Having a basic understanding of the three types of policy-making is essential to navigating your nursing advocacy journey in California.
What you'll learn in this section:
Get an introduction to the legislative process in California and how it impacts the nursing profession
Learn who the predominant regulatory agency is in California and how they implement and enforce changes.
Understand the steps needed to create policy change in your institution.
Bookmarkable links to quickly find calendars, committees, and meeting times.
Having a working knowledge of policy and politics is essential to creating sustainable change for nurses and patients in California. Every successful campaign starts with understanding how change is created through each of our state's governing bodies.
This section of the Advocacy Institute Guide will give you a basic understanding of the three types of policy-making:
Each policy arena operates differently, influencing how you advocate, the methods you use, and who you will need to influence in order to see sustainable change.
Introduction to Legislative Process in California
Legislation sits at the top of the hierarchy of change. California Senators and Assemblymembers, often referred to as 'Legislators' or 'the California Legislature', make decisions that affect hundreds of thousands of people just like you.
From tobacco and agriculture to public health and the nursing profession, legislation can affect multiple industries within a single bill.
When the California Legislature introduces new legislation, it will either be introduced in the first or the second year of a two-year legislative cycle, depending on the complexity and/or potential impact of the bill. However, each bill will follow the same legislative process.
Understanding the broad process of how a bill becomes law will demonstrate where you, other nurses, and the public have opportunities to advocate.
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Legislative Process: From Idea to Law
It is important to note that all legislation first begins with an idea or concept.
The motivation for creating legislation varies - sometimes influenced by businesses and agencies, sometimes by citizens, the governor, or lobbyists - but presumably, they are for the good of the districts they represent and all of California.
When a Senator or Assemblymember decides to author a bill, they send the bill to the Office of the Legislative Counsel, where it is drafted into bill form and returned to the legislator.
What does a bill marked with 'AB' or 'SB' mean?
When a California Senator introduces legislation, the bill is designated by 'SB' (Senate Bill) followed by the bill number. An Assemblymembers' bill will start with 'AB'. The Senate and Assembly are referred to as the bill's 'house of origin.'
Each legislative cycle, bill numbers will be reset. Meaning if you look up AB 410 in 2023, it will be a completely new bill in 2025.
First Reading or Introduction
At the beginning of the legislative cycle in January, each bill is introduced by a member of the California Legislature.
Each bill goes to the rules committee to decide which policy committee hearings are appropriate. The California Legislature must then wait 31 days before Committee Hearing(s) can start.
During the 31-day waiting period, after bill introductions, advocates like you will have approximately one month to:
read the first draft of the bill,
understand the intended and unintended consequences of the bill, and
begin to develop an advocacy campaign with messaging.
For nurse advocates, this is a critical time to connect with colleagues and coalition partners to discuss how to respond cohesively.
During the Committee Hearing the bill author, citizens, experts (nurses!), and lobbyists have an opportunity to share public comments. As a lobbying association with a contracted lobbyist, ANA\California frequently comments on bills at this time as well as notes which legislators are in support or opposition of the bill.
Bookmark This! You can keep track of each house’s schedule of legislative committee hearings by visiting the California State Senate's Committee, Offices & Caucuses page and California State Assembly's Committees page.
Second and Third Readings
Following the first Committee Hearing, the bill may undergo several changes in the form of Recommendations and Amendments, before proceeding to second and third readings by the house of origin.
If the bill fails to gain support from its house of origin, the bill may be refused and will be considered 'dead.'
Some bills require hearings by more than one committee, in which case a committee may re–refer the bill to another committee because their recommendations or amendments require additional approval.
For example, bills with monetary implications must be re–referred to the proper fiscal committee in each House before they are sent to the second reading file and final action.
Repeat the Process in the Opposite House
After the second and third readings, bills will switch to the opposite house. If the bill originated in the Assembly, then it will switch to the Senate, and vice-versa.
Once the bills have switched houses, the process repeats:
The bill is introduced,
assigned to a committee(s),
a committee hearing meeting is set,
the public can comment,
possible amendments during potential second and third readings, and
Each time there is a Committee Hearing, you have an opportunity to speak directly to the entire committee.
And for those who’ve listened in to a hearing before, you can hear the weight of each individual's words as they speak to a group of elected officials representing millions of Californians.
What if a bill is amended?
If a bill is amended in the second house, it must go back to the house of origin for concurrence, meaning agreement on those amendments.
If the house of origin does not agree with those amendments, the bill is referred to a two-house conference committee to resolve the differences. Three members of the committee are from the Senate and three are from the Assembly. If they are able to reach a compromise, the bill is returned to both houses for an additional vote.
Governor to California Law
Should new legislation pass both the Senate and Assembly Committee Hearings, the bill will return to its house of origin for final approval before ultimately arriving on the Governor's desk for signing into California Law, or veto, within 12 days.
The California Legislature then has 60 days to veto the Governor's decision with 2/3 vote or the bill becomes law on January 1st of the following year.
Note: Due to emergencies such as COVID-19, legislation may include 'urgency clauses', allowing for legislation to take effect immediately following the Governor's signature.
Introduction to Nursing Regulation in California
When legislation is passed, someone must be responsible for ensuring the laws are followed. This makes regulatory agencies next in the hierarchy of change.
In California, the predominant regulatory agency overseeing nurses is the California Board of Registered Nursing (BRN). The California BRN is designed to facilitate compliance with new legislation as well as adopt, amend, or repeal regulations in order to enforce or administer a statute, bill, or legislation.
Their mission, as stated on their website, is to, "protect and advocate for the health and safety of the public by ensuring the highest quality registered nurses in the state of California."
This includes implementing and enforcing changes, such as:
Nursing Education (Example: The amount of clinical hours a nursing student must complete.)
Licensure (Example: The requirement to fulfill a certain numbers of Continue Education (CEs) credits to maintain a Registered Nurse license.)
Practice (Example: the Nurse Practice Act, which outlines the scope of nursing practice.)
Discipline (Example: Fines, license suspension, etc.)
How is the Board of the California BRN elected?
The nine-member Board is composed of four members of the public and five registered nurses. The five registered nurses include two direct-patient care nurses, an advanced practice nurse, a nurse administrator, and a nurse educator.
Seven of the members are appointed by the California Governor and two of the public members are appointed by the California Legislature. Each member serves a four-year term and can be re-appointed, although the member cannot serve more than two consecutive terms.
Much like the legislative process, the regulatory process has many nuances that can affect how a bill will impact nursing. We will cover the process briefly in this section to illustrate when nurses are able to advocate in support or opposition of a bill.
When can you advocate for regulatory changes in the nursing profession?
Following the start of new legislation on January 1st, the BRN is tasked with creating and updating regulations to facilitate compliance with the new legislation.
This can be in as little as a few months to a few years depending on the resources needed to facilitate compliance with a new bill.
In order to do so, the BRN's Board of Directors meets publicly. And because the BRN is a governmental organization, all meetings, agendas and minutes must be accessible and the availability for public comments is required.
The BRN has two different types of public meetings: Committee Hearings and Board Meetings.
BRN Committee Hearings
There are four different Committee Hearings:
Nursing Practice Committee
BRN Committee Hearings may discuss issues pertaining to multiple committees within the same session. Hearings occur typically every 3 to 4 months depending on the Board Members’ schedules and other policy activities.
Bookmark This! You can learn more about the BRN’s Committee and view upcoming hearings here.
Bookmark This! If you'd like to learn more details about each committee and the regulations they review, click here.
BRN Board Meetings
Board Meetings, in contrast to Committee Hearings, vary in topics. During these meetings, Board Members put items on the agenda for "Discussion and Possible Action." This could include legislation, reports from committees, or administrative actions.
Both Committee Hearings and Board Meetings have time designated for "Public Comment for Items Not on the Agenda; Items for Future Agenda."
However, a common misconception is that all discussions and actions from the Board Members of the BRN can be commented on by the public during the current session. Instead, you must provide comments so they will be recognized for the next meeting.
This means it is important to join calls consistently and to offer comments when available.
Bookmark This! You can access a calendar of upcoming, past, and archived meeting agenda and notes on the BRN website here.
We recommend opening the agenda in a separate tab or printing it out for BRN Committee Hearings and Board Meetings to take notes. This way we can better advocate at the next scheduled meeting(s).
Bookmark This! Also, in case you're interested, here are other regulatory agencies that can affect nursing.
Introduction to Nursing Policy in California
Note: Often in the world of politics and media, 'policy' is a term that is used to refer broadly to all levels within the hierarchy of change, hence the term 'policy-making.' However, in this section below, we will be referring to 'policy' as institutional, private, and public health policy.
Policy change, while lower on the hierarchy of change than legislation and regulation, has a significant impact on your day-to-day and the future of your nursing profession.
When new regulations are passed, health organizations must update or write new facility policies in order to comply with the new regulations.
Policies can range from documentation, to direct patient care and human resources; from private healthcare systems and public health institutions to government agencies, research facilities, and education systems.
Because policy changes are specific to the institution or system in which they are created, there is no standardized process for updating or creating new policies.
Depending on the size of the organization, direct patient care nurses, managers, directors, Chief Nursing Officers, and Boards of Directors may be involved in the policy-making process.
9 Steps to establishing new health policies
However, speaking generally, the following steps are needed to establish new or update outdated policies:
Pressure for change (new problem)
Review evidence and consult experts
Review policy options
Review health impact of each option
Identify barriers to local implementation
Evaluate policy's impact
In California hospitals, the Joint Commission - a federal accreditation organization - requires nurse managers, directors, or other management to review policies every three years to ensure its compliance with new regulations, culture, and other important factors.
However, this does not mean that all policies will be updated or improved.
Policy development is a constant process by groups of individuals working in the best interest of patients and professionals. In order to advance new and updated policies, we must continue to advocate and innovate.
When is Legislation, Regulation, or Policy the answer?
To quickly summarize:
Legislation is the process of developing bills to become law
Regulation is the process of ensuring that laws are adhered to.
Policymaking is the process of private and public institutions following the regulations so you can adhere to the law(s).
So, when is legislation, regulation, or policy the solution to your problem?
The more one advocates and the more one understands the system of politics in California, the easier it is to answer this question.
Start by asking questions like:
Does the 'scope' of your issue affect one individual institution or many nurses throughout California?
Does your issue involve multiple professions or organizations who disagree?
Asking questions about who the issue will affect is a quick indication of whether legislation, regulation, or policy is the solution.
While change does often flow 'downstream' from legislation to regulation and policy, new regulations and policies are created even when new legislation doesn't require it - as in the case of new technology or cultural changes.
Now that you have a basic understanding of the processes of change in California, it is time to begin developing your advocacy campaign.
In this next section of the Advocacy Institute Guide, we will walk you through a simple advocacy process you can use anywhere, anytime - for legislative, regulatory, or policy advocacy.
Don’t have any specific issue in mind? No problem!
ANA\California advocates for multiple nursing campaigns in California and analyzes on average 2,500+ legislative bills each legislative cycle.
Visit anacaliforna.org to see what we're working on.