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Legislative Visit #1
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General Considerations Before the Visit

While this information is designed to be delivered in one visit, if your time is limited or the legislator or staff member requires a lot of education about APNs, you may need to break this conversation into two visits. If a small group is visiting, we recommend assigning specific points to various members of the group. Whether delivering the message alone or in a group, rehearsing the message with others who can give feedback prior to the visit will improve your effectiveness.

Points to Remember:

1 Avoid using abbreviations and medical jargon.

2 This is just like patient education. First assess the knowledge, select the starting point for information based on that knowledge,

3 Be clear and concise.

4 Use examples.

5 Succinctly make your request at the end of the conversation.

6 Be prepared with the appropriate handout/s.

1) APNs Meet the Healthcare Needs of Texans; and

2) Nursing Board-Granted Prescriptive Authority for APNs (for legislators)

Also take:

3) Your business card;

4) Possibly a brochure or handout about your particular practice and/or APN role; and

5) For visits made between legislative sessions when legislators and staff members have more time, an article on how your particular APN role improves outcomes, or the Harvard Business Review article titled, "Will Disruptive Innovations Cure Health Care?” (The full version of this article will require that you purchase online at If including entire articles, be sure to highlight important statements.)

The Visit

1. Introduce yourself. Thank the legislator or staff member for making time to see you to discuss Advanced Practice Nurses and an issue that is important to APNs in the 2009 legislative session. Be sure to get the business card for all staff members attending the meeting.

2. Assess the legislator or staff member’s knowledge of Advanced Practice Nurses, e.g. "While it is more common than it used to be for people to receive health care from Advanced Practice Nurses such as Nurse Practitioners and Nurse-Midwives, a lot of people are still not familiar with APNs. What is your experience with Advanced Practice Nurses?” If not at all familiar, then you will need to start from the beginning.

"An APN is a registered nurse with advanced education, usually with a master’s degree. APNs can do medical histories and physicals, treat certain medical conditions, order laboratory tests, x-rays and other diagnostic tests, and prescribe medications. There are four types of Advanced Practice Nurses: Certified Registered Nurse Anesthetists, often referred to as CRNAs, Nurse-Midwives, Clinical Nurse Specialists, and Nurse Practitioners. I am a _____ [e.g. Family Nurse Practitioner and I practice in_______.]”

1 Briefly describe your background.

2 Describe your work site / practice.

3 Describe how you improve the health care for the legislator’s constituents [or how you plan to do so if you are a student].

3. Describe the current restrictions under which APNs practice in Texas and the problems associated with those restrictions. Again, base the level of detail on the individual’s knowledge of APN practice in Texas.

a) "The ability to make a medical diagnosis must be delegated by a physician because the Nursing Practice Act has not kept up with current advances in education and the definition of "professional nursing” currently excludes acts of medical diagnosis. This definition has been in place since the 1960’s and has certainly not kept up with changes in education. APNs have been educated to diagnose in their educational programs and the Board of Nursing Rules and national Advanced Practice Nursing program standards require that APN students attain diagnostic skills. No APN could treat a patient without first making a medical diagnosis so it makes sense to include that in their scope of practice in Texas.

Other tasks an APN performs, such as ordering and interpreting laboratory tests, doing physical exams, and providing counseling, are already performed under the APN’s license.”

b) "Regarding prescriptive authority, physicians can only delegate to APNs if the APN is working in a qualifying site and the physician provides certain supervision. However, supervision does not mean the physician has to be delivering care at the same practice site as the APN. As a matter of fact, in the majority of cases ‘supervision’ occurs long after the services were provided. The amount of time a physician must be on-site with the APN varies from once every 10 business days in medically underserved sites to the majority (at least 50%) of the physician’s time in certain primary practice sites. The number of APNs one physician may supervise for prescriptive authority varies from an infinite number in medically underserved and facility-based hospital practices to only 3 in primary practice and alternate sites.” (This information is more fully explained in the handout "APNs Meet the Health Care Need of Texans.” It is recommended that you also take this handout to the visit. This handout provides a succinct and relatively complete explanation of current APN practice and delegation of prescriptive authority based on the type of practice site.)

c) Explain some of the problems with the current laws governing practice (emphasizing those that are a barrier in your practice):

o Reduces access to health care services.

§ Takes physicians away from their own practice sites, sometimes for up to 20% or more of the physician’s time to provide "supervision” that is required by law but not required for good patient care. Example: Retail clinics have the narrowest scope of services of almost any type of site where Nurse Practitioners practice, but physicians must be on site 20% of the time with each NP that works there. This is a waste of a physician’s precious time and the physician is rarely, if ever, seeing patients. They are contracted to review 10% of the charts. That certainly does not consume 20% of the time the physician must be on site.

§ Health care dollars are being spent for supervision instead of direct patient services.

§ Site-based prescriptive authority for APNs keeps them geographically tied to physician’s locations. As long as physicians must visit practice sites, then APNs will have to practice within a reasonable distance of physicians.

§ Example: Texas does not require Nurse Anesthetists (CRNAs) to be supervised and, as a result, CRNAs are the only anesthesia providers in over 50% of rural Texas counties in which surgical or obstetrical services are available.

o Currently, APNs are unable to write Schedule II [two] narcotics (demerol, morphine, etc) that are needed for pain management in certain long-term care and hospice patients. Despite training and education to do so, APNs cannot care for all the needs of these patients. This is an inefficient use of time and money for the state of Texas and it prevents APNs from being able to care for more patients.

o Supervision requirements are designed to reduce competition. If the supervision requirements were based on patient safety they would be the same in all practice sites and the same supervision would be required in all 50 states.

o All APNs learn to prescribe in their educational programs. APNs are professionals and know when to consult a physician or other health care provider. Supervision is not necessary, and 33 states require no supervision.

o Give examples specific to your practice. (PLEASE stay away from the following observations / complaints that will not be affected by Nursing Board-Granted Prescriptive Authority legislation. These issues will all be addressed in other ways.

Issues regarding Medicaid – ordering diapers, supplies, etc.

Issues regarding Home Health – this is a federal issue.

Inability to sign verifications patients require Disabled Parking

4. Nursing Board-Granted Prescriptive Authority. "In 2009, our focus will be on getting rid of the barriers that prevent APNs from being as effective as possible. Texas is one of the most restrictive states in the nation regarding prescriptive authority for Advanced Practice Nurses and it is costing Texas in terms of health care dollars and access. Texas can’t afford to underutilize qualified health care professionals any longer when the cost of health care continues to skyrocket. We understand that the Texas Medical Association is concerned about competition. But we know you care about good quality, affordable health care for your constituents and the state of Texas. The best way to utilize Advanced Practice Nurses effectively is to accurately reflect the practice of APNs in the Texas Nursing Practice Act by including diagnosis and prescribing /ordering therapeutic measures.

Here’s what legislation to create Nursing Board-Granted Prescriptive Authority for Advanced Practice Nurses would do. It will make changes in the Nursing Practice Act and related statutes to:

a) Include medical diagnosis as a function that APNs may perform;

b) Include prescribing drugs, biologicals, and medical devices as functions the APN may perform;

c) Give APNs full prescriptive authority, including Schedule II, Controlled Substances; and

d) Grant specific authority to the Texas Board of Nursing to regulate those functions.”

5. It is important for legislators to know what you want from them, and that we begin to overcome the understandable reluctance that legislators have about dealing with any scope of practice issues. You can say something like this.

"We know that you have heard [or if this is a new legislator, will hear] a lot about avoiding scope of practice fights, and we certainly understand that. But the reality is – by continuing to avoid scope of practice fights, we avoid looking at new ways of addressing problems in our health care system, and we are never going to find new solutions. The problems will continue to grow. Fewer and fewer businesses will insure employees; fewer and fewer individuals will pay for their own health care; and more and more people will be dependent on the state. We think you are the type of legislator [your boss is the type of legislator, or you will be the type of legislator] that has the foresight and courage to deal with these hard issues.

I ask you to commit to three things.

1) Keep an open mind;

2) Please do NOT commit to medical organizations or individual physicians to oppose any scope of practice issue (particularly the change in the law to remove delegated, site-based prescriptive authority); and

3) Be willing to allow me to have conversations with you and your staff on Nursing Board-Granted Prescriptive Authority for APNs.”

If this is a staff person, staff cannot commit for a legislator, but you can ask that they convey your request.

6. Be sure to share handouts, if not given previously. Ask the legislator or staff person, "Do you have any questions?” As always, if you are not sure of the answer say, "I am not sure so I will find out and get back to you.” Then follow-up promptly with the correct information after the visit.

7. Conclude the meeting by thanking them for their time and their commitment (if they gave one). Then say, "I’ll leave my card in case you think of anything later. Please do not hesitate to contact me if you have any questions about Advanced Practice Nurses or health care, in general.” If you did not get the business card for staff members who attended the meeting at the beginning of the visit, be sure to do so now.

8. Be sure to report the visit to CNAP by completing the survey posted on CNAP’s Advocacy Section titled, "Legislative Visit Report”. (

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