WEBVTT 00:00:07.000 --> 00:00:12.110 position:50% align:middle - [Nicole] Hello and welcome to the APRN Compact: Advancing Licensure Mobility. 00:00:12.110 --> 00:00:15.570 position:50% align:middle My name is Nicole Livanos, and I'm the associate director of legislative 00:00:15.570 --> 00:00:18.670 position:50% align:middle affairs at NCSBN. 00:00:18.670 --> 00:00:23.510 position:50% align:middle The targets I hope to address today include the growing number of health care compacts, 00:00:23.510 --> 00:00:27.960 position:50% align:middle the APRN Compact fundamentals, including the compact's relationship to the 00:00:27.960 --> 00:00:36.660 position:50% align:middle Consensus Model, the progress and growing support for the APRN Compact, its opposition, and our path forward. 00:00:36.660 --> 00:00:41.630 position:50% align:middle There is no doubt that healthcare professionals and other licensed professionals are looking to interstate 00:00:41.630 --> 00:00:47.630 position:50% align:middle compacts to mobilize their workforce and modernize regulation to meet today's demands. 00:00:47.630 --> 00:00:51.570 position:50% align:middle This map shows the number of healthcare compacts enacted in each state. 00:00:51.570 --> 00:00:56.540 position:50% align:middle The darkest orange color shows those states with six or more healthcare compacts. 00:00:56.540 --> 00:01:01.470 position:50% align:middle Those include the Nurse Licensure Compact, the longest operating healthcare compact for registered 00:01:01.470 --> 00:01:07.650 position:50% align:middle nurses and licensed practical nurses, and compacts for psychologists, physical therapists, 00:01:07.650 --> 00:01:11.080 position:50% align:middle occupational therapists, physicians, and others. 00:01:11.080 --> 00:01:16.230 position:50% align:middle On the horizon are compacts for physician assistants, social workers, and dentists. 00:01:16.230 --> 00:01:21.490 position:50% align:middle The APRN Compact looks to provide this coveted mobility, increased access to care, 00:01:21.490 --> 00:01:28.960 position:50% align:middle and reduced duplicative regulatory processes for APRNs and patients across the country. 00:01:28.960 --> 00:01:34.720 position:50% align:middle The structure and operations of the APRN Compact are modeled after the Nurse Licensure Compact. 00:01:34.720 --> 00:01:40.450 position:50% align:middle The compact follows the mutual recognition model, meaning an APRN would hold one multi-state license 00:01:40.450 --> 00:01:45.660 position:50% align:middle in their primary state of residence and have the privilege to practice in other states that are party 00:01:45.660 --> 00:01:47.580 position:50% align:middle to the compact. 00:01:47.580 --> 00:01:52.410 position:50% align:middle In order to obtain a multi-state license, the applicant would need to first meet their home state 00:01:52.410 --> 00:01:58.550 position:50% align:middle licensure requirements and then also meet the uniform licensure requirements of the compact. 00:01:58.550 --> 00:02:03.040 position:50% align:middle Again, identical to the NLC, the governing body is a commission made up of one 00:02:03.040 --> 00:02:05.940 position:50% align:middle voting member of each party state. 00:02:05.940 --> 00:02:12.280 position:50% align:middle The body will govern the operations of the compact and have no role in multi-state licensee scope or 00:02:12.280 --> 00:02:14.380 position:50% align:middle other practice issues. 00:02:14.380 --> 00:02:20.520 position:50% align:middle The commissioner shall be regulators of APRNS in each state as is appropriate and common 00:02:20.520 --> 00:02:24.370 position:50% align:middle for compact governing structures. 00:02:24.370 --> 00:02:30.000 position:50% align:middle Many of the uniform licensure and practice requirements in the APRN Compact will look familiar. 00:02:30.000 --> 00:02:36.250 position:50% align:middle The Consensus Model elements are codified in the uniform licensure requirements an applicant must meet 00:02:36.250 --> 00:02:39.620 position:50% align:middle in order to obtain a multi-state license. 00:02:39.620 --> 00:02:45.932 position:50% align:middle An applicant must be licensed as a registered nurse, authorized to practice as an APRN in a role 00:02:45.932 --> 00:02:49.150 position:50% align:middle in one of the six population foci. 00:02:49.150 --> 00:02:54.470 position:50% align:middle They must be educated at graduate level or higher, passed a national certification exam, 00:02:54.470 --> 00:02:57.450 position:50% align:middle and hold current certification. 00:02:57.450 --> 00:03:02.300 position:50% align:middle Multi-state licensees can practice independent of a supervisor or a collaborative agreement 00:03:02.300 --> 00:03:04.600 position:50% align:middle with a healthcare provider. 00:03:04.600 --> 00:03:09.670 position:50% align:middle For prescribing, a multi-state licensee can prescribe non-controlled substances. 00:03:09.670 --> 00:03:14.290 position:50% align:middle For controlled substances, however, the licensee must follow all statutes governing 00:03:14.290 --> 00:03:19.130 position:50% align:middle controlled substances in the state where the patient is located. 00:03:19.130 --> 00:03:24.520 position:50% align:middle In addition to the licensure requirements above, an applicant must have practiced for 2,080 hours 00:03:24.520 --> 00:03:26.850 position:50% align:middle as a licensed APRN. 00:03:26.850 --> 00:03:33.750 position:50% align:middle This requirement does not require an APRN to have supervised or collaborative practice but rather 00:03:33.750 --> 00:03:39.960 position:50% align:middle complete 2,080 hours of practice under their single-state license or multiple licenses. 00:03:39.960 --> 00:03:45.240 position:50% align:middle The 2,080 hours was a solution to the prevalence of transitions to practice. 00:03:45.240 --> 00:03:51.360 position:50% align:middle Those periods of supervised practice that many states have enacted in hard fought battles many of us here 00:03:51.360 --> 00:03:53.170 position:50% align:middle are involved in. 00:03:53.170 --> 00:03:58.990 position:50% align:middle The practice hours have no impact on holding a single-state license in the primary state of residence 00:03:58.990 --> 00:04:02.180 position:50% align:middle nor multiple licenses across states. 00:04:02.180 --> 00:04:09.170 position:50% align:middle It's also important to note that about 90% of APRNs would meet this requirement on day one. 00:04:09.170 --> 00:04:12.910 position:50% align:middle So let's talk advocacy. 00:04:12.910 --> 00:04:20.090 position:50% align:middle The 2021 legislative session was the first since adoption of the new APRN Compact model language. 00:04:20.090 --> 00:04:24.470 position:50% align:middle There were two introductions and two enactments in 2021. 00:04:24.470 --> 00:04:32.260 position:50% align:middle Both Delaware and North Dakota enacted the APRN Compact with nearly unanimous legislative support. 00:04:32.260 --> 00:04:38.600 position:50% align:middle Stacey Pfenning and Pam Zickafoose will share their experiences from Delaware and North Dakota and share 00:04:38.600 --> 00:04:42.760 position:50% align:middle some lessons learned from the process. 00:04:42.760 --> 00:04:47.910 position:50% align:middle In 2022, two more states introduced the APRN Compact, Maryland and Utah. 00:04:47.910 --> 00:04:52.680 position:50% align:middle Both bills have been supported by large and diverse coalitions. 00:04:52.680 --> 00:04:58.370 position:50% align:middle Utah unanimously passed the APRN Compact, and we're anxiously awaiting the signing 00:04:58.370 --> 00:05:00.170 position:50% align:middle by the governor. 00:05:00.170 --> 00:05:04.680 position:50% align:middle In Maryland, supporters including APRNs, the Department of Defense, 00:05:04.680 --> 00:05:12.010 position:50% align:middle and the APRN bill sponsor testified to the benefits of the APRN Compact and encouraged Maryland to lead the 00:05:12.010 --> 00:05:18.600 position:50% align:middle way on the APRN Compact as they did with the NLC over 20 years ago. 00:05:18.600 --> 00:05:23.610 position:50% align:middle In order for the compact to come into effect, seven states must enact the legislation. 00:05:23.610 --> 00:05:31.890 position:50% align:middle We're hopeful our momentum will continue so licensure mobility for APRNs can become a reality soon. 00:05:31.890 --> 00:05:36.410 position:50% align:middle Since Pam and Stacey will cover Delaware and North Dakota, I will share some lessons learned from the 00:05:36.410 --> 00:05:39.310 position:50% align:middle process thus far in Utah. 00:05:39.310 --> 00:05:44.120 position:50% align:middle The Utah Nurse Practitioners Association led the charge in Utah. 00:05:44.120 --> 00:05:49.430 position:50% align:middle After careful consideration of the provisions of the compact, the group decided to move forward 00:05:49.430 --> 00:05:57.120 position:50% align:middle with introducing the bill and leading a coalition that included the Utah Nurses Association, CRNA Association, 00:05:57.120 --> 00:06:01.200 position:50% align:middle University of Utah School of Nursing to name a few. 00:06:01.200 --> 00:06:03.600 position:50% align:middle There was opposition from two organizations. 00:06:03.600 --> 00:06:10.300 position:50% align:middle The Utah Medical Association opposed the full practice authority provisions in the compact, 00:06:10.300 --> 00:06:15.930 position:50% align:middle and the American Association of Nurse Practitioners who continue to have concerns over various provisions 00:06:15.930 --> 00:06:18.900 position:50% align:middle of the compact also opposed. 00:06:18.900 --> 00:06:24.470 position:50% align:middle Despite the opposition, Utah nursing stakeholders united behind the compact. 00:06:24.470 --> 00:06:31.520 position:50% align:middle They propelled the bill to be passed with unanimous support in both the House and Senate. 00:06:31.520 --> 00:06:37.060 position:50% align:middle I want to take a moment now to appreciate the growing support for the APRN Compact among nursing, business, 00:06:37.060 --> 00:06:41.880 position:50% align:middle patient, and military family organizations. 00:06:41.880 --> 00:06:47.040 position:50% align:middle Nursing support at the state and national level include support from the American Organization 00:06:47.040 --> 00:06:54.280 position:50% align:middle of Nurse Leaders, National League for Nursing, State Nurses Associations, APRN role associations, 00:06:54.280 --> 00:06:57.250 position:50% align:middle and boards of nursing. 00:06:57.250 --> 00:07:01.460 position:50% align:middle Interstate compacts benefit from having diverse coalition groups. 00:07:01.460 --> 00:07:06.530 position:50% align:middle This slide highlights many of our non-nursing stakeholders who support or have endorsed 00:07:06.530 --> 00:07:08.860 position:50% align:middle the APRN Compact. 00:07:08.860 --> 00:07:14.080 position:50% align:middle These organizations include telehealth minded organizations such as the American Telemedicine 00:07:14.080 --> 00:07:20.780 position:50% align:middle Association and the Alliance for Connected Care whose board members include Amazon, CVS, 00:07:20.780 --> 00:07:23.210 position:50% align:middle and Walmart to name a few. 00:07:23.210 --> 00:07:30.000 position:50% align:middle The Department of Defense-State Liaison Office continues to be a strong partner in our NLC and APRN 00:07:30.000 --> 00:07:36.620 position:50% align:middle Compact work, advocating for licensure mobility for military families that is high on the military's 00:07:36.620 --> 00:07:40.750 position:50% align:middle priority lists along with many lawmakers. 00:07:40.750 --> 00:07:46.170 position:50% align:middle At the state level, we have partnered with AARP state groups, hospital associations, 00:07:46.170 --> 00:07:49.600 position:50% align:middle and facilities across rural and urban areas. 00:07:49.600 --> 00:07:55.480 position:50% align:middle To date, over 40 nursing and non-nursing organizations support the APRN Compact. 00:07:55.480 --> 00:07:59.620 position:50% align:middle We're confident that number will continue to rise. 00:07:59.620 --> 00:08:06.830 position:50% align:middle Turning to opposition to the APRN Compact, first, it will come as no surprise to many that physician 00:08:06.830 --> 00:08:11.900 position:50% align:middle organizations at the national and state level have opposed the APRN Compact. 00:08:11.900 --> 00:08:18.390 position:50% align:middle A formal request from the American Medical Association to remove full practice authority provisions 00:08:18.390 --> 00:08:21.850 position:50% align:middle for multi-state licensees went unanswered. 00:08:21.850 --> 00:08:27.880 position:50% align:middle Full practice authority is key for the mobility of practitioners and aligns with our support for the 00:08:27.880 --> 00:08:30.730 position:50% align:middle Consensus Model elements. 00:08:30.730 --> 00:08:36.380 position:50% align:middle Next, various nursing organizations have expressed opposition to the APRN Compact. 00:08:36.380 --> 00:08:41.550 position:50% align:middle The main source of opposition is to the 2,080-hour practice requirement. 00:08:41.550 --> 00:08:47.170 position:50% align:middle We continue to believe the practice hour requirement, which requires no physician supervision or 00:08:47.170 --> 00:08:52.070 position:50% align:middle collaborative practice, is necessary for the compact success as long 00:08:52.070 --> 00:08:58.650 position:50% align:middle as transitions to practice are still widely adopted and supported in states. 00:08:58.650 --> 00:09:05.210 position:50% align:middle So I want to close by sharing my thoughts on how we move the APRN Compact forward. 00:09:05.210 --> 00:09:10.810 position:50% align:middle I think first and foremost, we do it through continuing to engage and educate APRNs 00:09:10.810 --> 00:09:17.510 position:50% align:middle on what the APRN Compact could mean for their practice, the future, and their patients. 00:09:17.510 --> 00:09:24.190 position:50% align:middle Three surveys over the last two years demonstrated robust support for the APRN Compact. 00:09:24.190 --> 00:09:32.680 position:50% align:middle In Wyoming, 45% of APRN surveyed responded that they currently hold active licenses in more than one state. 00:09:32.680 --> 00:09:40.880 position:50% align:middle Seventy-two percent of survey respondents indicated they support adoption of the revised APRN Compact. 00:09:40.880 --> 00:09:48.810 position:50% align:middle In Maryland, a survey conducted by the board of nursing found 92.57% of participants would be supportive of a 00:09:48.810 --> 00:09:53.150 position:50% align:middle 2022 introduction of the APRN Compact. 00:09:53.150 --> 00:09:59.601 position:50% align:middle And most recently, in Arizona, 65% of APRNs responded that they had a need to provide 00:09:59.601 --> 00:10:05.960 position:50% align:middle APRN care or educational services to individuals living or traveling outside of the state. 00:10:05.960 --> 00:10:14.750 position:50% align:middle 92.5% of APRNs in Arizona responded that they are in favor of Arizona adopting the compact. 00:10:14.750 --> 00:10:17.150 position:50% align:middle The surveys confirm what we are finding. 00:10:17.150 --> 00:10:24.270 position:50% align:middle When we are able to have conversations with state APRN organizations and nursing leaders, they get it. 00:10:24.270 --> 00:10:29.550 position:50% align:middle They see the benefit of licensure mobility, the prevalence of compacts in their states, 00:10:29.550 --> 00:10:33.110 position:50% align:middle and that APRNs cannot be left behind. 00:10:33.110 --> 00:10:37.270 position:50% align:middle In partnership with nursing organizations, state regulatory boards, 00:10:37.270 --> 00:10:42.550 position:50% align:middle and diverse coalition partners from business, the military, and patient groups, 00:10:42.550 --> 00:10:47.960 position:50% align:middle we are confident the APRN Compact will be successful for many years ahead. 00:10:47.960 --> 00:10:49.300 position:50% align:middle Thank you. 00:10:49.300 --> 00:10:54.594 position:50% align:middle And next up, we have Stacey Pfenning who will be talking about lessons learned in North Dakota. 00:10:58.514 --> 00:11:01.782 position:50% align:middle - [Dr. Pfenning] Nicole, thank you for all you've shared and all your assistance with the 00:11:01.782 --> 00:11:03.397 position:50% align:middle APRN licensure compact. 00:11:03.397 --> 00:11:05.190 position:50% align:middle And I'd like to say hello to everyone. 00:11:05.190 --> 00:11:11.410 position:50% align:middle I'm excited to be here to share North Dakota's story of success enacting the APRN Compact in 2001. 00:11:11.410 --> 00:11:13.110 position:50% align:middle I'm Dr. Stacey Pfenning. 00:11:13.110 --> 00:11:15.980 position:50% align:middle I'm the executive director for the North Dakota Board of Nursing. 00:11:15.980 --> 00:11:20.820 position:50% align:middle I've been a family nurse practitioner since 2002 with experience in a variety of settings, 00:11:20.820 --> 00:11:25.310 position:50% align:middle lots of different settings throughout North Dakota, and also a variety of roles as an Advanced 00:11:25.310 --> 00:11:26.960 position:50% align:middle Practice Registered Nurse. 00:11:26.960 --> 00:11:31.350 position:50% align:middle I'm also in my fourth year as vice chair for the Nurse Licensure Compact. 00:11:31.350 --> 00:11:37.640 position:50% align:middle My contributions to the presentation today include a description of the political strategies and experiences 00:11:37.640 --> 00:11:43.620 position:50% align:middle leading to the enactment of the APRN Compact in North Dakota, including how we went about building support 00:11:43.620 --> 00:11:45.690 position:50% align:middle and overcoming opposition. 00:11:45.690 --> 00:11:52.220 position:50% align:middle In addition, I'll also lead an exploration in the strategic activities to promote licensing mobility 00:11:52.220 --> 00:11:56.710 position:50% align:middle for advanced practice nurses across the United States. 00:11:56.710 --> 00:12:00.170 position:50% align:middle To start with, North Dakota is a very rural state in the Midwest. 00:12:00.170 --> 00:12:05.390 position:50% align:middle North Dakota embraces interstate compacts, especially professional interstate compacts 00:12:05.390 --> 00:12:09.400 position:50% align:middle for healthcare, and has implemented compacts in the Nurse Licensure Compact, 00:12:09.400 --> 00:12:11.170 position:50% align:middle physical therapy, and medicine. 00:12:11.170 --> 00:12:18.530 position:50% align:middle In fact, the North Dakota Century Code 43-51-07 provides law allowing for professional licensing boards 00:12:18.530 --> 00:12:21.060 position:50% align:middle to enter compacts. 00:12:21.060 --> 00:12:25.790 position:50% align:middle To give a little bit of history, the new APRN Compact passed delegate assembly 00:12:25.790 --> 00:12:27.150 position:50% align:middle in August 2020. 00:12:27.150 --> 00:12:32.040 position:50% align:middle And this slide shows the legislative process for House Bill 1040, which was the Advanced Practice 00:12:32.040 --> 00:12:38.360 position:50% align:middle Licensure Compact, what was a state agency pre-filed bill in October of 2020. 00:12:38.360 --> 00:12:43.640 position:50% align:middle Since North Dakota was already a member of the original Advanced Practice Licensure Compact, 00:12:43.640 --> 00:12:49.990 position:50% align:middle the legislative council required moving forward with amendments versus repeal and reenactment of the bill. 00:12:49.990 --> 00:12:56.450 position:50% align:middle So, we did as a board go through and do the highlighting and the writing out to making read the new 00:12:56.450 --> 00:12:58.460 position:50% align:middle pieces of the compact. 00:12:58.460 --> 00:13:05.150 position:50% align:middle So this is a great picture of North Dakota Board of Nursing sharing and celebrating the enactment with Lt. 00:13:05.150 --> 00:13:08.180 position:50% align:middle Governor Sanford and Governor Burgum. 00:13:08.180 --> 00:13:11.920 position:50% align:middle The board had a great opportunity to share key points and provisions of the compact, 00:13:11.920 --> 00:13:17.270 position:50% align:middle including the enhanced mobility of the workforce among member states without regulatory barriers, 00:13:17.270 --> 00:13:23.070 position:50% align:middle which included redundant processes, fees, and more importantly loss of valuable time to licensure 00:13:23.070 --> 00:13:25.860 position:50% align:middle when mobilizing workforce was heightened during the pandemic. 00:13:25.860 --> 00:13:27.688 position:50% align:middle There was lots of question and answer. 00:13:27.688 --> 00:13:29.970 position:50% align:middle We spent 45 minutes with the governor and lieutenant governor. 00:13:29.970 --> 00:13:32.400 position:50% align:middle It was just a beautiful opportunity. 00:13:32.400 --> 00:13:37.150 position:50% align:middle So getting into the political strategy, keys to success leading to the enactment of the 00:13:37.150 --> 00:13:42.760 position:50% align:middle Advanced Practice Registered Nurse Licensure Compact in North Dakota included early and consistent building 00:13:42.760 --> 00:13:47.430 position:50% align:middle of support among nursing and other healthcare-related special interest groups. 00:13:47.430 --> 00:13:53.950 position:50% align:middle Education on compacts and rationale for the changes in the legislation became important points of exploration 00:13:53.950 --> 00:13:59.280 position:50% align:middle and clarification for stakeholders including policymakers. 00:13:59.280 --> 00:14:05.310 position:50% align:middle Another key feature for the success and successful movement or momentum of the legislative process 00:14:05.310 --> 00:14:10.604 position:50% align:middle in North Dakota was addressing the act of opposition through transparent and consistent education and that 00:14:10.604 --> 00:14:13.290 position:50% align:middle transparent and consistent messaging. 00:14:13.290 --> 00:14:17.080 position:50% align:middle So in building of support, early and consistent education, I had stated, 00:14:17.080 --> 00:14:18.190 position:50% align:middle was a key. 00:14:18.190 --> 00:14:23.530 position:50% align:middle The North Dakota Board of Nursing staff and board members do annual reports related to the compact 00:14:23.530 --> 00:14:27.710 position:50% align:middle for all the nursing associations across the state on an annual basis. 00:14:27.710 --> 00:14:31.830 position:50% align:middle And so this has been going on for several years, and any time there's anything new with the compacts or 00:14:31.830 --> 00:14:35.350 position:50% align:middle even just a refresher, we always bring that to our associations. 00:14:35.350 --> 00:14:41.850 position:50% align:middle There's also a podium presentation that we do across the states for facilities, and for stakeholders, 00:14:41.850 --> 00:14:44.700 position:50% align:middle and also for any conferences that come up that are nursing-based. 00:14:44.700 --> 00:14:47.880 position:50% align:middle And we have the opportunity to present on the compacts. 00:14:47.880 --> 00:14:50.970 position:50% align:middle That's always included in our presentations. 00:14:50.970 --> 00:14:57.230 position:50% align:middle And also we have quarterly newsletters that we always include updates on the compacts. 00:14:57.230 --> 00:15:05.040 position:50% align:middle And once we had our pre-filed agency bill submitted in October of 2020, we also held two public open forums 00:15:05.040 --> 00:15:08.300 position:50% align:middle that were sponsored or hosted by the North Dakota Center for Nursing. 00:15:08.300 --> 00:15:14.410 position:50% align:middle And this provided a really great overview of the changes in the advanced practice licensure compact 00:15:14.410 --> 00:15:18.370 position:50% align:middle from the original that was adopted in North Dakota and enacted in North Dakota in 2017, 00:15:18.370 --> 00:15:22.720 position:50% align:middle and just what those changes were, what they meant, the rationale for the changes, 00:15:22.720 --> 00:15:27.060 position:50% align:middle and provided a question and answer opportunity for the stakeholders that attended. 00:15:27.060 --> 00:15:29.340 position:50% align:middle And that was done in December of 2020. 00:15:29.340 --> 00:15:35.040 position:50% align:middle And the next slide shows the great pictures of our North Dakota Association of Nurse Anesthetists. 00:15:35.040 --> 00:15:36.880 position:50% align:middle They were a very supportive group. 00:15:36.880 --> 00:15:41.570 position:50% align:middle We also had support and testimony from the North Dakota Nurse Practitioner Association, 00:15:41.570 --> 00:15:45.700 position:50% align:middle the North Dakota Center for Nursing, and also the North Dakota Nurses Association. 00:15:45.700 --> 00:15:50.910 position:50% align:middle In a real grassroots effort, we were able to visit with each of these entities and 00:15:50.910 --> 00:15:54.210 position:50% align:middle develop letters of support and full support from each of them. 00:15:54.210 --> 00:15:57.870 position:50% align:middle Some other support that I'd like to mention, National Council of State Boards of Nursing was 00:15:57.870 --> 00:16:00.690 position:50% align:middle definitely a phone call away or an email away. 00:16:00.690 --> 00:16:02.810 position:50% align:middle And thank you, Nicole, for being so responsive. 00:16:02.810 --> 00:16:08.130 position:50% align:middle We had times when she answered the phone for me at 7:00 at night, and she truly did help us 00:16:08.130 --> 00:16:09.770 position:50% align:middle through the entire process. 00:16:09.770 --> 00:16:16.160 position:50% align:middle We also received some national support letters to North Dakota legislators from Cross Country Healthcare, 00:16:16.160 --> 00:16:21.160 position:50% align:middle from American Telemedicine Association, and the National Military Family Association. 00:16:21.160 --> 00:16:27.020 position:50% align:middle And there were other interstate compact support that's general support for compacts across the nation 00:16:27.020 --> 00:16:29.770 position:50% align:middle that were included. 00:16:29.770 --> 00:16:35.430 position:50% align:middle And in overcoming the opposition, the opposition in North Dakota emerged after the first 00:16:35.430 --> 00:16:38.820 position:50% align:middle bill passed the House Human Services Committee in January of 2021. 00:16:38.820 --> 00:16:44.210 position:50% align:middle The American Association of Nurse Practitioners president and lobbying team reached out to me 00:16:44.210 --> 00:16:49.640 position:50% align:middle to discuss communications that they had received from the American Association of Nurse Practitioners and 00:16:49.640 --> 00:16:55.120 position:50% align:middle described the request to have the North Dakota Nurse Practitioners Association oppose the bill due to the 00:16:55.120 --> 00:16:58.320 position:50% align:middle practice hour, you know, from licensure requirement. 00:16:58.320 --> 00:17:03.520 position:50% align:middle The AANP and the North Dakota Nurse Practitioner Association held meetings together 00:17:03.520 --> 00:17:05.690 position:50% align:middle to discuss this concern. 00:17:05.690 --> 00:17:09.470 position:50% align:middle After the meetings, the North Dakota Board of Nursing representatives met with the North Dakota Nurse 00:17:09.470 --> 00:17:14.590 position:50% align:middle Practitioner Association and provided clarification, and rationale, and reassurance. 00:17:14.590 --> 00:17:20.820 position:50% align:middle The practice hours was a regulatory common denominator for a uniform licensure requirement that would enable 00:17:20.820 --> 00:17:23.860 position:50% align:middle more states to join, which would allow. 00:17:23.860 --> 00:17:28.570 position:50% align:middle The compact to succeed, which was very important in this time of pandemic. 00:17:28.570 --> 00:17:30.850 position:50% align:middle Much discussion and education was provided. 00:17:30.850 --> 00:17:35.680 position:50% align:middle Regulation and scope of practice differentiations were highlighted. 00:17:35.680 --> 00:17:39.910 position:50% align:middle It's very important to show that this common denominator of a practice hour is 00:17:39.910 --> 00:17:40.960 position:50% align:middle not supervised practice. 00:17:40.960 --> 00:17:42.270 position:50% align:middle It's not a transition to practice. 00:17:42.270 --> 00:17:49.500 position:50% align:middle It was a common denominator to allow more states to be able to be included in the company. 00:17:49.500 --> 00:17:54.190 position:50% align:middle So North Dakota as a plenary state does not have a minimal practice hour requirement 00:17:54.190 --> 00:17:55.980 position:50% align:middle for supervised practice. 00:17:55.980 --> 00:18:01.790 position:50% align:middle And this would not change with adding a multi-state level of licensure once the 2,080 hours was met by the 00:18:01.790 --> 00:18:04.540 position:50% align:middle advanced practice nurse in the compact state. 00:18:04.540 --> 00:18:11.100 position:50% align:middle And this was another important point that actually came up during the legislative hearing on the Senate side, 00:18:11.100 --> 00:18:19.990 position:50% align:middle and that was actually...the Senator asked, "Does this change our North Dakota hours 00:18:19.990 --> 00:18:22.000 position:50% align:middle once they graduate?" and I said, "Absolutely not." 00:18:22.000 --> 00:18:26.470 position:50% align:middle Our North Dakota nurse practitioners can graduate and go into full practice immediately. 00:18:26.470 --> 00:18:31.500 position:50% align:middle And so I said this is just how they get that second layer of a multi-state license to be able to move 00:18:31.500 --> 00:18:34.310 position:50% align:middle about other states in a uniform manner. 00:18:34.310 --> 00:18:38.840 position:50% align:middle Ultimately, the North Dakota Nurse Practitioner Association and the other nursing organizations 00:18:38.840 --> 00:18:43.930 position:50% align:middle supported the Board of Nursing agency bill and reiterated their desire to have a functioning licensure 00:18:43.930 --> 00:18:46.420 position:50% align:middle compact for the state. 00:18:46.420 --> 00:18:53.570 position:50% align:middle So moving on to how can we make our advanced practice nurse profession mobile across the United States. 00:18:53.570 --> 00:18:58.000 position:50% align:middle The first topic I wanted to touch on was the NCSBN Taskforce. 00:18:58.000 --> 00:19:03.050 position:50% align:middle The taskforce was between 2018 and '19, and I think we did a little work after that. 00:19:03.050 --> 00:19:10.440 position:50% align:middle But the taskforce was really charged to explore any necessary changes in the policy of the previous compact 00:19:10.440 --> 00:19:16.050 position:50% align:middle to allow for forward movement and successful implementation of the Advanced Practice Compact. 00:19:16.050 --> 00:19:20.110 position:50% align:middle There was recognition that there were certain parts of that compact that just were not going to allow 00:19:20.110 --> 00:19:21.730 position:50% align:middle for forward movement. 00:19:21.730 --> 00:19:27.330 position:50% align:middle There were in-person deliberations with a diverse team of executive officers, legal counsel, 00:19:27.330 --> 00:19:32.070 position:50% align:middle special interest groups, and stakeholder guests throughout the taskforce. 00:19:32.070 --> 00:19:37.230 position:50% align:middle There was provided recommendations to ensure achievable common denominators within uniform licensure 00:19:37.230 --> 00:19:42.390 position:50% align:middle requirements to promote the forward movement of the compact. 00:19:42.390 --> 00:19:44.310 position:50% align:middle There are really great deep dives. 00:19:44.310 --> 00:19:47.842 position:50% align:middle I think we did not leave a rock unturned during that taskforce. 00:19:47.842 --> 00:19:53.520 position:50% align:middle I was on the taskforce representing North Dakota and the deliberations were very, very detailed. 00:19:53.520 --> 00:19:57.970 position:50% align:middle There was a lot of research looked at, a lot of special interest groups brought in to discuss 00:19:57.970 --> 00:19:58.800 position:50% align:middle across the nation. 00:19:58.800 --> 00:20:04.180 position:50% align:middle It was just such a very intense group, but there was a lot of, kind of, 00:20:04.180 --> 00:20:07.950 position:50% align:middle eye-opening things that came to light during that group. 00:20:07.950 --> 00:20:12.850 position:50% align:middle And ultimately the revised compact was approved by the NCSBN delegate assembly in 2020. 00:20:12.850 --> 00:20:22.130 position:50% align:middle So the NCSBN taskforce was definitely a key talking point when I did my visits with the Nurse Practitioner 00:20:22.130 --> 00:20:27.870 position:50% align:middle Association and some of the other entities that had questions about where the 2,080 hours came from and how 00:20:27.870 --> 00:20:35.210 position:50% align:middle that truly was a compromise and negotiation a common denominator to help reduce the barriers of mobility 00:20:35.210 --> 00:20:36.960 position:50% align:middle for our profession. 00:20:36.960 --> 00:20:43.870 position:50% align:middle And the last piece to bring up about just, kind of, how can we become more of a mobile workforce 00:20:43.870 --> 00:20:45.230 position:50% align:middle across the United States? 00:20:45.230 --> 00:20:49.600 position:50% align:middle And I was able to dive into a policy analysis on the Advanced Practice Compact. 00:20:49.600 --> 00:20:53.970 position:50% align:middle According to Bardach and Patashnik's Eightfold Path. 00:20:53.970 --> 00:20:58.430 position:50% align:middle And there's a picture of my book, and that is my taco sign and the paper that I had 00:20:58.430 --> 00:20:59.670 position:50% align:middle written on the policy brief. 00:20:59.670 --> 00:21:03.570 position:50% align:middle And really when you look at a policy analysis, you look at what is the problem, 00:21:03.570 --> 00:21:06.330 position:50% align:middle what does the evidence show, what are alternative actions, 00:21:06.330 --> 00:21:11.110 position:50% align:middle and the deep dive really needs to be in the alternative actions, and then evaluating what are the 00:21:11.110 --> 00:21:14.470 position:50% align:middle evaluative criteria, what do we need to look at for cost analysis, 00:21:14.470 --> 00:21:19.650 position:50% align:middle cost risk analysis, benefit analysis, and what would some projective outcomes be of each 00:21:19.650 --> 00:21:22.780 position:50% align:middle of the different alternative actions, what the trade-offs are. 00:21:22.780 --> 00:21:25.280 position:50% align:middle And at the end, what is our decision as a profession? 00:21:25.280 --> 00:21:31.060 position:50% align:middle So during this time of healthcare crisis with the pandemic, thinking outside the box and outside of our 00:21:31.060 --> 00:21:32.640 position:50% align:middle comfort zone is essential. 00:21:32.640 --> 00:21:39.850 position:50% align:middle The APRN licensure compact and alternative ideas all lend to a more mobile workforce with positive impact 00:21:39.850 --> 00:21:43.600 position:50% align:middle to cost inefficiencies, which are much needed in this time of healthcare 00:21:43.600 --> 00:21:45.630 position:50% align:middle challenges across the nation. 00:21:45.630 --> 00:21:51.370 position:50% align:middle Of all the options discussed and all the alternative actions looked at, the APRN licensure compact presented 00:21:51.370 --> 00:21:55.150 position:50% align:middle the most achievable policy change that's actually right at our fingertips. 00:21:55.150 --> 00:22:00.080 position:50% align:middle And this is just a little bit of an overview of the policy analysis. 00:22:00.080 --> 00:22:03.740 position:50% align:middle In the height of the pandemic, it was clear that the APRN profession needed to find a 00:22:03.740 --> 00:22:09.230 position:50% align:middle solution to enhance efficiency and licensure and promote mobility of the workforce due to the 00:22:09.230 --> 00:22:11.020 position:50% align:middle expanding telehealth services. 00:22:11.020 --> 00:22:13.770 position:50% align:middle Telehealth just blossomed during the pandemic. 00:22:13.770 --> 00:22:18.670 position:50% align:middle And we also needed to have interstate practice without loss of precious resources of time. 00:22:18.670 --> 00:22:23.080 position:50% align:middle Time became such a valuable resource when you're looking at waiting six weeks to two months to be 00:22:23.080 --> 00:22:27.230 position:50% align:middle licensed in each state where you're needed, that is too precious of time to lose. 00:22:27.230 --> 00:22:32.850 position:50% align:middle And the fees also at each border became expensive for providers to do telehealth. 00:22:32.850 --> 00:22:36.770 position:50% align:middle More states implemented executive orders during the declared state of emergency to allow 00:22:36.770 --> 00:22:40.510 position:50% align:middle for interstate practice, but these executive orders are temporary. 00:22:40.510 --> 00:22:45.150 position:50% align:middle Many of them have already been repealed, but not all of them but many of them have been. 00:22:45.150 --> 00:22:50.120 position:50% align:middle In addition, a functioning nurse licensure compact proved to be a great asset and regulation for the 00:22:50.120 --> 00:22:57.490 position:50% align:middle member states as licensed and vetted nurses within the nurse licensure compact moved freely to the areas 00:22:57.490 --> 00:23:02.530 position:50% align:middle of greatest need across the nation without the burdensome barriers of regulation. 00:23:02.530 --> 00:23:08.840 position:50% align:middle Unfortunately, this worked for the RNs and LPNs but did not work for our APRMs. 00:23:08.840 --> 00:23:13.410 position:50% align:middle So in looking at possible alternative actions as outlined by my policy analysis, 00:23:13.410 --> 00:23:18.690 position:50% align:middle one option is to remain the status quo, which is licensing the APRN in each border. 00:23:18.690 --> 00:23:23.640 position:50% align:middle However, it has become apparent that the status quo is inefficient and is producing barriers to the needed 00:23:23.640 --> 00:23:29.010 position:50% align:middle mobile workforce of this important profession, especially when we have expansion of telehealth, 00:23:29.010 --> 00:23:34.320 position:50% align:middle distance education, and the need for help in areas of disaster and pandemic surges. 00:23:34.320 --> 00:23:39.027 position:50% align:middle According to current fees, an APRN with a license in six states would pay 00:23:39.027 --> 00:23:44.360 position:50% align:middle about $1,800 for initial licensure in those six days and 600 per year to maintain. 00:23:44.360 --> 00:23:47.750 position:50% align:middle And this would take six weeks to two months for the license. 00:23:47.750 --> 00:23:49.210 position:50% align:middle Imagine if that was 12 states. 00:23:49.210 --> 00:23:55.400 position:50% align:middle So federal action and national licensure did come up in the literature as other ways or alternative actions, 00:23:55.400 --> 00:24:00.670 position:50% align:middle but that really takes the power or the oversight away from the profession and gives it 00:24:00.670 --> 00:24:01.600 position:50% align:middle to the federal government. 00:24:01.600 --> 00:24:07.930 position:50% align:middle And that national regulation takes sovereignty away from the states. 00:24:07.930 --> 00:24:11.780 position:50% align:middle Other things that came up that I thought were interesting was the deregulation or deferring 00:24:11.780 --> 00:24:14.280 position:50% align:middle to a third-party certification. 00:24:14.280 --> 00:24:18.880 position:50% align:middle And that I thought was interesting, but those were less likely to be politically feasible. 00:24:18.880 --> 00:24:22.190 position:50% align:middle You'd have to have buy-in from the profession and the states and even federally, 00:24:22.190 --> 00:24:23.680 position:50% align:middle which I think would be a difficult thing. 00:24:23.680 --> 00:24:29.750 position:50% align:middle And we also know that the executive orders, as far as that being an option, they're temporary. 00:24:29.750 --> 00:24:32.620 position:50% align:middle So they do not totally fix the problem. 00:24:32.620 --> 00:24:38.610 position:50% align:middle And state-based regulation will even lead to more lack of uniformity among states. 00:24:38.610 --> 00:24:44.080 position:50% align:middle So the most feasible option to meet the environment and healthcare needs of the United States is by providing 00:24:44.080 --> 00:24:48.270 position:50% align:middle the agile and mobile APRN workforce is the APRN licensure compact. 00:24:48.270 --> 00:24:53.860 position:50% align:middle The compact has been vetted, revised for success, and has been enacted in seven states now. 00:24:53.860 --> 00:24:59.130 position:50% align:middle The APRN Compact can become a reality soon if states continue to move forward with the legislation. 00:24:59.130 --> 00:25:04.560 position:50% align:middle The time is now and the nation needs our advanced practice registered nurse workforce to be mobile and 00:25:04.560 --> 00:25:06.670 position:50% align:middle agile and ready to assist. 00:25:06.670 --> 00:25:12.260 position:50% align:middle So in summary, early and consistent building of support is a vital key to success. 00:25:12.260 --> 00:25:17.270 position:50% align:middle And this includes education, transparency, and rationale for why the changes were made. 00:25:17.270 --> 00:25:23.450 position:50% align:middle Overcoming opposition through open forums and addressing misconceptions was very key as well. 00:25:23.450 --> 00:25:28.780 position:50% align:middle And as far as how can we get our APRNs mobile and agile across the United States, 00:25:28.780 --> 00:25:35.940 position:50% align:middle the APRN Compact in the policy brief became the most politically feasible and most doable option. 00:25:35.940 --> 00:25:37.180 position:50% align:middle It's been vetted. 00:25:37.180 --> 00:25:41.780 position:50% align:middle It was revised to meet modernization of practice and codify the Consensus Model, 00:25:41.780 --> 00:25:47.910 position:50% align:middle and it's ready to pave the way to a mobile and agile workforce for APRNs across the United States. 00:25:47.910 --> 00:25:49.000 position:50% align:middle And I do have a few references. 00:25:49.000 --> 00:25:52.450 position:50% align:middle And at this point, I would like to invite Pam to join us. 00:25:52.450 --> 00:25:55.750 position:50% align:middle She's going to be sharing lessons learned from the Delaware journey. 00:25:55.750 --> 00:26:02.055 position:50% align:middle And thank you for listening. 00:26:02.055 --> 00:26:03.293 position:50% align:middle - [Pam] Thank you, Stacey. 00:26:03.293 --> 00:26:09.370 position:50% align:middle I am Pam Zickafoose from Delaware, and I'm going to be speaking about the APRN Compact 00:26:09.370 --> 00:26:12.370 position:50% align:middle journey in Delaware. 00:26:12.370 --> 00:26:16.610 position:50% align:middle The first part of our journey actually began in 2011. 00:26:16.610 --> 00:26:23.700 position:50% align:middle Although it's not on this slide, we reconvened, at that time, what was called the APN committee, 00:26:23.700 --> 00:26:31.350 position:50% align:middle and we started working on the Consensus Model and lace pieces of the Consensus Model. 00:26:31.350 --> 00:26:37.810 position:50% align:middle So, all in all, our timeline has really been about a 10-year journey. 00:26:37.810 --> 00:26:41.220 position:50% align:middle In 2011, we did a lot of education. 00:26:41.220 --> 00:26:45.030 position:50% align:middle We started out teaching about the Consensus Model. 00:26:45.030 --> 00:26:50.900 position:50% align:middle We spoke with nurse practitioners and all of the different types and roles of APRNs in Delaware. 00:26:50.900 --> 00:26:52.470 position:50% align:middle We spoke with legislators. 00:26:52.470 --> 00:26:57.270 position:50% align:middle We spoke with the hospitals and our medical society. 00:26:57.270 --> 00:27:00.360 position:50% align:middle And that was the beginning of our journey. 00:27:00.360 --> 00:27:06.090 position:50% align:middle Also, during that time, we conducted a survey of the APRNs in Delaware to see 00:27:06.090 --> 00:27:10.920 position:50% align:middle what their thoughts were about Consensus and whether or not we should try to eliminate 00:27:10.920 --> 00:27:12.680 position:50% align:middle the collaborative agreement. 00:27:12.680 --> 00:27:16.240 position:50% align:middle And that was almost a unanimous decision. 00:27:16.240 --> 00:27:20.200 position:50% align:middle Yes, all of the APRNs thought that we should move in that direction. 00:27:20.200 --> 00:27:25.005 position:50% align:middle And our journey culminated in 2015. 00:27:25.005 --> 00:27:31.674 position:50% align:middle We had Sen. Bethany Hall-Long at the time, who was a nurse, sponsored two bills for us 00:27:31.674 --> 00:27:32.701 position:50% align:middle in the Senate. 00:27:32.701 --> 00:27:39.180 position:50% align:middle And on September 1st, 2015, these bills were signed. 00:27:39.180 --> 00:27:45.354 position:50% align:middle This legislation at that time also attempted to eliminate collaborative agreements, 00:27:45.354 --> 00:27:47.933 position:50% align:middle but we couldn't quite get as far as we wanted to. 00:27:47.933 --> 00:27:53.291 position:50% align:middle The medical society and the Board of Medical Licensure and Discipline did not want to give up their control 00:27:53.291 --> 00:27:54.292 position:50% align:middle at that time. 00:27:54.292 --> 00:28:01.017 position:50% align:middle So we came to a negotiation, and we basically agreed to eliminate collaborative 00:28:01.017 --> 00:28:08.975 position:50% align:middle agreements for everyone except new graduates who had not practiced a minimum of 2 years and 4,000 hours. 00:28:08.975 --> 00:28:18.050 position:50% align:middle This new bill in 2015 did grant full practice authority and the ability to sign death certificates. 00:28:18.050 --> 00:28:24.560 position:50% align:middle However, it created an APRN committee which consisted of physicians, a pharmacist, and APRNs. 00:28:24.560 --> 00:28:30.300 position:50% align:middle And the sole purpose of that committee was to grant independent practice. 00:28:30.300 --> 00:28:36.240 position:50% align:middle So in March of 2017, we granted our first independent practice application 00:28:36.240 --> 00:28:39.560 position:50% align:middle to an APRN. 00:28:39.560 --> 00:28:48.230 position:50% align:middle At that time, the bill also required us to have a report to the general assembly that was required to be 00:28:48.230 --> 00:28:54.000 position:50% align:middle sent four years after we started this process of granting independent practice. 00:28:54.000 --> 00:28:57.980 position:50% align:middle We work collaboratively with the Board of Medical Licensure and Discipline, 00:28:57.980 --> 00:29:05.270 position:50% align:middle and we submitted a report on March 19th of 2019 that was signed by both the Board of Medicine and the 00:29:05.270 --> 00:29:07.360 position:50% align:middle Board of Nursing. 00:29:07.360 --> 00:29:13.100 position:50% align:middle At that time, we had granted 137 applications for independent practice, 00:29:13.100 --> 00:29:17.240 position:50% align:middle and we had zero disciplinary actions. 00:29:17.240 --> 00:29:21.360 position:50% align:middle We also had zero applications that have been denied. 00:29:21.360 --> 00:29:26.600 position:50% align:middle So based on those statistics, the nursing board recommended that we go ahead and 00:29:26.600 --> 00:29:30.990 position:50% align:middle change the language for independent practice and, in essence, to remove it. 00:29:30.990 --> 00:29:34.080 position:50% align:middle And of course the medical bsoard opposed. 00:29:34.080 --> 00:29:39.510 position:50% align:middle So the next part starts our journey into the 2021 legislation. 00:29:39.510 --> 00:29:44.509 position:50% align:middle And I have to say that this really started in 2018. 00:29:44.509 --> 00:29:51.790 position:50% align:middle At that time, the National Council of State Boards of Nursing was working on the compact for APRNs, 00:29:51.790 --> 00:29:57.500 position:50% align:middle and I went ahead and contacted, at that time, a representative and still Rep. 00:29:57.500 --> 00:30:01.870 position:50% align:middle Melissa Minor-Brown, who was also a nurse in Delaware. 00:30:01.870 --> 00:30:08.530 position:50% align:middle I said we need to get this APRN Compact in Delaware and I want you to sponsor the bill when we 00:30:08.530 --> 00:30:09.730 position:50% align:middle have the language. 00:30:09.730 --> 00:30:11.610 position:50% align:middle She said, "Absolutely." 00:30:11.610 --> 00:30:15.420 position:50% align:middle So in 2018, she agreed to do that. 00:30:15.420 --> 00:30:24.650 position:50% align:middle We also began the journey then, and finally, the APRN Compact was approved by the delegate assembly 00:30:24.650 --> 00:30:26.530 position:50% align:middle in August of 2020. 00:30:26.530 --> 00:30:36.830 position:50% align:middle Once that was approved, we had our DAG for the board, put it into legal terms, and it became House Bill 21, 00:30:36.830 --> 00:30:39.580 position:50% align:middle the APRN Compact. 00:30:39.580 --> 00:30:47.830 position:50% align:middle So we went to our first hearing from the House and before the House and Legislative Affairs Committee. 00:30:47.830 --> 00:30:54.190 position:50% align:middle And during that first initial hearing, the nurse practitioners in our state, 00:30:54.190 --> 00:30:58.310 position:50% align:middle as well as the medical society, opposed the compact. 00:30:58.310 --> 00:31:03.090 position:50% align:middle And as you've heard from the previous two presentations, I believe the nurse practitioners mostly 00:31:03.090 --> 00:31:09.530 position:50% align:middle opposed the 2,080 hours of practice, thinking it was more of a transition to practice 00:31:09.530 --> 00:31:17.450 position:50% align:middle as well as the fact that we didn't have them on the committee that basically would oversee 00:31:17.450 --> 00:31:19.660 position:50% align:middle the compact licensure. 00:31:19.660 --> 00:31:26.510 position:50% align:middle So at that time, we went to plan B, and I had already written the language, sort of, 00:31:26.510 --> 00:31:34.550 position:50% align:middle for what we now call the Companion Bill to basically lift everything that we wanted—to get rid of the 00:31:34.550 --> 00:31:38.142 position:50% align:middle collaborative agreements, to get rid of independent practice 00:31:38.142 --> 00:31:39.835 position:50% align:middle and grant it with licensure. 00:31:39.835 --> 00:31:47.160 position:50% align:middle So we brought that out as the Companion Bill to House Bill 21, and it became House Bill 141, 00:31:47.160 --> 00:31:50.670 position:50% align:middle which Melissa Minor-Brown also sponsored. 00:31:50.670 --> 00:31:55.190 position:50% align:middle Like I said, it does align the nursing statute with the compact language. 00:31:55.190 --> 00:32:01.710 position:50% align:middle It removes the collaborative agreements, and it removed the process for independent practice, 00:32:01.710 --> 00:32:10.270 position:50% align:middle basically giving the Board of Nursing full authority for licensure of APRNs in the state of Delaware. 00:32:10.270 --> 00:32:17.400 position:50% align:middle It also changed the APRN committee, and that made it all APRN where we have two 00:32:17.400 --> 00:32:20.950 position:50% align:middle representatives of each role and then one additional. 00:32:20.950 --> 00:32:25.780 position:50% align:middle So there are nine APRN members on that committee. 00:32:25.780 --> 00:32:31.590 position:50% align:middle In the process of all of this, trying to communicate with the nurse practitioners 00:32:31.590 --> 00:32:37.880 position:50% align:middle as well as the medical society was a big part of our goal before this went before the House and 00:32:37.880 --> 00:32:39.670 position:50% align:middle then the Senate. 00:32:39.670 --> 00:32:42.780 position:50% align:middle So we did conduct town hall meetings. 00:32:42.780 --> 00:32:49.560 position:50% align:middle We had a lot of support from all of the nursing associations in our state, 00:32:49.560 --> 00:32:55.530 position:50% align:middle all the roles of APRNs were now in support of the Companion Bill in particular, 00:32:55.530 --> 00:32:58.520 position:50% align:middle because of the removal of the collaborative agreement. 00:32:58.520 --> 00:33:04.890 position:50% align:middle So we're very happy to gain that support by bringing out the Companion Bill. 00:33:04.890 --> 00:33:13.700 position:50% align:middle Of course, the day before...well, actually now two hours before we had our hearing in the 00:33:13.700 --> 00:33:19.390 position:50% align:middle House for the Companion Bill, I received the letter from the American Medical 00:33:19.390 --> 00:33:22.660 position:50% align:middle Association opposing both bills. 00:33:22.660 --> 00:33:32.280 position:50% align:middle So that was two hours of craziness trying to come back with rebuttals and information so that when we got 00:33:32.280 --> 00:33:38.610 position:50% align:middle before the House committee for the House Bill 141, I was prepared to answer questions. 00:33:38.610 --> 00:33:45.939 position:50% align:middle Both bills passed out of the House and the Senate almost unanimously, and the bills were signed 00:33:45.939 --> 00:33:48.532 position:50% align:middle on August 4th of 2021. 00:33:48.532 --> 00:33:56.620 position:50% align:middle I cannot say enough about the teamwork and how everyone worked together to get this accomplished. 00:33:56.620 --> 00:34:00.430 position:50% align:middle And thank you to everyone who did. 00:34:00.430 --> 00:34:05.650 position:50% align:middle So I think it's important that we go over some of the strategies for success that I think were helpful 00:34:05.650 --> 00:34:07.190 position:50% align:middle here in Delaware. 00:34:07.190 --> 00:34:13.280 position:50% align:middle And the first thing I have to say is that we had the legislator who sponsored the bills both 00:34:13.280 --> 00:34:15.260 position:50% align:middle in 2015 and 2018. 00:34:15.260 --> 00:34:21.230 position:50% align:middle And I believe having a nurse as the sponsor is very important because they can talk both nursing 00:34:21.230 --> 00:34:25.120 position:50% align:middle and politics, which is really, really good. 00:34:25.120 --> 00:34:27.720 position:50% align:middle Communication, communication, communication. 00:34:27.720 --> 00:34:29.650 position:50% align:middle So vitally important. 00:34:29.650 --> 00:34:31.450 position:50% align:middle And we did try to share... 00:34:31.450 --> 00:34:39.980 position:50% align:middle One message is that this compact and this legislation, its whole purpose, was to increase access to care. 00:34:39.980 --> 00:34:44.900 position:50% align:middle Also, I think it was very important that we kept all of our stakeholders informed. 00:34:44.900 --> 00:34:50.340 position:50% align:middle Whenever I found out that there was going to be the hearing, I would send an email out to the eight 00:34:50.340 --> 00:34:56.830 position:50% align:middle Delaware AARP to all of the nursing associations within the state or Delaware Nurses Association. 00:34:56.830 --> 00:34:59.460 position:50% align:middle They were just vitally, vitally important. 00:34:59.460 --> 00:35:06.240 position:50% align:middle And then they spread the word even further out to their membership and those nurses and the membership went 00:35:06.240 --> 00:35:07.390 position:50% align:middle to their legislators. 00:35:07.390 --> 00:35:08.500 position:50% align:middle They talked with them. 00:35:08.500 --> 00:35:10.050 position:50% align:middle They educated them. 00:35:10.050 --> 00:35:11.260 position:50% align:middle They asked them to vote. 00:35:11.260 --> 00:35:17.620 position:50% align:middle And I think that that was...again, the communication, the collaboration, and the grassroots efforts were just 00:35:17.620 --> 00:35:21.810 position:50% align:middle vital in getting this legislation passed. 00:35:21.810 --> 00:35:25.780 position:50% align:middle Also, we had some pretty big national supporters. 00:35:25.780 --> 00:35:32.990 position:50% align:middle It's important I also think to have facts and data to support APRN prescribing practices and 00:35:32.990 --> 00:35:34.980 position:50% align:middle your disciplinary actions. 00:35:34.980 --> 00:35:39.730 position:50% align:middle Having that information was also very helpful. 00:35:39.730 --> 00:35:42.810 position:50% align:middle And also remember this has been a slow process. 00:35:42.810 --> 00:35:45.250 position:50% align:middle It's not something that happens overnight. 00:35:45.250 --> 00:35:51.130 position:50% align:middle In essence, it took us 10 years to get to this point. 00:35:51.130 --> 00:35:52.910 position:50% align:middle These are all the letters of support. 00:35:52.910 --> 00:35:59.290 position:50% align:middle I've already mentioned many of the organizations that were supportive of our APRN Compact and the Companion 00:35:59.290 --> 00:36:00.980 position:50% align:middle Bill here in Delaware. 00:36:00.980 --> 00:36:05.240 position:50% align:middle And these are all of the letters that were sent to every legislator. 00:36:05.240 --> 00:36:13.290 position:50% align:middle So we inundated them with communication, both verbally and written and in person. 00:36:13.290 --> 00:36:16.650 position:50% align:middle And it was very, very helpful. 00:36:16.650 --> 00:36:22.790 position:50% align:middle I think it was helpful to be in the compact and the NLC compact first, but I want to point out this 00:36:22.790 --> 00:36:25.920 position:50% align:middle is not mandatory. 00:36:25.920 --> 00:36:32.290 position:50% align:middle Basically for us it ensures that when we do go live with the APRN Compact licensure, 00:36:32.290 --> 00:36:38.720 position:50% align:middle that we have the system in place for licensing people with compact licenses. 00:36:38.720 --> 00:36:44.460 position:50% align:middle The Consensus Model and title protection is needed and is part of the APRN Compact. 00:36:44.460 --> 00:36:52.130 position:50% align:middle This ensures that the licenses issued are synonymous with the four roles and the populations of APRNs. 00:36:52.130 --> 00:37:00.000 position:50% align:middle It provides standards for all states who are members of the compact and licensing their licensees. 00:37:00.000 --> 00:37:04.830 position:50% align:middle You also need your board of nursing support for the compact as well as your division if you're 00:37:04.830 --> 00:37:08.420 position:50% align:middle an umbrella agency, which we are here in Delaware. 00:37:08.420 --> 00:37:10.230 position:50% align:middle We have many other boards and commissions. 00:37:10.230 --> 00:37:11.710 position:50% align:middle We're very small. 00:37:11.710 --> 00:37:15.380 position:50% align:middle We have very limited staff and resources. 00:37:15.380 --> 00:37:20.230 position:50% align:middle So by having my staff on board, they understand compact licensure, 00:37:20.230 --> 00:37:26.200 position:50% align:middle and they're able to talk to people who call in and provide information to inquirers 00:37:26.200 --> 00:37:28.900 position:50% align:middle regarding compact licensure. 00:37:28.900 --> 00:37:31.740 position:50% align:middle You also need the support of your nursing associations. 00:37:31.740 --> 00:37:35.610 position:50% align:middle I think I've emphasized that pretty heavily in this presentation. 00:37:35.610 --> 00:37:37.020 position:50% align:middle I hope I have. 00:37:37.020 --> 00:37:40.470 position:50% align:middle I can't say enough about trust and collaboration. 00:37:40.470 --> 00:37:41.652 position:50% align:middle I think it's important. 00:37:41.652 --> 00:37:44.500 position:50% align:middle You know, I've been in this role for quite a number of years. 00:37:44.500 --> 00:37:47.610 position:50% align:middle I've been a nurse in Delaware for over 40 years. 00:37:47.610 --> 00:37:56.180 position:50% align:middle So I have I believe good trust within the nurses in Delaware, and I think that we collaborated 00:37:56.180 --> 00:38:01.350 position:50% align:middle exceptionally well in order to be able to get this legislation passed. 00:38:01.350 --> 00:38:10.070 position:50% align:middle And the other piece is that the leadership of all the organizations, it says a lot for them as well as how 00:38:10.070 --> 00:38:18.600 position:50% align:middle they work together and everyone came together again with the common message of increasing access to care. 00:38:18.600 --> 00:38:25.470 position:50% align:middle We educated, educated, educated, first, the APRNs, then the legislators, other stakeholders. 00:38:25.470 --> 00:38:30.930 position:50% align:middle And the other thing is when you do have hearings, your legislators like to hear stories from your 00:38:30.930 --> 00:38:36.410 position:50% align:middle constituents like, "I went to my nurse practitioner and I had excellent care. 00:38:36.410 --> 00:38:44.340 position:50% align:middle She took the time to talk to me and explain everything, and I just really enjoy my nurse practitioner visits." 00:38:44.340 --> 00:38:51.290 position:50% align:middle We had those kinds of people ready and waiting to testify as necessary. 00:38:51.290 --> 00:38:58.860 position:50% align:middle I also think it was important that your key expert witness who speaks at the legislative hearings has a 00:38:58.860 --> 00:39:02.520 position:50% align:middle knowledge of the compact and nursing. 00:39:02.520 --> 00:39:05.957 position:50% align:middle I think that the questions that were asked of me in particular... 00:39:05.957 --> 00:39:08.981 position:50% align:middle I was the expert witness for Rep. Minor-Brown. 00:39:08.981 --> 00:39:17.300 position:50% align:middle And the questions that were asked during the hearings were questions more on how does it really work in the 00:39:17.300 --> 00:39:25.700 position:50% align:middle real world, what happens if you have a Maryland nurse who's working in Delaware and she commit some kind 00:39:25.700 --> 00:39:30.000 position:50% align:middle of unprofessional conduct, how does that discipline really look. 00:39:30.000 --> 00:39:36.360 position:50% align:middle And I was able to explain to them how it works currently in the NLC, Nurse Licensure Compact, 00:39:36.360 --> 00:39:41.760 position:50% align:middle and how I would anticipate it would probably work in the APRN Compact. 00:39:41.760 --> 00:39:45.900 position:50% align:middle And they asked some pretty tough questions, especially at the Senate committee. 00:39:45.900 --> 00:39:52.910 position:50% align:middle They were very tough questions I felt, but I also was able to answer them with confidence 00:39:52.910 --> 00:39:55.490 position:50% align:middle and competence, I thought. 00:39:55.490 --> 00:39:58.590 position:50% align:middle So I also have to say, yes, we did have opposition. 00:39:58.590 --> 00:40:02.230 position:50% align:middle I mentioned about the AMA letter and the nurse practitioners. 00:40:02.230 --> 00:40:08.300 position:50% align:middle And to counteract that opposition, these are some of the measures that we used. 00:40:08.300 --> 00:40:13.070 position:50% align:middle First of all with the nurse practitioner opposition, we brought out the Companion Bill, 00:40:13.070 --> 00:40:18.890 position:50% align:middle which basically eliminated the collaborative agreements, which made the NPs very, very happy. 00:40:18.890 --> 00:40:21.750 position:50% align:middle We also conducted town hall meetings. 00:40:21.750 --> 00:40:28.050 position:50% align:middle And in these town hall meetings, I really emphasize that this APRN Compact is a 00:40:28.050 --> 00:40:33.710 position:50% align:middle licensure model for regulation of nurses. 00:40:33.710 --> 00:40:37.710 position:50% align:middle It has nothing to do with changing the scope of practice. 00:40:37.710 --> 00:40:46.270 position:50% align:middle And that is why the committee composition, who will be the oversight of the APRN Compact, 00:40:46.270 --> 00:40:52.100 position:50% align:middle those administrators or whatever they end up being called, are usually representatives from the 00:40:52.100 --> 00:40:53.660 position:50% align:middle boards of nursing. 00:40:53.660 --> 00:41:01.830 position:50% align:middle And the purpose of that is because the people, nurses don't really understand compact licensure. 00:41:01.830 --> 00:41:06.036 position:50% align:middle That's evident every day in my work that people don't understand, "Oh, well, I live in Florida. 00:41:06.036 --> 00:41:07.623 position:50% align:middle I have to get my license in Florida." 00:41:07.623 --> 00:41:13.650 position:50% align:middle So that was something else that we explained to them. 00:41:13.650 --> 00:41:23.180 position:50% align:middle We also have APRNs who are executive directors in several states so they can also have that input. 00:41:23.180 --> 00:41:28.510 position:50% align:middle In Delaware, the other piece that we did was changed the composition of the APRN committee, 00:41:28.510 --> 00:41:37.540 position:50% align:middle and the purpose of that committee is now to provide guidance on rules, regulations, emerging practices, 00:41:37.540 --> 00:41:45.220 position:50% align:middle and things that APRNs can bring to the board, which we also have two board members who are APRNs. 00:41:45.220 --> 00:41:48.750 position:50% align:middle And then when it comes to the board, then I, as the executive director, 00:41:48.750 --> 00:41:57.100 position:50% align:middle can take that information back up to the council or the administrators and the APRN Compact. 00:41:57.100 --> 00:42:01.570 position:50% align:middle The second big, big opposition was the American Medical Association. 00:42:01.570 --> 00:42:07.920 position:50% align:middle And like I said, I received this letter two hours before the House hearing for the Companion Bill. 00:42:07.920 --> 00:42:17.570 position:50% align:middle So I had to do a lot of quick data collection as well as thoughts and ideas to counteract basically what the 00:42:17.570 --> 00:42:19.220 position:50% align:middle AMA letter was saying. 00:42:19.220 --> 00:42:21.947 position:50% align:middle They said that we were going to remove physicians from practice. 00:42:21.947 --> 00:42:22.843 position:50% align:middle No. 00:42:22.843 --> 00:42:25.580 position:50% align:middle They said that we were changing our scope of practice. 00:42:25.580 --> 00:42:27.977 position:50% align:middle This whole thing was to preempt scope of practice. 00:42:27.977 --> 00:42:28.821 position:50% align:middle No. 00:42:28.821 --> 00:42:33.560 position:50% align:middle Many things in this letter were so erroneous. 00:42:33.560 --> 00:42:38.660 position:50% align:middle So what I ended up doing after that hearing, I wrote a letter of rebuttal back to the 00:42:38.660 --> 00:42:46.100 position:50% align:middle AMA allegations, and I sent it to every House representative and state Senator. 00:42:46.100 --> 00:42:51.370 position:50% align:middle So we did share that with them before we went on forward before the House floor, 00:42:51.370 --> 00:42:56.270 position:50% align:middle and before we went to the Senate hearings, and then to the Senate floor. 00:42:56.270 --> 00:42:59.160 position:50% align:middle Of course, anesthesiologists were in opposition. 00:42:59.160 --> 00:43:04.267 position:50% align:middle And I did receive one in particular letter from an anesthesiologist. 00:43:04.267 --> 00:43:05.330 position:50% align:middle So I contacted her. 00:43:05.330 --> 00:43:13.320 position:50% align:middle We did a Zoom meeting where we discussed her concerns, and I believe that we were able to squelch some of the 00:43:13.320 --> 00:43:18.170 position:50% align:middle misconceptions that were actually there. 00:43:18.170 --> 00:43:21.320 position:50% align:middle And then last was the Medical Society of Delaware. 00:43:21.320 --> 00:43:25.680 position:50% align:middle As I said, in 2015, we met with them many, many times. 00:43:25.680 --> 00:43:30.400 position:50% align:middle We drove several hours to get to the meetings in Wilmington at 5 a.m. 00:43:30.400 --> 00:43:34.180 position:50% align:middle to meet with them so that we could be there when they were available. 00:43:34.180 --> 00:43:41.250 position:50% align:middle And we made negotiations back in 2015, but this time, I stood the ground. 00:43:41.250 --> 00:43:45.740 position:50% align:middle I said, no, we're not making any changes in these bills. 00:43:45.740 --> 00:43:50.430 position:50% align:middle This is what we need to go forth with, and that is what we did. 00:43:50.430 --> 00:43:53.720 position:50% align:middle So I'm very happy to say again that we did. 00:43:53.720 --> 00:43:58.000 position:50% align:middle We were successful in getting these bills passed. 00:43:58.000 --> 00:44:01.660 position:50% align:middle So that basically concludes my part of the presentation. 00:44:01.660 --> 00:44:08.290 position:50% align:middle And now I believe we're going to go into a question and answer session with all three of us. 00:44:08.290 --> 00:44:09.566 position:50% align:middle Thank you very much.