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Making a difference through grassroots legislative action

Kaplan, Louise PhD, ARNP, FNP-BC, FAANP

doi: 10.1097/01.NPR.0000433085.24184.d3
Department: Advocacy in Practice

There are approximately 150,000 nurse practitioners (NPs) in the United States.1 The influence of NPs on legislative change has increased over the past few years; however, it is still not in proportion to the numbers. At a recent national conference, an NP leader commented on the apathy of her colleagues in a state that had recently passed legislation that she viewed as a setback for NPs. It is interesting to wonder if this was apathy, if NPs were normalized to oppressive practiced conditions, or if NPs need more knowledge to effect legislative change.

Nevada NPs shine as an example of hard working, committed, and savvy citizen lobbyists who succeeded in eliminating physician involvement in their practices. The exception is for controlled substance prescribing, which requires physician collaboration if the NP does not have 2 years or 2,000 hours of clinical experience.2 This article provides an overview of strategies for successful grassroots legislative action.

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Why should NPs get involved?

NPs are experts at what they do and can inform legislators and other stakeholders, such as legislative staff, about the implications and effects of restrictive laws. NPs are not just advocates for their own scope of practice; they are advocates for consumers who want access to quality care and a choice of providers.

For example, NPs in Oregon successfully lobbied the passage of a law that requires insurers to reimburse NPs and physician assistants in independent practice; reimbursement is at the same rate as physicians for the same services when providing the same primary care and mental health services and billing under the same code.3 Without this legislation, the fiscal viability of NP-owned practices or practices that employ NPs would be reduced and, which could limit access to primary care.4

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How should NPs get involved?

Engaging in collective action through professional associations provides an infrastructure and resources for effective change. Professional associations typically have staff, lobbyists, and experienced members. Staff and lobbyists are able to work with legislators and other stakeholders on a day-to-day basis when an NP needs to be at his or her practice. Experienced members can serve as leaders, spokespersons, and mentors.

Another key strategy for involvement is for NPs to become acquainted with their legislators. A personal relationship with legislators creates access to provide important and timely information. A personal relationship also allows NPs to be viewed as experts and trusted sources of information.

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Who are the stakeholders?

Legislators are obviously the most important stakeholders, since they have power to decide if a bill receives a hearing in committee, a vote by a committee to move forward in the legislative process, and, ultimately, to vote on passage of the bill. There are other critical stakeholders who can affect the success or failure of a bill. Legislative staff can provide NPs access to legislators and assure that any requested information for a legislator to review is passed on. Staff also advise legislators on constituent's responses.

Employing an effective lobbyist can be critical to legislative success. The lobbyist should be respected by legislators and considered a reliable source of information. The lobbyist represents the position of the NPs and must carefully explain the implications of the passage or failure of a bill.

Constituents may also provide support or opposition to proposed legislation. Legislators are sensitive to the experiences and stories of their constituents who elected them to office. While NPs may be perceived as watching out for their turf, legislators must watch out for their constituents.

The media may influence the course of a bill. Press coverage and blogs can bring attention to proposed legislation and increase pressure on legislators to take action. Similarly, staff and elected officials from the executive branch can affect a legislator's perspective on a bill. Agency staff may present information about what should be required to implement a bill or potential unintended consequences.

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How does a bill become a law?

Each state determines the process used for passage of a bill; the federal government also has its own process. A bill is typically introduced into a chamber (usually the House of Representatives or Senate) and is referred to a committee for initial consideration. After passage in the initial chamber, it must also pass through the other one and be signed into law by the Governor or President. Understanding this process is important in knowing who, when, and where to influence the process.

Typically, the focus is on passage of legislation; however, it can be equally important to prevent passage of a bill. For example, in Washington State, a Senate bill ( to require transparency for patients regarding the training and qualifications of healthcare professionals was opposed by advanced registered nurse practitioners (ARNPs) United of Washington State. This legislation was considered a veiled attempt to prevent ARNPs with a DNP from referring to themselves as “doctor.” The state's Uniform Disciplinary Act ( already prohibits misrepresentation or fraud in any aspect of the conduct of business or one's profession. This law was successfully cited to demonstrate the lack of need for additional legislation.

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How do NPs provide testimony?

Providing testimony is an important strategy to persuade legislators to support a position on a bill. It is important for NPs to be prepared with a brief, focused statement that uses reliable and relevant data. NPs should prepare a briefing document to submit at the conclusion of the testimony. They should also be prepared to answer questions; if the answer is not known, NPs should provide a response at a later date and follow through. Many states have educational materials on how to testify. Washington State has a document ( that helps guide the process, and the Oregon State Legislature has a short video ( on testifying.

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What are strategies for successful grassroots legislative action?

There are many strategies that can contribute to the success of grassroots legislative action. Key strategies include developing a plan and timeline, assuring there is sufficient money for lobbyists and media, and securing powerful and respected legislators to sponsor a bill.5 Use data to support a position, and put issues in the context of cost, access, public safety, and quality. The Institute for Healthcare Improvement's Triple Aim framework can be used to organize an NP's position: better care for individuals, better health for populations, and lower costs.6

It is essential for NPs to attend public forums and speak on issues to educate legislators, the public, and media. Effective communication— without the use of jargon—should be utilized in a way that establishes the NP's expertise. It is also essential to show the relevance of the issue beyond the nursing profession. Follow-up conversations via a letter or an e-mail should be conducted.

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What else is important to know about grassroots legislative action?

It is important to understand that grassroots legislative action may take a long time. The recession in the economy, attention to implementation of the Patient Protection and Affordable Care Act, and the countervailing forces of other special interest groups, such as medical associations, may derail the best-laid plans for changes in NP laws. It can sometimes take years for an idea to gain traction or for some event to bring attention to the need for change. NPs should be alert to attempts to limit or rescind the practice authority they already have. If NPs do not advocate for themselves, progress will not be made.

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1. U.S. Department of Health and Human Services, Health Resources and Services Administration. The registered nurse population: findings from the 2008 National Sample Survey of Registered Nurses. 2010.
2. Harasim P. New law lets nurse practitioners get more involved. Las Vegas Review-Journal. 2013.
3. Oregon Legislative Information System. HB 2902 B. 2013.
4. Oregon Nurses Association. HB 2902 B, payment parity for NPs and Pas in primary care and mental health. 2013.
5. Pruitt RH, Wetsel MA, Smith KJ, Spitler H. How do we pass NP autonomy legislation. Nurse Pract. 2002;27(3):56–65.
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