8 districts with 8 captains

• Targeted districts of House & Senate HP Committee members

• One-page fact sheets

• Coached members and provided bulleted legislative meeting scripts with 3-4 key, unified messages; updated as needed

• Asked members to get 2-3 family/friends to send email letters or calls

• System for handling legislators’ questions/concerns

Legislative Strategy - Stake

• What’s at STAKE? (See C. McGoff, 2015)

- PUSH+ PULL

Adaptation of C. McGoff’s Graphic re: Stake, C. McGoff, 2015)

Key House & Senate Leaders

• House Search

• Senate Search c. C

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The Legislative Story

• Bill introduced January 2013

• Health policy committees’ heavy lift in 2013 delayed hearing until 2014

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Tale of Two Legislative Bodies & Two Chairs• Senate

• Compromise

• Progress

• House

• Two bills

• Left with shell bill

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The Opposition

• MN Medical Association

• MN Chapter of American Academy of Family Physicians

• MN Society of Anesthesiology

• MN Psychiatric Society

• Intervention Pain Physicians

• Emergency Room Physicians

Presented anecdotal stories, used exaggerated scare tactics (“what ifs “), & lacked credible evidence

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The Supporters• All MN APRN Organizations in Minnesota

• Every major nursing organization in MN (MNA, MNORN, MOLN, MACN, etc.)

• MN Chapter & National AARP

• MN Association of Community Health Centers

• MN National Alliance on Mental Illness

• MN Health Action Group

• Service Employees International Union – Health sector

• Students from MN schools of nursing

• Many physicians, nurses, consumers of health care

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Senate Progress

• Committee process

• Needed compromise

• 2,080 hour transition-to-practice with MD or APRN

• CRNAs doing invasive chronic pain management procedures must continue to do so under a practice/prescriptive agreement

• Senate Floor – eloquent bipartisan debate

• Victory on May 1, 2014 with unanimous vote 64-0

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End Around in the House

• House shell bill for H.F. 435

• House maneuver in rules committee to take up S.F. 511 in the House in place of H.F. 435

• 11 Amendments dropped in House within 24 hours of hearing

• All amendments defeated

• Victory in the House on May 8, 2014 with 119 to 13 vote!

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Basic Principles in the Legislative Trenches & Lessons Learned

• Be unified, settle differences internally, NEVER publicly

• Harder to change law than to maintain the statusquo.

• You have to leverage enough power to force your opposition to the table.

• Warm, trusting relationships with legislators are key to garnering legislative support

• Taking the high road of honesty, integrity, credibility, and kindness wins the day!

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Basic Principles in the Trenches& Lessons Learned

• Good health policy should garner bipartisan support. Don’t put all of your eggs in one party’s basket.

• Begin with a bill that allows for future compromise; don’t begin with the compromise that leaves you with no where to go.

• Expect a legislative campaign to be like a Chutes and Ladders game; stay calm and carry on!

• It’s not over until it’s over. NEVER GIVE UP UNTIL THE SESSION GAVELS TO A CLOSE!

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Key External Events

• 2013 MN MA Expansion & MN-Sure Legislation

• Majority of MN is rural, underserved (119 PC & 51 Mental Health HPSAs)

• Decades of evidence of APRN quality & safety

• Key evidence-based reports• 2010 IOM Future of Nursing Report

• 2012 MN Gov’s HC Reform TF Report

• 2014 FTC’s APRN Report

• Strong Nurse Legislators in Leadership Roles

• Increasingly positive public opinion about APRNs

Comparison of Resources

• Organized medicine had all the advantages as far as resources:

• Association paid staff; human resources

• 7 lobbyists compared to the APRN’s 2 FTE lobbyists

• Membership numbers

• Established relationships with press/media

• Seats on various legislative task forces and workgroups throughout the years

Strategies = Winning Differences

• APRNs built broad, formal coalition of key external and internal stakeholders

• Unified voice, message, and agenda (MD groups had varied agendas, issues, messages)

• Coalition members remained engaged throughout

• Strategic, organized, targeted grassroots campaign

• Two lobbyists – 1 democrat and 1 republican

• Leveraged key external events, evidence & personal stories to refute physicians’ key arguments; presented during testimony (MD testimony lacked evidence; MDs used only anecdotes, scare tactics, and opinions