Lynda Woolbert “You will never change anything by talking to yourselves. Stop complaining to other APNs and start educating people who can help fix the problem.” —Kathy Hutto All advanced practice nursing legislation introduced in Texas from 1979 to 1985 was defeated. Texas advanced practice nurses (APNs) finally got physician-delegated prescriptive authority in 1989. This passed only with stipulations that APNs work sites that serve certain medically underserved populations and because Texas would have lost federal funds if it hadn’t passed (Texas Nurses Association, 2009). Four women changed the political balance of power for Texas APNs. Elaine Brightwater, a certified nurse midwife (CNM); Carol Cody and Zo DeMarchi, both women’s health nurse practitioners (WHNPs); and Ira Gunn, a certified registered nurse anesthetist (CRNA), advocated at the Texas State Capitol for their respective advanced practice nursing (APN) organizations. They recognized the need to hire a lobbyist to focus on APN issues and to have a policy group directly accountable to their organizations. The nurses knew legislation that was good for nurse practitioners (NPs) and clinical nurse specialists (CNSs) sometimes undermined the practices of CNMs and CRNAs, so this new group had to balance the needs and interests of the four APN roles. In 1991, the four APNs met with a few others to devise a plan to obtain funding and support from their organization’s boards and members. They desired to form a coalition of APN organizations and hire a lobbyist. By November 1991, these goals were accomplished. By 1992, the Coalition for Nurses in Advanced Practice (the CNAP or the Coalition) had officers, and it was incorporated and designated as a 501(c)(6) organization. The CNAP was, and remains, a coalition of Texas APN organizations. The group’s primary purpose is to advocate for APNs at the Texas legislature and with Texas regulatory agencies. The CNAP has no individual members and is accountable to its member organization’s boards. Each board determines how much it contributes and names representatives to attend CNAP meetings. The CNAP operates on consensus. If a decision has the potential to harm any group of APNs, the Coalition does not pursue it without specific approval by the group that might be harmed. It is a “one for all and all for one” philosophy set forth in the operating principles adopted in February 1992 (CNAP, 1992). These principles have never been amended and serve to keep the CNAP true to its roots. The structure is nimble and produces swift decisions when needed. The consensus model is a key to the CNAP’s continued existence and success. The leaders who established the CNAP knew that power must be balanced among the four APN groups. CNAP representatives need to have a good understanding of each other’s practices to make wise policy decisions. To that end, the initial CNAP representatives educated the lobbyist and each other about each APN role’s history, legal framework for practice, and resulting practice barriers, as well as the history and structure of each member organization. Kathy Hutto, the Coalition’s principal lobbyist, led the transition from talk to action. She said, “It’s been important to learn about your practices and the barriers you work around to take care of your patients. Now it’s time to figure out what to do about it. You need to identify three goals to focus our efforts.” Three broad objectives were defined that remain the core of the CNAP’s legislative and regulatory work today (Box 87-1). The three-pronged approach serves APNs well. In years when the Coalition cannot make progress in one area, representatives focus on one or both of the others. Kathy Hutto gave CNAP representatives another valuable insight regarding taking action: “You will never change anything by talking to yourselves. Stop complaining to other APNs and start educating people who can help fix the problem.” In 1992, the Texas Medicaid program reimbursed only four types of APNs. CNMs were reimbursed at 65% of the physician’s fee, and CRNAs, FNPs, and PNPs were reimbursed at 70% of the physician’s level. APNs wanted to expand Medicaid coverage to include all types of NPs and CNSs and increase the reimbursement rate to 100% for all categories of APNs. The Texas Medical Association opposed those changes. At the time, the Texas Department of Human Services Board approved the types of Medicaid providers and their reimbursement rates. Most of the Human Services Board members were not familiar with advanced nursing practice. APNs were selected to testify at a hearing on the matter, and Kathy Hutto, the lobbyist, helped them prepare testimony. Critical work occurred before the hearing. CNAP members educated board members, while Kathy Hutto and others met with Texas Medicaid staff. Supportive board members were asked to discuss the issue with other members and were encouraged to ask questions that reinforced information favorable to APNs. The CNAP left the Human Services Board hearing with a substantial win that day. All APN categories would be reimbursed at 85% of the physician’s fee. Any organization that retains lobbyists requires a healthy revenue stream. The CNAP does not have that. The Coalition values the participation of essential APN stakeholders over money, and minimum dues to join are only $500. Member organizations contribute in proportion to their membership and ability. The CNAP relies on contributions from individual APNs; those represent about half of the Coalition’s income. The CNAP negotiates relationships with a number of organizations. When it was established, it intruded on the Texas Nurses Association’s “turf.” A mediator helped the parties develop a good working relationship. The Coalition must actively maintain relationships with its member organizations. The CNAP bears the responsibility for delivering unique services and consistently articulating the value of its services to member organizations so they continue to recognize the Coalition’s value. The biggest challenge the CNAP faces is also the reason it exists. The Texas Medical Association (TMA) has 43,000 members (Texas Medical Association, 2009). Through its county medical societies, TMA has a network of physicians that keep legislators informed about medicine’s issues. In 2009, TMA had 27 lobbyists, and an additional 22 lobbyists represented other medical associations (Texas Ethics Commission, 2009). In contrast, CNAP member organizations had about 6000 individual members and 8 lobbyists (Table 87-1). TABLE 87-1 Number of Texas Advanced Practice Nurses and Physicians and Their Affiliated Lobbyists
Taking Action
A Rough Road in Texas: Advanced Practice Nurses Build a Strong Coalition
All is Not Rosy in Texas
The Coalition for Nurses in Advanced Practice is Born
The Coalition’s Operating Procedures
The Coalition’s Objectives
Action Leads to Accomplishment
The Coalition’s Challenges
Funding
Negotiating Boundaries with Established Organizations
The Opposition
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Taking Action: A Rough Road in Texas: Advanced Practice Nurses Build a Strong Coalition
