Betty R. Dickson “There are two things you don’t want to see being made—sausage and legislation.” —Attributed to Otto von Bismark “So, what do you do?” is a question I am frequently asked. To which I reply, “I am a lobbyist.” The looks that follow are either scornful, surprised, quizzical, astonished, or thoughtful. I wonder if the questioner associates all lobbyists with those who have been involved with high-profile scandals. Most likely the question is a reflection of not knowing what I do and a curiosity about the job. The reality is that few people know what really happens in the halls and offices of government. To be a successful lobbyist includes attending plenty of committee meetings, knowing the bill-writing process, watching and understanding political maneuvering, sitting through innumerable working meals and receptions, developing different friendships, watching and working in elections, and imparting reams of information. While nurses are excellent caregivers and the backbone of our health care system, few understand the influence that laws and regulations have on their practice; fewer are skilled at the long process of creating positive outcomes. My role as a lobbyist parallels advice from my mother: “Don’t cross the street without looking both ways.” In other words, “don’t approach a legislative body without a professional lobbyist, one who knows the ins and outs of the system.” I watch hundreds of schoolchildren, parents, teachers, and single-issue citizens converge on the Mississippi state capitol during the annual three-month legislative session. I watch as they wander the halls of what is probably one of the most beautiful capitol buildings in the United States. They come to observe, speak out about their issue, be recognized from the visitor gallery, and tour the magnificent capitol building. Then they go home. For 20-plus years, I have mentored nursing students and practicing nurses as they come to observe and be publicly recognized by legislators in the chambers. A few have spent the entire day with me, following closely as I attend committee meetings, listen to testimony and debates, and conduct personal visits with legislators. They leave with a new respect for the role of a lobbyist and the importance of having someone represent nursing during the legislative session. There’s an old cliché—There are two things one ought not to watch: making sausage and observing the legislative process. Watching the lack of/or uninspiring debate, or the grandstanding by legislators can be strange to the novice. Most of those who look behind the scenes or witness the process in depth are fascinated. Some even become “hooked” and come back again. With these one-day visits, visitors miss stories like the Bilbo statue, a bronze, life-size rendering of one of Mississippi’s most notorious racist governors who also served in the U.S. Senate. It once stood in a prominent place in the capitol, and as more and more African Americans were elected to the legislature, the statue began to be moved around. Today it has been relegated to one of the conference rooms—an insignificant place on the first floor of the capitol. Many of the older lobbyists know the significance of Bilbo’s positioning today—a tribute to how far Mississippi has come and a testimony to the rise in power and influence of African-American legislators. Visitors may not appreciate the excitement of watching a plan for legislation come to fruition—all the time, effort, and expertise negotiating that made it possible. As a result, they may not appreciate why a profession, business, or organization needs representation by a lobbyist. I started working as a lobbyist (Figure 69-1) in 1989 when I began a long journey learning the ropes of lobbying in a small state, rich with tradition and history—some bad, some notorious. In 1988, I became executive director of the Mississippi Nurses Association (MNA) and began my career as a lobbyist. Thankfully, my background as a journalist and newspaper editor, and my experience in government and public relations was a perfect combination for the responsibility of lobbying. Throughout the years, the MNA has had 95% of its legislation passed, some of which includes the following: • Securing significant annual funding for nursing education • Obtaining additional pay for school nurses who become certified • Increasing the number of school nurses • Obtaining controlled substance authority for nurse practitioners I worked for a group of nursing leaders in the MNA who understood the value of using the political arena to protect and advance the profession. My lobbying career got off to a big start. Innocently, I took the MNA leadership seriously when they told me their major objective was to have nurses at the seat of every table where health care decisions were made. During my first year at the MNA, our lobbyist was a nurse-attorney. During Desert Storm, the nurse/lobbyist went to work full-time for a law firm to fill a vacancy created by an attorney/guardsman who was called to active duty. I became the MNA’s only lobbyist. But while she was still working, we developed a strategy to access every code section in the law for every health care agency. We planned to try and amend the law to mandate that a nurse be on every governing board of any health-related agency, including the Department of Education. Although the legislation would define my career and reputation, I was totally unaware of the enormous opposition to “touching” any regulatory board’s composition. That first legislative session turned out to be one of getting acquainted with division and department heads, getting a comprehensive education about government agencies, and getting a ton of teasing from other lobbyists who thought this was a pretty gutsy move for a newcomer. Of course, the bill had little chance of passage, but once we searched the Mississippi code, drafted the bill’s language, asked a legislator to introduce the bill, and attempted to get a committee hearing on the bill, I learned the legislative process from the bottom up. To this day, those agency heads who are still around ask me at the beginning of each session if I have any surprises up my sleeve. It’s good to keep them guessing. As a result of that initiative and even without passage of the bill, the Department of Mental Health and the Department of Health, to this day, have a registered nurse on the Boards, including one who served as chair. As nurses serve on various boards, their value increases. Today nurses serve on numerous boards and committees in state government. Every time a piece of legislation comes forward in the Mississippi legislature, I am there as a lobbyist to ensure the insertion of the words nurse, school nurse, and nurse practitioner where appropriate in health-related legislation and regulation. Lobbying is about counting. I can count, nursing leadership can count, and legislators especially know the value of numbers. We use the strength of numbers to influence legislators. In the early 1990s, there were over 40,000 RNs and licensed practical nurses (LPNs) practicing in Mississippi, and we had to establish a mechanism to bring representatives from all those nurses together. We created the MNA’s Nursing Organizations Liaison Committee (NOLC) to bring 25 nursing organizations together to plan and agree on a legislative agenda. Representatives from each group worked collaboratively on a statewide nursing summit that 700 to 800 RNs and students attend annually. We invited key legislators to join us, and they could count the numbers for themselves. It was through this coalition that nursing began to be recognized as a significant force at the state capitol. That same coalition continues to work today in a collaborative effort to maintain a strong legislative presence. When the NOLC was formed, I told the group, “MNA is furnishing the lobbying for all of you. There’s a way for you to participate and to provide support for this effort” and they have. This group was involved in passing the law creating the Office of Nursing Workforce (ONW). My role as a lobbyist is to ensure that this office is adequately funded. The nursing shortage has been a major focus of the group. We developed long-range legislative plans. The first step was to retain nursing faculty, and the best way to do so was to provide faculty with a competitive salary. In 2007, we worked with the legislature to obtain a $6000 pay raise for all nursing faculty in the state. In 2008, the second installment of the pay raise was enacted; nursing faculty received their second raise of $6000. Many of those considering retiring changed their minds, while others decided to become teachers. In 2008, the next step was to add one additional faculty in all schools of nursing. That too was successfully enacted. In 2008, I lobbied to fund a study about simulation labs and how they could increase enrollment. The legislature appropriated $75,000 for this initiative. In 2009, they funded the next step, allocating $500,000 to the Office of Nursing Workforce to coordinate where, when, and how to implement a simulation lab program. A million here, a million there, and the next thing you know is that Mississippi has invested millions of dollars to resolve the nursing shortage. As a result, faculty numbers have stabilized and enrollment has increased. It helps to have a successful political action committee behind you (which the MNA has), and it helps to have a plan to “call in the nurses” when the need arises. I know that legislators really fear having large droves of citizens come to the capitol—whether it’s truckers, physicians, loggers, hair braiders … or nurses. I remember one issue in the early 1990s when an attempt was made to establish medication technicians in nursing homes. Nurses were strongly opposed to this new provider whose only requirement was a high school education and a few weeks of training. The vice chair of the House of Representatives Public Health and Welfare Committee was assigned the bill and scheduled a public hearing. MNA arranged for over 100 nurses, in uniform, to attend the hearing. When the committee chair couldn’t get everyone in the regular conference room on the first floor because there were so many nurses, he moved us to a larger room on the second floor. It became apparent that the second room was too small, so he moved us to an even larger room back again on the first floor. Imagine 100 nurses marching to a room on the first floor, and then marching upstairs to another room, then down the stairs to the room on the opposite end of the hall. It created a lot of excitement, lots of stares, and lots of curiosity. It also established several points about the nursing community: We are well organized, there are a lot of us, and we will make plenty of calls to our legislators. When the chair finally got the hearing under way, the nurses were breathing pretty heavily; but when testimony began, the breathing became a little more pronounced. And when one of the opponents, during testimony, said something disparaging about nurses, all 100 gasped in unison. It even scared me, and I was on their side. Needless to say, the chair ended the hearing without a vote on the bill. Mississippi still does not have medication technicians. Successful lobbying often depends on being in the right place at the right time. Once a state senator called me to review an immunization bill he wanted to introduce. After reading through the bill, I told him that I thought we were already doing what he wanted to do with the legislation. His reply was that he wanted an immunization bill! I told him I would get back with a suggestion. I was the MNA’s representative on the Mississippi State Health Department’s Immunization Task Force, so I called the chief of staff at the health department, a nurse. She suggested that we convince him to introduce a bill for a statewide immunization registry, one of the goals of the task force. I did. He loved the idea. He introduced a bill, and we worked very hard for passage. Today there is a statewide registry for tracking immunization. The result is that Mississippi has one of the highest immunization rates in this country. The same nurse and I were in the capitol during a legislative session when we were called by the chair of the Public Health and Welfare committee, who wanted to implement a school-based clinic pilot for the state. We were given the assignment to come up with language for an amendment to an education bill that would authorize the pilot project. She grabbed an envelope, and we crafted the language on the back. Reading it over carefully, we went back into the meeting where she handed the chair the envelope and he passed it to the bill writer. It became law. Sometimes humor can disarm even the most stoic adversary. After we were successful in getting the bill passed to create the Office of Nursing Workforce (ONW) through the House and the Senate and then back to the House for final approval, a community college president appeared at the weekly committee meeting and told the chair that the community colleges were opposed to our bill. We were completely blown away by this opposition at the final hour. The chair gave us one day to work out the problem. Luckily, the community college presidents were meeting the next day, so I arranged an audience with them by convincing an old friend, who was a president, to get a group of us on the agenda. Several of us appeared the next day but were getting nowhere. The head of the community college board kept saying we didn’t need the ONW. We tried to reason with him: “We have no accurate data on nursing in Mississippi; we need better communication between the schools of nursing and hospital nursing administration; we need to develop workforce strategies.” Nothing was working with the all-male audience. Finally, I placed both hands on the table and asked: “Mr. Chairman, have you ever tried to put frogs in a wheelbarrow?” A slight smile appeared on his face. “Where are you going with this?” he asked. I explained, “We have been trying to get these folks working together. First, we get the community college nursing programs in the wheelbarrow. Then we turn around and try to pick up the baccalaureate programs and put them in the wheelbarrow. Then we try to get hospital administration in the wheelbarrow. Then we turn around, and the other two have jumped out. We need a way to get them all in the wheelbarrow at the same time.” They all laughed and, with further discussion, agreed to support our bill. When Mississippi’s first Republican governor since reconstruction, Kirk Fordice, created the state’s Health Care Commission, I was appointed to represent nursing. When it came time for nursing to make a presentation on nursing’s role in health care and how we could improve the status of health care in Mississippi, MNA chose three outstanding leaders to make our case. The first was a diminutive, perky nurse president of MNA who could spit out data in rapid fire delivery; the second was our impressive Board of Nursing executive director, whose ability to think on her feet and whose sense of humor was incredible; and finally, a tall blond dean of a school of nursing and former Alabama Maid of Cotton, whose intelligence was only exceeded by her good looks. When the nurses finished their presentation and walked back to their chairs, the president of the hospital association whispered to me, “You don’t play fair!” As a result of our unfair play, the commission recommended, and the legislature passed, legislation to increase funding to three existing nurse practitioner programs and to add two new programs—all to increase the numbers of NPs so that rural Mississippi could experience better health care coverage. Learning from past experiences was important when nurse practitioners asked MNA to help with regulations about signing forms that, by law, required a physician signature. Once again, we did a code search of the rules and found every law requiring a physician signature and drafted a bill to change the language to say “or nurse practitioner” (see Chapter 65). The process was the same as the one we used to get nurses on state agency boards; finding a simple word or phrase that could be added to an existing law—and thus expand NP practice. It involved numerous forms, one of which was an authorization for handicapped parking. The addition of “nurse practitioner” affected many agencies, thus creating a lot of attention. We explained that the NP was the provider and that the physician was not always on site. In order to get a physician signature, the patient had to schedule an appointment with the physician, thus creating additional cost and additional paperwork. The bill passed, and the result was that all agencies affected changed all their forms to include NP signatures. My job as a lobbyist has been to shepherd legislation to expand NP practice. In the early 1980s, there were only a handful of NPs practicing in the state. In the early 1990s, there were about 400. By 2009, there were almost 2000, not including Certified Registered Nurse Anesthetists (CRNAs). Eventually, some NPs opened their own practices. This was perceived as a threat by the Mississippi State Board of Medical Licensure (MSBML) and the Mississippi Medical Association (MMA). Under the old law, the Board of Nursing (BON) was required to “jointly promulgate” any regulation affecting the NP. The MNA was successful in getting a law passed in 1994 that required the BOML to also “jointly promulgate” any regulations affecting NPs. This meant that both boards had to “jointly promulgate.” This set up a scenario in which we spent fifteen years arguing back and forth between the two professions whenever any regulatory changes were suggested by one of the boards. We were able to gain ground by introducing bill after bill to remove the restrictions, and, through legislative support, we actually forced the BOML to compromise on many of the restrictions. But keeping the regulatory process effective and timely was impossible, much like walking through molasses. It took 2 to 3 years to get anything done. When the NPs approached the MNA regarding prescriptive authority for controlled substances, we went to the BOML asking for an opportunity to jointly promulgate regulations to make it happen. They refused to work with us. We went to the legislature and asked for a bill to give the NPs controlled substance prescriptive authority. We also told the legislators that it could be done through the regulatory process, but the BOML would not cooperate. The chairman of Public Health and Welfare called all stakeholders to his office and gave strong directions for the two parties to work together through the regulatory process, or else he would look at a change in the law. It took another year, but regulations were passed to give controlled substance prescriptive authority. In 2009, the MNA went back to the legislature with a bill to completely remove joint promulgation of rules. Once again, the Public Health Chairman forced the parties to work together, and, after many negotiations, all parties came to agreement and the bill became law on July 1, 2010. Now the Board of Nursing could regulate NPs without joint promulgation with the BOML. But it took 20 years! What made the difference? First was the fatigue factor; after all those years, key legislators were tired of trying to resolve issues between the BON and the BOML. Secondly, there was a vast increase in the number of NPs. More and more legislative families were using NPs as their primary provider. Many had daughters and sons who were NPs. And MNA pounded the legislators with the outcome data about NP practice. Thirdly, we figured out some fancy political maneuvering. When the BOML opposed our legislation, we suggested that we take the regulations under which the NPs had been successfully practicing for years and move them into legislation. This was a strategy I had considered for 20 years. It actually was suggested by a physician who supported NPs and encouraged us to consider legislation instead of regulation. The legislators thought the logic was sound, because NPs were already practicing successfully under the regulations and moving them into legislation did not change any of their practices. Today, NPs continue to work in a “collaborative” arrangement with physicians. The efficiency of eliminating joint promulgation has greatly shortened the promulgation of rules. For example, practice guidelines for NP hospitalists and NPs in pain management were developed quickly but thoroughly. The process is simple: Bring together interested NPs, look at national guidelines, study the research, create appropriate practice guidelines, present them to the BON, seek public and medical input, and present final proposals to the BON. Instead of taking 2 years, as it would under joint promulgation, it took from 1 to 3 months to implement. This new painless, seamless, timely process would not have been possible without years of work by a seasoned lobbyist. There are no secret ingredients to lobbying. Legislators, especially in states where staff are limited, depend on lobbyists to provide information about issues, to muster support for pet projects, and to help with their campaigns. There is so much legislation that can affect nursing practice. From issues like Medicaid to the State Department of Health, from the nursing shortage to mandatory overtime, there must be nursing representation in state and federal policy arenas. Box 69-1 provides an example of how nurses can use lobbying to provide patient care. It requires expertise in the intricacies of the legislative and regulatory process, in knowing the implications of suggested legislation or regulation, knowing who is your ally and who is your obstacle, developing trust among policymakers and other stakeholders, and knowing when the “right” people are in the “right” places to implement change. It requires seeing the process like a puzzle or poker game: “Know when to hold and when to fold.” It helps to be creative and look at surprise approaches to problems. Lobbyists keep their fingers on the pulse of health care legislation and regulations. They are skilled communicators, who know when to call out the nurses. Organizational success in policy arenas is often directly related to the effectiveness of the lobbying effort. Unless nurses do this as a full-time job, they rarely have the time to assume the lobbying function. My advice to nursing: Don’t be caught without one.
Taking Action
An Insider’s View of Lobbying
Getting Started
Political Strategies
Getting Nurses on Every Health-Related State Agency
Numbers Connote Strength
Long-Term Strategies for Long-Term Solutions: Tackling the Nursing Shortage
Call in the Nurses
Be in the Right Place at The Right Time
Putting Frogs in A Wheelbarrow: Use Humor As A Tool
Use Your Best Assets
Use Proven Strategies
Be Patient; Do Not Give Up
There Really Is a Need for Lobbyists
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