Be Patient; Do Not Give Up
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.