Shaping Public Policy: The Nurse Regulator's Role

Article originally appeared in Journal of Nursing Regulation on 04/15/10

Nurse regulators may be executive officers of a board of nursing (BON) or board members, or they may hold other staff positions on the board. Legally, the legislative role a nurse regulator can take varies significantly among the 60 U.S. BONs. In states where nurse regulators cannot play a direct role, the board relies on another state agency or organization to propose legislation on its behalf. However, most states allow nurse regulators to participate actively in shaping public policy throughout the development of legislation. In some cases, they may be required to register as lobbyists. The public policy role of a nurse regulator may include attending and testifying at committee hearings, drafting bills, and working with legislators or legislative staff.

Core Competencies

Core competencies of legislative liaisons and lobbyists for a nursing board or other state agency include fluency and familiarity with political strategies, such as the legislative process, the subject of the proposed legislation, and its stakeholders.

Several steps must be taken before a legislative proposal is introduced. Attention should be given to key factors, the legislative climate, and how it could affect the proposal. Stakeholders and other interested parties need to be identified and a judgment made about how they may react to the proposal. In addition, the following fundamental questions should be addressed:

  • What problem will the legislation solve?
  • Why should this approach be used?
  • Who else follows this approach?
  • Do nonlegislative solutions exist? If so, have they been tried?
  • Has a legislative effort been tried before?
  • What costs would be imposed by the proposed solution and who would bear them?
  • If the proposal is not undertaken, what costs would be borne and who would bear them?
  • Who will sponsor the legislation?
  • What coalition building will need to be done?
  • Who will support the effort, who will oppose it, and who will sit on the sidelines and remain neutral?

Once these questions have been answered, the nurse regulator may begin the drafting effort, which must take into account the factors certain to be raised during the legislative process.

History Matters

The BON and its legislative liaison or lobbyist need to know the history of the subject that the proposal addresses, including any administrative, legislative, and judicial actions taken. If the legislature has considered a similar proposal before, assume the sponsor of the proposal will be informed of the prior difficulties by those who oppose the bill. If the courts have taken a position on the issue, expect legislative staff or opponents to inform the legislature of the precedent. Also, if the board previously attempted to address the issue administratively and encountered difficulties, anticipate that those difficulties are likely to become the focus of discussion as the legislation progresses.

The experiences of other regulatory agencies may be relevant to the board’s effort. Accordingly, the focus should not be limited to the state’s nurse practice act. Instead, attention needs to be given to regulations regarding other health professions and how the legislature, judiciary, and other administrative departments have addressed efforts similar to the BON proposal.

Importance of Legislative Staff

The legislative staff play an important role. Some staff members focus on drafting the new statutory language and have little need to be concerned about the interests and pressures the legislature may focus on during the session. Others may concentrate on stakeholders and the political strengths and constituencies the various interest groups represent, but may not appreciate the need to define the issues faced by the legislature. The staff assistant who works directly for a legislator plays a key gatekeeper role, communicating messages from the legislator, relaying messages from the legislative liaison and nurse regulator, and scheduling meetings with parties who have concerns related to the bill.

Each legislative staff member requires a different type of attention. The legislative liaison or nurse regulator must spend time with legislation-drafting staff to make sure they understand the issue, the proposal’s objectives, the specific language chosen, and how the proposal fits within existing laws. Be prepared to share an anecdote that illustrates the problem at hand and the need for a policy solution. Also be ready to provide evidence, data, and other relevant facts that show the proposal addresses a problem and not merely an anecdotal incident or isolated event (Foley, 2007).

The legislative liaison or nurse regulator also must invest time with legislative committee staff so they can appropriately communicate the rationale for the proposal to legislators as it moves toward a committee hearing. A staff briefing will precede the committee hearing. Committee staff will draft a bill summary to explain the bill, the reason for its introduction, and the proposed changes it contains. Throughout this effort, others will comment on the bill to legislative staff and legislators. Typically, these comments and concerns will be raised repeatedly throughout the effort, which will test the nurse regulator’s or legislative liaison’s expertise, familiarity with the subject matter, and candor.

Framing the Issue

Consider how best to frame the nursing board’s message in support of the proposed bill and how to convey this message to the bill sponsor and legislative staff. Expect to prepare several different messages, each keyed to a particular audience. Anticipate spending more time framing the issue with the bill’s sponsor than with a legislator who does not sit on the committee that will hear the bill. Similarly, prepare to spend more time with legislators who have shown an interest in the issue or, conversely, who are known to be skeptical of the proposal. Finally, anticipate spending more time with the legislative staff who will deliver briefings on the bill to legislators, than with staff who will not spend time working with the substance of the legislation (See Figure 1).

The key to framing the issue successfully is to be brief and to the point. Legislators face hundreds, if not thousands, of proposals in a legislative session. One-page summaries, bullet-pointed memoranda, and tabular references may be the best way to convey key points to them.

Other strategies include:

  • Phone calls can be used to leave short messages with legislators or their assistants.
  • E-mail increasingly is the preferred mode for communicating information about legislation. However, it should be used with caution because e-mails can be easily forwarded to others.
  • Letters and attachments often can be persuasive, if for no other reason than their relative novelty in an age of electronic communication.
  • Sending a hard copy of a summary or memorandum will save the legislator or staff members the time and expense of printing a document that has been sent electronically.
  • Personal visits provide a venue for planned message delivery as well as a chance to address others’ comments or concerns.

Preparing for the Legislative Hearing

Once the issue has been framed and the bill has been placed on a committee agenda, the next phase—preparing for the hearing— begins. Like the first phase, this step requires identification of issues that will be raised about the bill before the committee. Assume some unknown issue or question will be raised during the hearing. Work with legislative staff, legislators, allies, and supporters of the bill to help gain a sense of the issues or questions that may be raised.

Adequate preparation also requires knowing the format of the committee hearing process, including how to submit advance written testimony and how bill-related materials are to be distributed to committee members when the bill is heard. The hearing room should be studied, as should the protocol to address the committee chair and committee members during the hearing.

The committee chair, staff, and committee members will provide a sense of their understanding of the bill and what they expect of you at the hearing. With this advance intelligence, listen closely to the committee’s questions and reaction to the bill rather than speaking to fill the silence. Use good judgment about whether to participate as committee members engage in dialogue on the bill.

Hearing preparation also should include an assessment of other issues considered by the legislature during the session, bills that have come before the committee during that session, and issues that also will be on the agenda when the bill is heard. This information helps the nurse regulator understand the committee’s orientation to the subject of the board’s bill, the likelihood that the bill will attract attention as it moves forward, and the reason for this attention. Thus, the committee agenda will provide insight into the bill’s relative prominence or controversy.

It is not uncommon for a bill to be heard by more than one legislative committee. If the bill already was heard in a committee, its previous reception heightens the need for its supporters to know of any overlap of members between the committees, the nature of the issues raised during the prior hearing, and whether the concerns were resolved.

When several nursing representatives plan to testify on a bill, it is important that the “persons testifying coordinate their testimony, raising different aspects of an issue rather than repeating the same points” (Santa Anna, 2007). It is also helpful to emphasize where there is unified agreement on the issues.

Committee Testimony Process

A senior legislator chairs the committee hearing and usually begins with remarks. Committee members may come and go during this process; legislative staff will ensure that key testimony is relayed and written documents are provided.

During testimony, the nurse regulator may be asked an unanticipated question that warrants further research for a factual response. Resist the tendency to guess. Instead, committee members should be told you need to research that question. A wrong guess could impair the BON’s efforts and harm the bill’s progress. Promising to get back to the committee members or a particular legislator provides both an opportunity to get the answer right and to follow up to be sure all concerns are addressed.

After the Hearing

Once the proposed bill clears its first committee, prepare for additional hearings. Use the experience gained in front of each committee to prepare and improve presentations to subsequent committees.

Legislative staff may require more information to brief legislators who did not participate in the hearing for the bill. Issues may be identified that require amendments to be offered when the entire legislative body debates the bill; this will entail drafting amendments and understanding their meaning. Maintain and continue to cultivate relationships with legislative staff to learn if others have proposed amendments, and be prepared to support or oppose those efforts.

Intelligence Gathering During the Legislative Process

During the legislative session, part of the discovery and intelligence-gathering campaign includes asking direct questions of those with an interest in the bill and, more importantly, obtaining commitment in support of the bill. Legislators and their staff will ask if others support or oppose the bill and the rationale for opposition. Strength of the BON’s efforts will be advanced by candor.

Understanding the legislature’s mindset also is important to the bill’s success. If the bill will impose costs, determine how those costs can be paid and if a funding source exists. During economic downturns, legislators will view any spending (particularly new spending) with skepticism. Consider whether a proposal that includes new spending should be brought forward at all or whether the measure’s cost-generating aspects can be postponed until the budget crisis passes.

Nurse regulators and legislative liaisons also must understand the policy preferences of the legislature and of individual legislators. Legislators who vote against a given set of bills may be encountered. It is important to understand the reason for their position, as their votes may never be gained and efforts to accommodate them may simply build opposition or unnecessary tension.

Challenges and Opportunities

Working on legislation presents both challenges and opportunities. Preparation in advance of the bill’s introduction will enable the nurse regulator or legislative liaison to anticipate and address these challenges and opportunities.

If the proposed legislation was analyzed at the outset (as described above) and the bill’s policy goal was identified, persons who may have different positions or may oppose the bill will have been identified. Be prepared for the prospect that complete agreement with others involved in the process may never be achieved. For this reason, stay prepared in several areas. First, make sure the bill’s sponsor and champion know what arguments will be presented against the bill so they will not be blindsided. Second, work with others who support the bill; this is particularly important in the context of a regulatory proposal to demonstrate that support for the measure includes main constituencies and not just the BON. Inform the sponsor of the positions being taken, as this information will assist the legislator to gauge potential opposition and support for the effort. The legislator will view this additional information as a sign of the extent to which the nurse regulator or legislative liaison is prepared to address the issues and as an indication that this legislative effort has been fully vetted.

Finally, a differentiated set of rules applies to the legislative process, with its own language and rituals that need to be understood. Although success may come even to those who do not grasp these points, lack of familiarity with them can interfere with the effort and may cause others to view the effort as not being serious. This does not mean the lobbyist or nurse regulator needs to be “seasoned.” Instead, it means the individual who leads the legislative initiative needs to understand that success requires homework, teamwork, and preparation.

Future Role of the Nurse Regulator in Advancing Public Policy

Nursing regulators must develop specific strategies to make the most of their regulatory expertise and to partner with legislative liaisons to successfully enact legislative changes that benefit the public. Identifying and developing the core competencies of current and future nurse regulators in shaping public policy is crucial and is best achieved through mentoring, role modeling, and direct practice in the legislative arena.

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