Taking Action: Nurse, Educator, and Legislator
My Journey to the Delaware General Assembly
“I have come to the conclusion that politics are too serious a matter to be left to the politicians.”
General Charles de Gaulle
My Political Roots
I am a nurse and I became the first health care professional elected into the Delaware General Assembly, as well as the first registered nurse elected. The roots of my public service began in a farming community where I volunteered to help others in my church and at neighborhood organizations. At the age of 12, I was a candy-striper in a local hospital and continued my civic work during my teen years. When I entered college I joined a political party. Though my parents were not politically active, my great-grandfather was a member of the Delaware House of Representatives in the 1920s and I am a descendent of Delaware’s 16th governor.
My interest in politics began while working with underserved residents at the same time I was completing my master’s degree in community health nursing in the late 1980s. I used an earlier edition of this book in my graduate program and vividly recall reading the chapters about becoming involved in politics. I began working with my local city government, the League of Women Voters, and a federal health clinic that served the homeless. Before these experiences, I had thought that public policy was remote to nursing and somewhat dry. These experiences changed my perspective.
Volunteering and Campaigning
I went on to volunteer with nonprofit and civic organizations, join professional associations, and to complete my doctoral degree in nursing administration andpublic policy. During this time, I served as a United States Senate Fellow and as a U.S. Department of Health and Human Services policy analyst for the Secretary’s Commission on Nursing. These experiences exposed me to national policy work, federal officials, leaders in the nation’s health associations, and international researchers. I became actively involved with veteran’s organizations because my husband was on active duty in the military. I also became a volunteer on political campaigns with the Democratic Party. I had excellent mentors to assist me with both my nursing and political career paths. All of these experiences helped me to understand the policy process and the importance of building relationships.
I began my work in politics to make a difference in the lives of many citizens who lack life’s necessary resources. As a public health nurse, I had an interest in improving the services available to vulnerable populations. I continue to work to advance issues important to the residents I represent. These include health care, the environment, land preservation, education, and economic development.
There’s a Reason It is Called “Running” for Office
A number of factors influenced my decision to run for public office in 2000, including my desire to make a significant contribution to the public’s health. As a university faculty member, I assigned students to various public health and health policy assignments. During these experiences, I witnessed the need for expert health knowledge in the Delaware General Assembly. The time was ripe within the political party and within my district to run for the Delaware legislature. I ran for office for the first time in 2000 and lost by a mere 1%. I had run against a long-term, male incumbent and learned some important political lessons. In 2002, political redistricting left a vacant seat and I ran again. This time I won in a tough election against the president of the local school board. After serving 6 years in the House, I campaigned for, and won, a state senate race in 2008 (Figure 55-1).
FIGURE 55-1 Dr. Hall-Long’s campaign literature identifies her as a nurse and educator.
A Day in the Life of a Nurse-Legislator
No two days in politics are alike. Each elected official’s experiences and perceptions are linked to his or her beliefs, the district’s beliefs, the state’s legislative rules, and external economic or social pressures. In Delaware, serving as a legislator is a part-time job. Delaware’s bicameral legislative session is active for a total of 45 days per year. Session convenes each January, and the legislature must pass the budget bill and recess by July 1. We meet three days a week: Tuesday, Wednesday, and Thursday. I spend the remaining days on 467constituent work, in meetings, delivering speeches, and conducting my job as a nursing faculty member. Between July and January, my days are filled with at least 8 to 12 hours of meetings, community work, and, in election years, campaign activities. On occasion, there are Special Sessions in the fall when the senate convenes.
Much of a state legislator’s time is spent on the capital and operating budgets of the state, as well as handling senate confirmations. These activities need to be completed by the end of the state’s fiscal year: July 1. My most important role is to represent my constituents at committee meetings, public hearings, on task forces, and as a sponsor or cosponsor of relevant bills. My district is both rural and suburban and has numerous policy needs: smart growth, transportation, education, health care, and economic development.
I juggle caring for my family, legislative work, and nursing education. I’m up at 5 AM to exercise and then I have breakfast meetings with constituents or campaign committee members. Following the meetings, I usually put on my other hat and spend time with my nursing students. I return phone calls in my car as I head into the state capital. When I arrive in my office, I’m greeted with phone messages, e-mail, and the pressing issues of the day. I share one staff member with another senator. Session begins around 2 PM when we enter caucus for 30 to 45 minutes to discuss the legislative agenda and bills to be voted upon. One day a week there are committee hearings. In the afternoons, I squeeze in more phone calls, RSVPs, research with the lawyers, and then head back to the floor for votes.
After each legislative day, there are usually receptions sponsored by interest groups. These provide time for lobbyists and members to review issues andconcerns and highlight state funding efforts or programs. Typically, I attend several civic or association meetings each evening after the session in my district (I balance these with my son’s sporting and school events.). These meetings are important for gathering community input, staying current on issues, and letting my constituents know that I am concerned about their issues. It all takes a lot of time, energy, and a few cups of coffee.
What I’ve Been Able to Accomplish as a Nurse-Legislator
I have sponsored or cosponsored a range of legislation as a member of the house and senate: health, education, transportation, veteran’s affairs, agriculture, natural resources and the environment, homeland security, community and county affairs, and insurance committees. As the only health care professional in the Delaware General Assembly, I have been the prime sponsor of some important health bills and on task forces such as the necessary code changes for the state’s Health Exchange as a result of the federal Affordable Care Act (www. heatlthcare.gov), Governor’s Cancer Council, and the Health Fund Advisory (Master Tobacco Settlement Committee). I have worked on many licensure/scope of practice and public health and environmental policies. These policy issues have included occupational health, substance abuse prevention and treatment, cancer, minority health, dental care access, health professions, environmental justice, chronic illness, mercury removal from the environment, school health, early childhood education, prescription assistance, and end-of-life care decisions. I have found that having a nursing background is extremely valuable in influencing a wide variety of policy issues.
I have worked very closely with the farmers in my district. I myself was raised on a farm, and my knowledge of farming has proved vital. I was pleased to sponsor, as my first piece of legislation, the farmland preservation license tag. In addition, I have sponsored land use legislation that helps with county, municipal, and state communication. Only 1% of the U.S. population consumes more than 20% of all health care expenditures, and 5% of the population accounts for more than 50% of the total expenditure (The National Institute for Health Care Management [NIHCM] Research and Educational Foundation Data Brief, 2012). Chronic illness is a major issue for Delaware, as it is for the nation. I sponsored legislation to establish a blue ribbon task force to analyze the problem of chronic illness in Delaware and to develop policy recommendations. The task force identified strategies including 468disease standards of care for health professions, improved communication between insurers and providers, outreach to the at-risk, and the use of a disease management approach with Medicaid patients and among the business community.
I was the prime sponsor of legislation creating a cancer consortium for Delaware. This group has completed a comprehensive assessment and plans to tackle our high cancer mortality rates. I am pleased to say that the cancer incidence and cancer rates have dropped since the creation of this body. The state has implemented the consortium’s many recommendations, including establishing a free treatment program for cancer patients who lack insurance, adding statewide caseworkers, and creating screening programs. Recently, I was pleased to update the state’s Indoor Tanning Laws to prohibit children under age 14 years from using tanning beds and for those aged 14 to 18 years to require parental consent.
HIV infection rates in Delaware are among the highest in the nation. Several years ago I cosponsored needle exchange legislation, and it has shown a positive impact on HIV infection rates. I was pleased to sponsor the legislation to create a state Office of Health and Safety for public programs. All these examples of sponsored legislation involve a team effort with other officials, individuals, lobbyists, and organizations or advocates.
Tips for Influencing Elected Officials’ Health Policy Decisions
What have I learned as a legislator who can help other nurses who are seeking to influence policy? You must communicate well to influence policy, and nurses are naturally gifted communicators and problem solvers. In a study of nurse leaders in federal politics, I found that the political strategies used most frequently by nursing organizations are direct contacts, grassroots efforts, and coalition formation (Hall-Long, 1995). Nurses should not be intimidated by the need to call, write, or visit their elected officials. It is important when meeting with elected officials that you are prepared. Have a one-page fact sheet to leave behind (as opposed to a binder of information), and be prepared to summarize your issue and offer solutions in less than 5 minutes.
If nurses don’t speak up on health care issues, who will? Physicians? Hospital associations? Insurers? If nurses don’t speak up, legislators will only hear from other groups. Given health reform and a push for a nursing consensus model, advanced practice nurses are expected to take on a broader scope of practice andmust be engaged in state-level policy discussions. You have heard the expression, “It’s not whether you win or lose but how you play the game.” Well, in politics, how you play the game can determine whether you win or lose an issue. Increasing your influence by working in a group or coalition is an extremely effective strategy.
Is It Worth It?
Life as an elected official has been better than I could have imagined. Though it has taken some time away from my family and my scholarship, it has been worthwhile. I encourage other nurses to consider how they might serve the public, including running for elected office.
Hall-Long B. Nursing education at political crossroads. Journal of Professional Nursing. 1995;11(3):139–146.
The National Institute for Health Care Management [NIHCM] Research and Educational Foundation Data Brief. The concentration of health care spending. [Retrieved from] 2012 www.nihcm.org/pdf/DataBrief3%20Final.pdf.
A Nurse in the Boardroom
Marilyn Waugh Bouldin
“What I want in my life is compassion, a flow between myself and others based on a mutual giving from the heart.”
Marshall B. Rosenberg
One evening in February 2012, I sat in the audience at a hospital board meeting in rural Colorado wondering how I could convince five board members to support the local clinic for uninsured patients. As president of the independent nonprofit clinic board of directors and a past public health director and nurse, I was concerned about meeting this population’s needs. When the discussion began about the election of new hospital board members, a light bulb came on. I thought, “I could do that!”
This is the story of my campaign to become a member of the Board of Directors of the hospital in my community, the factors leading to my decision to run for the board, the campaign I launched, its success and challenges, and my experience serving as a board member.
I have always believed nurses should be full partners with other health care professionals in designing health care systems, as the Institute of Medicine’s (IOM) report on The Future of Nursing recommended (IOM, 2011). Here was my opportunity! I knew it would be a challenge, and I would be stretching my comfort zone. Historically, nurses have not been welcomed into the boardroom (Hassmiller & Combes, 2012); nor have many sought out board membership. However, with nurses’ broad holistic perspective of patient care, knowledge of quality and safety issues, and understanding of concepts such as team leadership, accountability, professionalism and relationship building, nurses are, in fact, perfect for the job.
At a very young age, as I helped my mother care for younger siblings, I decided to become a nurse. Raising a family, returning to school, and becoming aware of the feminist movement, I enjoyed learning new things, meeting new people, and accepting challenges. Sometimes I failed. The infant-toddler childcare center I started went bankrupt, and once I was fired for insubordination. But I learned that failure wasn’t the end of the world, and I always maintained my passion for taking care of people and my community.
I have been a risk taker ever since I left my promising career at a major urban hospital and moved by myself to a small town in Colorado. When I began developing a new Associate Degree nursing program at our local community college, I was not afraid to ask for help. Fellow nursing directors across the state were a tremendous source of information and support as I tackled this major project. I learned that positive relationships and collaborations were critical to any accomplishment.
FIGURE 52-1 Hospital Board candidate Marilyn Bouldin talking to two constituents during her campaign.
My Political Career
Friends have been key assets on my journey. I met a friend in my rural community (where everyone knows everyone!) who was extremely politically active. One day, she told me about an opening on the state board of health and encouraged me to apply, as they needed representation from my geographic area. I still remember a comment made during my interview with the State Senate Confirmation Committee almost 40 years ago: I was “good looking enough to be appointed.” I felt humiliated 443but was too intimidated to reply. My term in office was a time of tremendous learning and growth, as I was young and very inexperienced. My fellow board members treated me with respect, and I enjoyed discussing state health issues.
Throughout my public health career I learned the importance of developing positive and diverse relationships through my involvement with many community projects. I participated in assessing my community’s health needs and developing new programs to meet those needs. I served on several not-for-profit boards and learned how to be an effective board member. Professionalism and respectful communication were key characteristics being an effective board member. My job required I make periodic presentations to the county commissioners about our work, so I learned how to speak clearly, concisely, and in a politically correct manner, speaking within my time allotment and answering questions truthfully but sensitively.
When I became aware of the upcoming election for hospital board members, I decided this would be an interesting and valuable board to serve on. I had something to offer, and I could influence the board’s direction; also I was retired and had the time to serve. Because of our hospital’s quasi-governmental designation as a “special hospital district,” the board members must be elected by the voters who reside within the hospital district. (Special districts are described in Box 52-1.) However, I had no experience in running a campaign or giving political speeches. I thought I did not have much to lose by trying. Over the years I had developed a tough skin and had learned I could never please all the people all the time. Many professionals in the community assured me that I was very competent to do the job and supported me.
Special Hospital Districts of Colorado
Special Districts in Colorado are local governments (political subdivisions of the state). Local governments include counties, municipalities (cities and towns), school districts, and other types of government entities such as authorities and special districts.
Colorado law limits the types of services that county governments can provide to residents. Districts are created to fill the gaps that may exist in the services that counties provide and the services that the residents may want. Examples include ambulance, fire, water, sanitation, park and recreation, libraries, and health services.
Upon incorporation as a special district, bylaws are written which describe the election process for the board of directors in accordance with state statutes.
My friends volunteered to help. A nurse friend who was a retired Lt. Colonel decided to be my informal campaign manager. Another friend who was a graphic designer developed the campaign materials. Others offered to support me financially and introduce me to their friends.
The relationships I developed were extensive and varied, even though I had only lived in this community for 5 years. My membership in Rotary International, a service club with weekly meetings, provided me with many networking opportunities. I also belonged to a quilt guild, a church group, and a hiking group for women, all of which provided me with access to people who could be mobilized to support my candidacy and vote in the election.
My campaign was 2 months long. There were nine candidates, two women and seven men, running for two seats. I decided to commit time, energy, and money to run an active, high-profile campaign.
My first job was to learn about the hospital so I could speak knowledgeably. I studied its website, read the bylaws, learned about the services offered, reviewed the latest strategic plan and interviewed existing board members. I also met with people in the C-Suite, a term I learned referred to all the executive chiefs: the Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Nursing Officer (CNO), and Chief Financial Officer (CFO). Understanding the management of a multimillion-dollar budget was one of my biggest challenges. I had to be willing to ask a lot of questions.
I became familiar with the characteristics of my hospital district (three rural counties with a population of 20,000) to learn about the demographics, the health issues, and other characteristics. I talked 444to health professionals to learn about their concerns, and to people in the district about their experiences and perceptions of the hospital.
Next, I learned about the Secretary of State’s office and campaign laws and regulations. I sought advice from friends who had run campaigns and stayed in close communication with the designated election official at the hospital. She kept me informed about campaign law, election timelines, and report deadlines.
Then I determined my campaign platform. I felt strongly that the hospital (the second largest employer in the region) was essential to having a healthy and economically viable community. I believed the hospital should also be a community health partner and should extend services beyond their walls. The Affordable Care Act (ACA) had recently passed and I decided to use my campaign to increase awareness of this significant legislation. I am a firm believer in an integrated approach to health care using the triple aim model, and wanted to explain this concept to the community. This model promotes a three-pronged approach to developing an effective health care delivery system for the future: improving the experience of care by providing effective, safe, and reliable care; improving the health of the population by focusing on prevention, wellness, and managing chronic conditions; and decreasing per capita health care costs (Bisognano, 2012).I thought there should be more diversity on the board as most of the directors had a financial or business background and all had limited health care experience.
Developing campaign materials was critical. Wherever I went, I wore a nametag that read “Marilyn Bouldin, RN, Hospital Board Candidate.” I had business cards printed and used my personal phone number and e-mail address, as I believed accessibility was important. I developed fliers and newspaper ads, and a friend created a website about me, at the urging of my marketer sister.
Launching the Campaign
I believe that most people are interested in their local hospital. If they haven’t used it themselves, they know someone who has. Many people had stories to tell me about their experiences and I made a point to listen. If someone had a complaint I helped them contact the appropriate person. I empathized with them and sometimes gave health advice. I invited them to contact me anytime if they had concerns about the hospital and told them I hoped to represent them on the board.
I contacted community leaders to identify opportunities to speak to groups. One night I drove 30 miles out into the countryside to attend a community potluck dinner. Another time I drove to the other end of the district to speak at a women’s luncheon. I was a guest speaker at a local political party meeting and a radio talk show, to discuss the ACA and the hospital board election process. I went to my favorite coffee shop and hung out all morning to engage people in informal conversations. I went to Business After Hours where local businesses network over appetizers, and attended Chamber of Commerce events. I talked with my friends as we hiked in the Rocky Mountains, and they in turn talked to their friends.
One effective strategy was having a letter-to-the-editor writing party. A friend hosted this in her home, complete with wine and cheese. We helped people compose letters of support and submit them to the newspapers. (See Box 52-2 for one of the letters that was submitted.) We had fun doing it! I 445had an extensive e-mail list and composed a message about who I was, what I believed and why I wanted to be on the hospital board. I then sent this out to everyone I knew asking for their vote.
Letter to the Editor
April 26, 2012
I want to recommend Marilyn Bouldin to your community. It is logical and fortunate that she has offered herself to serve as an elected member of your HRRMC Hospital Board. As my clinical colleague, former boss, and years-long friend, I am familiar with her broad knowledge of health care, her respect for those who work in this field and of her advocacy for consumers who present for its services.
Marilyn is known for her fairness and ability to listen and intelligently weigh out multiple sides of the issues she tackles. Her enthusiasm and commitment to follow-up is legendary. Should I ever require such health-care decisions in my own behalf, Marilyn heads my list of go-to consultants. Though not a member of your community, I would confidently cast my vote for her in your upcoming election for HRRMC Hospital Board membership. It is my opinion that your community could do no better.
Marilyn Russell, RN, MSN
One of my most nerve-racking experiences was participating in the League of Women Voters candidate forum. Each candidate was given 3 minutes to talk, followed by questions from the audience. The forum was videotaped to play in the library, and the a newspaper reporter was there to cover the story (the editor did not endorse me because he thought other candidates had a better financial background). I was worried I would make mistakes or not know all the answers, and had a sleepless night before the event, which, of course went fine!
I decided that, regardless of the outcome on election night, I wanted to celebrate with all the people who had helped me. We had a pizza party at a local restaurant and it was a truly wonderful time, especially when I got the news that, not only had I won a seat, but I had also received the most votes!
The following week I wrote by hand many personal thank-you notes to people who had helped me. I also sent flowers to my informal campaign manager and graphic designer. I put one last ad in the paper expressing my appreciation to the people who had voted for me and invited them to contact me with any comments or concerns.
Although I have had many professional successes and received many awards over the years, what mattered most in my election were my relationships with people. My ability to listen, to be genuinely interested and compassionate, and to follow through with people’s questions and concerns served me well. Once people found out I was a nurse they trusted and confided in me.
I was pleased overall with my campaign strategies. I decided early on not to accept monetary donations for my expenses. I was intimidated by the additional requirements and documentation required by the Secretary of State’s office for campaign donations. I was also bothered by the thought that I might be beholden to the people who contributed. Next time I will accept contributions! I did not develop a budget at the start and did not realize how much it would cost me to run a campaign, which turned out to be over $600.
I did have one negative experience. After going around town on a windy day to place fliers on windshields, a stranger came to my house to tell me he did not appreciate me polluting the streets with my papers. In hindsight, I think he had a good point!
During my first year on the board I spent a lot of time listening, reading, learning about the culture of the board, and building trust with my fellow board members. Even though I had served on many boards in the past and had spent decades working in health care, I was surprised at the steep learning curve necessary for me to understand how a hospital functions. Being the new kid on the block gave me permission to ask lots of questions. I had several one-on-one sessions with the board chair to learn more. I met with key nurses in the organization to hear their concerns and learn how I could be supportive. I read my board packet thoroughly in preparation for meetings. I was appointed to the 446performance improvement committee as the board representative and actively participated. Refreshing my knowledge of good communication skills was also helpful to me, and I attempted to use nonviolent communication (NVC) as much as possible. The objective of NVC is to establish relationships based on honesty and empathy that will fulfill everyone’s needs (Rosenberg, 2003). I attended a national hospital conference, which I found enlightening and informative. I have also tried to take the initiative when appropriate. For example, I worked on developing a new board member orientation manual, compiling all the information that would have been helpful to me during my first month in office (such as an explanation of the bylaws of the foundation board to which I was automatically appointed when I was elected to the hospital board).
I learned quickly that serving on the board requires much more time than just attending monthly meetings! Although being a board member is a volunteer position, as an elected official I felt obligated to do the best job I could and to represent the hospital’s interests and those of our constituents, the taxpayers in the district who legally own the hospital. Consequently, I committed a significant amount of time to reviewing policies, attending hospital-sponsored events and employee-recognition ceremonies, meeting physician candidates, supporting the volunteer auxiliary, serving on the hospital foundation board, and responding to feedback from community members. I also spent time reading publications related to hospital administration.
I have learned to pick my battles and to ask myself “How important is it?” There are times when I choose to remain silent. There are times when significant informal communication happens outside of board meetings, and I make sure to participate in hallway talks. I learned that maintaining positive relationships is of the utmost importance. Nothing happens through divisiveness. I try hard to keep an open mind and to be willing to compromise.
Even after 2 years, I continue to ask a lot of questions, which I find is very helpful to everyone during a meeting. The responsibilities I have in my position continue to be daunting to me and I take them very seriously, especially in the areas of credentialing physicians, overseeing a very large budget, and evaluating the CEO.
I have become skilled at answering the question I get from community members, “How’s it going on the board?” Some people are just making polite conversation and don’t need an in depth answer. I try to be honest yet tactful and am careful not to undermine anyone or gossip. I constantly need to determine what I can share and what I cannot, and am always aware of the language I use. Once the board has made a decision, we must all present a united opinion, whether we agreed personally with the decision or not. This is sometimes challenging.
The way we deliver health care and medical services is changing rapidly and represents a paradigm shift. Leaders need to have vision, health care knowledge, critical thinking skills, and collaborative expertise, all of which nurses possess. I look forward to a time when nurses are seen as essential participants in every boardroom in every hospital, and they see themselves that same way.