Silence Gives Consent: Practice, Politics, and Patient Care

Forty years after the establishment of their professions, PAs and NPs can look back with pride at the advances they have made. Yet each year, on both state and national levels, new legislation is proposed that will impact—for better or worse—their ability to provide high-quality patient care.

Staying on top of the issues can be a full-time job, and the one thing practicing clinicians never seem to have is enough time. It leaves many to wonder, “Can’t someone else take care of those details?”

Therein lies folly, say leaders from both the American Academy of Nurse Practitioners (AANP) and the American Academy of Physician Assistants (AAPA). “If you don’t participate, then you are at the mercy of those who choose to,” says Ann Davis, PA-C, Director of State Government Affairs for AAPA. “And they may not make decisions that you like.”

Furthermore, clinicians’ livelihoods depend on the policy decisions of local, state, and federal governments. The bottom line, according to Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for AANP, is “you’re not going to keep your ‘real’ job if you don’t have laws and regulations and policies that allow us to function.”

A Matter of Priorities
Lest anyone suspect Towers is exaggerating, a case in point: Last year, the PA Practice Act in Illinois—which, in a nutshell, gives PAs the right to practice in the state—was due for renewal. The Illinois Academy of Physician Assistants (IAPA) set to work at the start of 2007, contacting other organizations and state departments to iron out any potential areas of conflict in advance; the organization purposely avoided any controversial requests in SB149. In March, the bill made it through the Senate without difficulty and moved to the House.

However, in a crowded legislative session, the bill languished there—and the addition of five separate amendments further delayed its progress. (Each time an amendment is proposed, a bill must go back to committee for review and approval.) Salvation came only when a senator added the renewal of the PA Practice Act (along with those of many other professions) to HB1284, which had passed in the House and was under consideration by the Senate. Thanks to the persistent efforts of IAPA and many individual PAs, the bill zipped through three committees in one day, was placed on the agenda, and passed on November 2.

“Could it have happened without everybody calling? Maybe,” says IAPA President Sherie Turner, PA-C. “But we’ve never seen anything happen that rapidly before.”

Turner was informed by her local representative that “there was so much pending legislation in Illinois at the end of the year that our bill could certainly have gotten lost.” [After another nail-biting wait, Gov. Rod Blagojevich signed the bill into law on December 31—just in time.]

While opposition to a bill is perhaps a more obvious cause for concern, matters of priority are increasingly common. “Our issues, on the scale of things like a trillion-dollar budget, are relatively small, so it’s hard to get them to rise to the surface unless there’s a lot of push from the constituencies,” Towers observes.

This emphasizes the importance of PAs and NPs—collectively and individually—to the success of a legislative initiative.

If You Don’t, Who Will?
Turner understands the complacency that many feel when it comes to politics. “I can tell you I didn’t do anything much legislatively, or actively contact my representatives, before I was in this position and felt it was my responsibility,” she admits.

There are things that every clinician can do, “even when you have newborn twins with colic and your hair is on fire,” as AAPA’s Davis says. She adds that everyone should “become involved personally in the political process, to whatever extent you are able.”

Political activism can range from putting up a yard sign in support of a candidate at election time or occasionally attending a forum at which candidates discuss issues, to hosting a fundraiser or contributing to a political action committee “that is aligned with your interests or the interests of patients,” Davis says. Staying on top of issues related to clinical practice or other aspects of patient care is as easy as reading the newspaper, surfing the Internet, or staying in contact with your state professional organization.

“Every state is its own little country,” Davis says. “That’s the really great thing about having state chapters—those folks know what works here, who you can talk to.”

Yet, state professional organizations struggle with membership. The financial support from membership dues can enable a group to establish an office and have a full-time director who can monitor legislative and regulatory issues. More fiscally solvent professional groups can afford to have full-time lobbyists.

This is not to suggest that only full-time staff can make a difference. When resources are limited, Towers says, “Volunteers have done an excellent job of monitoring state board meetings, advocating for legislation in the state.”

Strong membership numbers can also impact legislators’ perceptions. If, for example, an organization professes to represent PAs in New York, a legislator may want to know what percentage of the state’s PAs belong to the group. “And you don’t want to have to say it’s five,” Davis says. “You want to be able to say it’s the majority.”

Did We Mention Networking?
Active involvement is the best way to make a difference. While letter-writing and cold-calling campaigns can help when legislation is on the table, everyone agrees that establishing long-term relationships is most beneficial.

“The more you have a rapport with a legislator or regulator, so they understand the issues when you really need them, then they’re going to be there for you,” Towers says. She adds that frequent staff turnover in legislators’ offices often necessitates repeat visits or calls to ensure that the legislator stays on top of health care issues.

It may be an arduous process, but connections can pay off in the long run—as NPs in Oregon learned last year when legislation to establish a “scope-of-practice review board” was proposed. The original bill was intended to evaluate new scope-of-practice requests from a variety of health care providers, and was not viewed by the sponsoring senator—herself an RN—as a threat to established practitioners, according to Bunny Lewis, NM, NP, Chair, Nurse Practitioners of Oregon (NPO; a special interest group affiliated with the Oregon Nurses Association [ONA]).

“What became a problem was when they were trying to fund it, the Board of Medical Examiners stepped up and said, ‘Hey, we’ll be glad to do this,’” Lewis explains. At that point, concern among NPs escalated. “We would not be comfortable with that,” Lewis says—especially if future amendments to the bill allowed reconsideration of already-approved practice parameters.

The NPO and ONA capitalized on their long-standing relationship with the sponsoring senator to find ways to water down and eventually stifle the bill. What made the difference, Lewis says, was “meeting one-on-one with the senator, going to her and saying, ‘You’ve got to stop this. This is threatening every NP in the state.’”

It didn’t hurt that NPO and ONA “have a reputation for being honest and trustworthy and supporting those issues that are truly important,” Lewis adds. “We’ve worked for a lot of years; this is not something that just happened overnight.”

Of course, legislators are not the only people PAs and NPs need to connect with if they want to continue to advance their practice. “You really need to be in tune with what’s going on with the department of insurance in your state, with the state boards of nursing [or medicine]—the people who make the rules, not just the statutes,” Towers points out.

And never underestimate the power of forming coalitions with like-minded groups. “The more you can reach out to groups that are interested in the same issues, whether it be other health care professional groups or other citizen groups, such as AARP, and create coalitions there, the better it is,” Towers says.

Davis agrees. If the state legislature is considering legislation to allow parents to administer insulin on school grounds, for example, PAs alone may have a modest influence. However, she says, “if we show up with the pediatricians and the certified diabetes educators and the nurses association and the emergency room physicians and the American Diabetes Association local chapter to talk about the same issue, that’s pretty good—we’ll get their attention.”

At the Heart of It
Perhaps the most important thing to remember, when legislative initiatives seem too difficult or time-consuming to tackle, is that patients are at the heart of them all. “It’s very important to look at it from the perspective of patient care and not just ‘me, me, me,’” Towers says. “This has to do with our ability to provide care to our patients and has to do with access and quality of care.”

Clinicians cannot practice at all without laws and regulations that allow them to do so, and each additional privilege they receive enhances their ability to help someone else. Asking the state legislature to open the formulary isn’t about résumé enhancement for clinicians; it’s about providing patients with the medications they need. But even local issues that may not directly relate to PAs and NPs—such as the closure of an adult day care facility in the area—can impact patients’ well-being, and these may provide a small but vital opportunity to speak up. “If something is good for patients, then of course we must endorse it,” Davis says.

“We truly are in the trenches,” NPO’s Lewis says. “And we have a responsibility to make sure that our patients get safe health care and that it’s also the best health care they can get. So it’s more than just us.”

Towers says advocating for patients “needs to go beyond the walls of where you’re providing your care. Everyone should see themselves as someone who does advocate for their patients in this way.”

This is why, even when the odds seem to be against you and you have to make repeated attempts to get legislation passed, “you don’t give up,” Lewis says. “You just keep building relationships with those in power, and then those relationships will hold in the long run for you.”     

Forty years after the establishment of their professions, PAs and NPs can look back with pride at the advances they have made. Yet each year, on both state and national levels, new legislation is proposed that will impact—for better or worse—their ability to provide high-quality patient care.

Staying on top of the issues can be a full-time job, and the one thing practicing clinicians never seem to have is enough time. It leaves many to wonder, “Can’t someone else take care of those details?”

Therein lies folly, say leaders from both the American Academy of Nurse Practitioners (AANP) and the American Academy of Physician Assistants (AAPA). “If you don’t participate, then you are at the mercy of those who choose to,” says Ann Davis, PA-C, Director of State Government Affairs for AAPA. “And they may not make decisions that you like.”

Furthermore, clinicians’ livelihoods depend on the policy decisions of local, state, and federal governments. The bottom line, according to Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for AANP, is “you’re not going to keep your ‘real’ job if you don’t have laws and regulations and policies that allow us to function.”

A Matter of Priorities
Lest anyone suspect Towers is exaggerating, a case in point: Last year, the PA Practice Act in Illinois—which, in a nutshell, gives PAs the right to practice in the state—was due for renewal. The Illinois Academy of Physician Assistants (IAPA) set to work at the start of 2007, contacting other organizations and state departments to iron out any potential areas of conflict in advance; the organization purposely avoided any controversial requests in SB149. In March, the bill made it through the Senate without difficulty and moved to the House.

However, in a crowded legislative session, the bill languished there—and the addition of five separate amendments further delayed its progress. (Each time an amendment is proposed, a bill must go back to committee for review and approval.) Salvation came only when a senator added the renewal of the PA Practice Act (along with those of many other professions) to HB1284, which had passed in the House and was under consideration by the Senate. Thanks to the persistent efforts of IAPA and many individual PAs, the bill zipped through three committees in one day, was placed on the agenda, and passed on November 2.

“Could it have happened without everybody calling? Maybe,” says IAPA President Sherie Turner, PA-C. “But we’ve never seen anything happen that rapidly before.”

Turner was informed by her local representative that “there was so much pending legislation in Illinois at the end of the year that our bill could certainly have gotten lost.” [After another nail-biting wait, Gov. Rod Blagojevich signed the bill into law on December 31—just in time.]

While opposition to a bill is perhaps a more obvious cause for concern, matters of priority are increasingly common. “Our issues, on the scale of things like a trillion-dollar budget, are relatively small, so it’s hard to get them to rise to the surface unless there’s a lot of push from the constituencies,” Towers observes.

This emphasizes the importance of PAs and NPs—collectively and individually—to the success of a legislative initiative.

If You Don’t, Who Will?
Turner understands the complacency that many feel when it comes to politics. “I can tell you I didn’t do anything much legislatively, or actively contact my representatives, before I was in this position and felt it was my responsibility,” she admits.

There are things that every clinician can do, “even when you have newborn twins with colic and your hair is on fire,” as AAPA’s Davis says. She adds that everyone should “become involved personally in the political process, to whatever extent you are able.”

Political activism can range from putting up a yard sign in support of a candidate at election time or occasionally attending a forum at which candidates discuss issues, to hosting a fundraiser or contributing to a political action committee “that is aligned with your interests or the interests of patients,” Davis says. Staying on top of issues related to clinical practice or other aspects of patient care is as easy as reading the newspaper, surfing the Internet, or staying in contact with your state professional organization.

“Every state is its own little country,” Davis says. “That’s the really great thing about having state chapters—those folks know what works here, who you can talk to.”

Yet, state professional organizations struggle with membership. The financial support from membership dues can enable a group to establish an office and have a full-time director who can monitor legislative and regulatory issues. More fiscally solvent professional groups can afford to have full-time lobbyists.

This is not to suggest that only full-time staff can make a difference. When resources are limited, Towers says, “Volunteers have done an excellent job of monitoring state board meetings, advocating for legislation in the state.”

Strong membership numbers can also impact legislators’ perceptions. If, for example, an organization professes to represent PAs in New York, a legislator may want to know what percentage of the state’s PAs belong to the group. “And you don’t want to have to say it’s five,” Davis says. “You want to be able to say it’s the majority.”

Did We Mention Networking?
Active involvement is the best way to make a difference. While letter-writing and cold-calling campaigns can help when legislation is on the table, everyone agrees that establishing long-term relationships is most beneficial.

“The more you have a rapport with a legislator or regulator, so they understand the issues when you really need them, then they’re going to be there for you,” Towers says. She adds that frequent staff turnover in legislators’ offices often necessitates repeat visits or calls to ensure that the legislator stays on top of health care issues.

It may be an arduous process, but connections can pay off in the long run—as NPs in Oregon learned last year when legislation to establish a “scope-of-practice review board” was proposed. The original bill was intended to evaluate new scope-of-practice requests from a variety of health care providers, and was not viewed by the sponsoring senator—herself an RN—as a threat to established practitioners, according to Bunny Lewis, NM, NP, Chair, Nurse Practitioners of Oregon (NPO; a special interest group affiliated with the Oregon Nurses Association [ONA]).

“What became a problem was when they were trying to fund it, the Board of Medical Examiners stepped up and said, ‘Hey, we’ll be glad to do this,’” Lewis explains. At that point, concern among NPs escalated. “We would not be comfortable with that,” Lewis says—especially if future amendments to the bill allowed reconsideration of already-approved practice parameters.

The NPO and ONA capitalized on their long-standing relationship with the sponsoring senator to find ways to water down and eventually stifle the bill. What made the difference, Lewis says, was “meeting one-on-one with the senator, going to her and saying, ‘You’ve got to stop this. This is threatening every NP in the state.’”

It didn’t hurt that NPO and ONA “have a reputation for being honest and trustworthy and supporting those issues that are truly important,” Lewis adds. “We’ve worked for a lot of years; this is not something that just happened overnight.”

Of course, legislators are not the only people PAs and NPs need to connect with if they want to continue to advance their practice. “You really need to be in tune with what’s going on with the department of insurance in your state, with the state boards of nursing [or medicine]—the people who make the rules, not just the statutes,” Towers points out.

And never underestimate the power of forming coalitions with like-minded groups. “The more you can reach out to groups that are interested in the same issues, whether it be other health care professional groups or other citizen groups, such as AARP, and create coalitions there, the better it is,” Towers says.

Davis agrees. If the state legislature is considering legislation to allow parents to administer insulin on school grounds, for example, PAs alone may have a modest influence. However, she says, “if we show up with the pediatricians and the certified diabetes educators and the nurses association and the emergency room physicians and the American Diabetes Association local chapter to talk about the same issue, that’s pretty good—we’ll get their attention.”

At the Heart of It
Perhaps the most important thing to remember, when legislative initiatives seem too difficult or time-consuming to tackle, is that patients are at the heart of them all. “It’s very important to look at it from the perspective of patient care and not just ‘me, me, me,’” Towers says. “This has to do with our ability to provide care to our patients and has to do with access and quality of care.”

Clinicians cannot practice at all without laws and regulations that allow them to do so, and each additional privilege they receive enhances their ability to help someone else. Asking the state legislature to open the formulary isn’t about résumé enhancement for clinicians; it’s about providing patients with the medications they need. But even local issues that may not directly relate to PAs and NPs—such as the closure of an adult day care facility in the area—can impact patients’ well-being, and these may provide a small but vital opportunity to speak up. “If something is good for patients, then of course we must endorse it,” Davis says.

“We truly are in the trenches,” NPO’s Lewis says. “And we have a responsibility to make sure that our patients get safe health care and that it’s also the best health care they can get. So it’s more than just us.”

Towers says advocating for patients “needs to go beyond the walls of where you’re providing your care. Everyone should see themselves as someone who does advocate for their patients in this way.”

This is why, even when the odds seem to be against you and you have to make repeated attempts to get legislation passed, “you don’t give up,” Lewis says. “You just keep building relationships with those in power, and then those relationships will hold in the long run for you.”     

Forty years after the establishment of their professions, PAs and NPs can look back with pride at the advances they have made. Yet each year, on both state and national levels, new legislation is proposed that will impact—for better or worse—their ability to provide high-quality patient care.

Staying on top of the issues can be a full-time job, and the one thing practicing clinicians never seem to have is enough time. It leaves many to wonder, “Can’t someone else take care of those details?”

Therein lies folly, say leaders from both the American Academy of Nurse Practitioners (AANP) and the American Academy of Physician Assistants (AAPA). “If you don’t participate, then you are at the mercy of those who choose to,” says Ann Davis, PA-C, Director of State Government Affairs for AAPA. “And they may not make decisions that you like.”

Furthermore, clinicians’ livelihoods depend on the policy decisions of local, state, and federal governments. The bottom line, according to Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for AANP, is “you’re not going to keep your ‘real’ job if you don’t have laws and regulations and policies that allow us to function.”

A Matter of Priorities
Lest anyone suspect Towers is exaggerating, a case in point: Last year, the PA Practice Act in Illinois—which, in a nutshell, gives PAs the right to practice in the state—was due for renewal. The Illinois Academy of Physician Assistants (IAPA) set to work at the start of 2007, contacting other organizations and state departments to iron out any potential areas of conflict in advance; the organization purposely avoided any controversial requests in SB149. In March, the bill made it through the Senate without difficulty and moved to the House.

However, in a crowded legislative session, the bill languished there—and the addition of five separate amendments further delayed its progress. (Each time an amendment is proposed, a bill must go back to committee for review and approval.) Salvation came only when a senator added the renewal of the PA Practice Act (along with those of many other professions) to HB1284, which had passed in the House and was under consideration by the Senate. Thanks to the persistent efforts of IAPA and many individual PAs, the bill zipped through three committees in one day, was placed on the agenda, and passed on November 2.

“Could it have happened without everybody calling? Maybe,” says IAPA President Sherie Turner, PA-C. “But we’ve never seen anything happen that rapidly before.”

Turner was informed by her local representative that “there was so much pending legislation in Illinois at the end of the year that our bill could certainly have gotten lost.” [After another nail-biting wait, Gov. Rod Blagojevich signed the bill into law on December 31—just in time.]

While opposition to a bill is perhaps a more obvious cause for concern, matters of priority are increasingly common. “Our issues, on the scale of things like a trillion-dollar budget, are relatively small, so it’s hard to get them to rise to the surface unless there’s a lot of push from the constituencies,” Towers observes.

This emphasizes the importance of PAs and NPs—collectively and individually—to the success of a legislative initiative.

If You Don’t, Who Will?
Turner understands the complacency that many feel when it comes to politics. “I can tell you I didn’t do anything much legislatively, or actively contact my representatives, before I was in this position and felt it was my responsibility,” she admits.

There are things that every clinician can do, “even when you have newborn twins with colic and your hair is on fire,” as AAPA’s Davis says. She adds that everyone should “become involved personally in the political process, to whatever extent you are able.”

Political activism can range from putting up a yard sign in support of a candidate at election time or occasionally attending a forum at which candidates discuss issues, to hosting a fundraiser or contributing to a political action committee “that is aligned with your interests or the interests of patients,” Davis says. Staying on top of issues related to clinical practice or other aspects of patient care is as easy as reading the newspaper, surfing the Internet, or staying in contact with your state professional organization.

“Every state is its own little country,” Davis says. “That’s the really great thing about having state chapters—those folks know what works here, who you can talk to.”

Yet, state professional organizations struggle with membership. The financial support from membership dues can enable a group to establish an office and have a full-time director who can monitor legislative and regulatory issues. More fiscally solvent professional groups can afford to have full-time lobbyists.

This is not to suggest that only full-time staff can make a difference. When resources are limited, Towers says, “Volunteers have done an excellent job of monitoring state board meetings, advocating for legislation in the state.”

Strong membership numbers can also impact legislators’ perceptions. If, for example, an organization professes to represent PAs in New York, a legislator may want to know what percentage of the state’s PAs belong to the group. “And you don’t want to have to say it’s five,” Davis says. “You want to be able to say it’s the majority.”

Did We Mention Networking?
Active involvement is the best way to make a difference. While letter-writing and cold-calling campaigns can help when legislation is on the table, everyone agrees that establishing long-term relationships is most beneficial.

“The more you have a rapport with a legislator or regulator, so they understand the issues when you really need them, then they’re going to be there for you,” Towers says. She adds that frequent staff turnover in legislators’ offices often necessitates repeat visits or calls to ensure that the legislator stays on top of health care issues.

It may be an arduous process, but connections can pay off in the long run—as NPs in Oregon learned last year when legislation to establish a “scope-of-practice review board” was proposed. The original bill was intended to evaluate new scope-of-practice requests from a variety of health care providers, and was not viewed by the sponsoring senator—herself an RN—as a threat to established practitioners, according to Bunny Lewis, NM, NP, Chair, Nurse Practitioners of Oregon (NPO; a special interest group affiliated with the Oregon Nurses Association [ONA]).

“What became a problem was when they were trying to fund it, the Board of Medical Examiners stepped up and said, ‘Hey, we’ll be glad to do this,’” Lewis explains. At that point, concern among NPs escalated. “We would not be comfortable with that,” Lewis says—especially if future amendments to the bill allowed reconsideration of already-approved practice parameters.

The NPO and ONA capitalized on their long-standing relationship with the sponsoring senator to find ways to water down and eventually stifle the bill. What made the difference, Lewis says, was “meeting one-on-one with the senator, going to her and saying, ‘You’ve got to stop this. This is threatening every NP in the state.’”

It didn’t hurt that NPO and ONA “have a reputation for being honest and trustworthy and supporting those issues that are truly important,” Lewis adds. “We’ve worked for a lot of years; this is not something that just happened overnight.”

Of course, legislators are not the only people PAs and NPs need to connect with if they want to continue to advance their practice. “You really need to be in tune with what’s going on with the department of insurance in your state, with the state boards of nursing [or medicine]—the people who make the rules, not just the statutes,” Towers points out.

And never underestimate the power of forming coalitions with like-minded groups. “The more you can reach out to groups that are interested in the same issues, whether it be other health care professional groups or other citizen groups, such as AARP, and create coalitions there, the better it is,” Towers says.

Davis agrees. If the state legislature is considering legislation to allow parents to administer insulin on school grounds, for example, PAs alone may have a modest influence. However, she says, “if we show up with the pediatricians and the certified diabetes educators and the nurses association and the emergency room physicians and the American Diabetes Association local chapter to talk about the same issue, that’s pretty good—we’ll get their attention.”

At the Heart of It
Perhaps the most important thing to remember, when legislative initiatives seem too difficult or time-consuming to tackle, is that patients are at the heart of them all. “It’s very important to look at it from the perspective of patient care and not just ‘me, me, me,’” Towers says. “This has to do with our ability to provide care to our patients and has to do with access and quality of care.”

Clinicians cannot practice at all without laws and regulations that allow them to do so, and each additional privilege they receive enhances their ability to help someone else. Asking the state legislature to open the formulary isn’t about résumé enhancement for clinicians; it’s about providing patients with the medications they need. But even local issues that may not directly relate to PAs and NPs—such as the closure of an adult day care facility in the area—can impact patients’ well-being, and these may provide a small but vital opportunity to speak up. “If something is good for patients, then of course we must endorse it,” Davis says.

“We truly are in the trenches,” NPO’s Lewis says. “And we have a responsibility to make sure that our patients get safe health care and that it’s also the best health care they can get. So it’s more than just us.”

Towers says advocating for patients “needs to go beyond the walls of where you’re providing your care. Everyone should see themselves as someone who does advocate for their patients in this way.”

This is why, even when the odds seem to be against you and you have to make repeated attempts to get legislation passed, “you don’t give up,” Lewis says. “You just keep building relationships with those in power, and then those relationships will hold in the long run for you.”