Written: 4/30 - 5/1. Excuse our lateness! There was much to unpack in this issue.

Let's shift gears this week...

Quarantine orders have heavily impacted California State Legislature's timeline and priorities. Nearly 500 Senate Health Committee bills scheduled for this year alone are to be whittled down to a whopping 30...

So what does this mean? Legislation is focusing on bills that meet three criteria: Coronavirus response, budget, or resources. The Senate is supposed to reconvene on May 11th, but on April 29th, Sacramento extended their stay-at-home order to May 22nd.

That means for the next few weeks it will be crucial to monitor and advocate for important legislation. ANA\California is on it, so here are the first few bills...

- Your ANA\California Team

AB 664 (Cooper & Gonzales) seeks to improve workplace protections by defining "injury." This bill would apply to certain state and local firefighting personnel, peace officers, hospital employees, and fire and rescue service coordinators who work for the Office of Emergency Services.

Under the bill, workers exposed to or who've contracted, on or after January 1, 2020, a communicable disease, including COVID-19, could seek protections. The bill would create a conclusive presumption that the injury arose out of and in the course of the employment.

Currently, protections only extend to "health care employees who provide direct patient care in an acute care hospital... " Full bill text can be accessed here.

However, Roxanne Gould, ANA\C contracted lobbyist, and Dr. Marketa Houskova, ANA\C Executive Director, discussed this bill with Asm. Cooper's staff where they offered an amendment aimed at the fundamental work of nurses caring for patients in subacute care facilities as also being on the frontlines of COVID-19 pandemics.

On January 1, 2020, Worker Status: Employees and Independent Contractors, previously known as Assembly Bill 5 (Gonzalez) or "gig worker bill", went into effect.

A very short background: In 2019, California’s Supreme Court determined that the rigorous, three-pronged “ABC Test” must be used to determine worker classification. A worker is presumed to be an employee unless the hiring company can successfully demonstrate that the worker satisfies all three criteria of the test.

Major lobbying efforts on both sides of the issue resulted in over 50 professions or types of businesses exempt from the bill, including doctors, dentists, insurance agents, lawyers, real estate agents, hairstylists, journalists, and a variety of creative professionals.

However, nurses' exemptions were not accepted even as 50+ coalition partners, including ANA\California and the California Hospital Association (CHA), fought on behalf of nurses and other healthcare workers.

Since, multiple solutions have been proposed to amend or repeal AB-5, and the calls for amendment have only become louder in the setting of the COVID-19 pandemic. The language in AB-5 provided exemptions for physicians and “certain licensed health care professionals performing professional or medical services provided to or by a prescribed health care entity.”

However, it is unclear whether advanced practice registered nurses (APRNs) fall under the umbrella of these exemptions, and this ambiguity is preventing healthcare organizations from caring for their communities by hiring them as independent contractors. 

One thing is for certain—that APRNs in California need the flexibility to be able to serve California communities. Many APRNs choose to be independent contractors because it allows them to work in multiple locations and provides rural hospitals with options when positions do not require full-time employees.

Senate Bills 900 & 990 seeks to amend and repeal AB-5 to exempt various members of health professionals, including “licensed professional clinical counselors, licensed clinical social workers, or licensed marriage and family therapists performing professional or medical services provided to or by a prescribed health care entity.” This bill does not, however, include language that would specifically provide exemptions for nurse practitioners, clinical nurse specialists, nurse midwives, and certified nurse anesthetists.

An Open Letter to California Gov. Newsom and all Members of the State Legislature, seeks to repeal AB 5. The letter has been signed by 151 distinguished PhD economists and political scientists, each affiliated with one of 40 colleges, universities, and think tanks in California. The signatories include Nobel Laureate Vernon Smith (Chapman U.), John Taylor (Stanford U.), Lee Ohanian (UCLA), David Teece (U.C. Berkeley) and others.

The letter reads: "By prohibiting the use of independent contractor drivers, health care professionals, and workers in other critical areas, AB-5 is doing substantial, and avoidable, harm to the very people who now have the fewest resources and the worst alternatives available to them."

You may also watch this video for a deep dive into AB 5. The video features Independent Institute's Senior Fellow Dr. Williamson M. Evers and Independent's President David J. Theroux to discuss the Open Letter and the urgent need to suspend AB-5.

Final note: Will the strategic decision to leverage SB 900 & SB 990 during COVID-19 will be of help or an impediment to the bills success?

In 1999, the Nurse Licensure Compact (NLC) was released. The National Council of State Boards of Nursing (NCSBN) became the first organization to develop and implement two interstate compacts to reduce regulatory barriers to cross-border nursing practice for LPN/LVNs, RNs, and APRNs.

Fast forward to today and thirty-two states have now joined the NLC. An increased demand for nursing care and technological developments, such as telehealth and remote case management, has increased demand for the provision of nursing services across state boundaries. The introduction of the NLC allows for fluidity and portability of nursing licensure with all other states party to the same compact. 

This fluidity has several benefits. Interstate licensure may help to ease the burden of nursing shortages, facilitate interstate collaboration to address licensure issues that may impede nurse recruitment, and tends to promote consistent administrative and disciplinary procedures. 

But nurse licensure, like most occupational and professional regulation, is administered by individual state governments, each overseeing the practice of nursing within its geography. Normally this would be the California Board of Registered Nursing... so let's queue up NCSBN's organizational structure.

NCSBN's website says they are a not-for-profit organization. But during a call between NCSBN and ANA's state chapter Executive Directors, a discovery was made that NCSBN refers to themselves as "quasi-governmental." If you're thinking I need to Google that, that's okay... Quasi means "seemingly; apparently but not really." So you may be thinking, if NCSBN is not-for-profit, how do they fund their regulatory oversight?

According to Vermont's Secretary of State Office of Professional Regulation, state's board of nursing would see upwards of one million dollars in lost revenue. If Vermont, with a population of 624,000, would lose nearly a million dollars, how much revenue does California, with a population of 39.5 million, stand to lose? Time to dust off those calculators.

In the simplest telling, a nursing license fee in a Board-regulated state is determined by regulatory expense divided by active licensees. If your state joined the NLC however, your State Board of Nursing (SBON) wouldn't collect fees from traveling nurses with compact licenses or non-traveling nurses with native workplaces but residences in compact states. Instead this revenue would be diverted to NCSBN.

Quasi-governmental also introduces an oversight issue. As a private organization, there is no legislative or government audit nor does the California BRN have a say in the internal bylaws. Will an internal audit by the NCSBN itself be satisfactory?

Furthermore, NLC currently lacks uniformity between states in regards to Enforcement and Diversion. Not all states have the same regulations or rules regarding misconduct. So this topic is best posed as a hypothetical, "If a nurse from another state was involved in misconduct of some kind, and said nurse returned back to their home state, could the California BRN still investigate and follow up on a corrective plan? What if s/he decides to come back to CA and work again? How would CA BRN know if s/he is working in CA again? How would we assure safety and high quality of patient care?

For more on disciplinary actions under nurse compact, read this.

Finally, states differ in the number of CEUs needed to renew licensure - California, in specific, requires 30 CEUs and has shortened license renewal from months a few years ago to approximately 27 days today. On a positive note, this would be a great opportunity for California to have a say in advocating for the importance of CEs across the nation. Many travel RNs do not have to meet any CE requirements.

In summary, nurses should understand two key points regarding their responsibility under NLC:

  • Multi-state license is based on state of residence, much like a driver's license. Once the nurse relocates, they must apply for a new license.
  • Crossing the state border either in person or via technology, the Compact license holder is accountable for all related statutory and regulatory provisions in which the patient, consumer, or student is located. No excuses.
  • It is the responsibility of the nurse to familiarize themselves with each states' Nursing Practice Acts.

ANA recommends the following to improve the Compact Licensure:

  1. Make registration a requirement when entering into the state. Boards of Nursing should know who is practicing - especially for purposes of workforce development and planning.
  2. Development of a standardized decision tree for determining scope of practice.
  3. Uniform implementation of the federal biometric background licensure requirement.
  4. Review, evaluate and make recommendations for alternative discipline programs for nurses with substance use disorders.
  5. Request full transparency from NCSBN regarding meeting agendas, minutes, reports etc) consistent with state public meeting laws.

Supporting and advocating for our fellow nurses in times of need is of utmost importance. That's why we're happy to announce in the past week nurse advocates sent more than 2,200 messages to Gov. Newsom, the Director of the DCA, and State Legislators supporting nursing students in their effort to graduate this semester. For all of those who participated, we thank you!
Hello. We're ANA\California.

We enhance the health and well-being of Californians and advance the profession of nursing by advocating for legislation, regulation, and policies. We focus on improving quality care, quality experiences, quality nurses, and the quality of our profession. We're the ANA\California Team and we're here for you. How can we help?

Thousands of nurses have participated in our advocacy campaigns recently and we thank you for your support!  For those of you who've missed out on these critical campaigns, we've made digital advocacy as easy as 1-2-3.

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-- Your ANA\California Team