News & Events
Coalition to Safely Reopen Schools Issues Position Statement Citing Serious Concerns to Be Addressed Prior to Allowing Schools to Open for In Person Learning
CANTON, Mass. – In response to the statewide push to reopen schools for in-person education, the recently formed Coalition to Safely Reopen Schools, has issued its position statement citing a number of issues that need to be addressed to ensure that schools can be reopened without jeopardizing the health and safety of students, staff or the communities schools serve. As a result of that analysis, the Coalition is calling for a phased approach to reopening, with no in-person learning unless and until those issues are resolved.
The Coalition is a statewide collaboration of school nurses, teachers, parents, bus drivers, cafeteria workers, librarians, school support staff, janitorial staff, labor, occupational health and community advocates, who came together to provide a frontline perspective and concrete medically-informed recommendations for what is needed to safely reopen for in-person learning. The group complements and builds on a number of other position statements issued by local and national teachers associations, including the Massachusetts Teachers Association, and American Federation of Teachers, as well as expert analysis and reports provided by the Harvard T.H. Chan School of Public Health, the Massachusetts Education Equity Partnership and the Massachusetts Coalition for Occupational Safety and Health. It also relies on the perspective of school nurses from throughout the state, who are responsible for the health and well-being of students and every member of the school staff, all of whom will be placing their own well-being and that of their families and communities at risk as a result of reopening during this unprecedented pandemic.
“This process represents one of the most consequential decisions our communities and our state will make as our state and nation construe to grapple with a pandemic that is still surging across the nation, showing signs of a second wave in our state, with the threat of the flu season looming,” said Patty Comeau, RN, a member of the Coalition, the Massachusetts Nurses Association and a school nurse in Methuen. “In confronting this challenge a safe, scientifically guided, well planned, adequately funded and appropriately resourced process must be the priority for all involved, as the stakes couldn’t be higher and the outcome of our decisions truly have life and death consequences.”
The statement also highlights the need to keep equity as the central focus of reopening in order to address the needs of families, and communities; particularly black, Latino and those residents of disadvantaged communities across the Commonwealth, who have been hardest hit by the pandemic, and whose communities often lack the funding and school infrastructure to support a safe reopening at this time.
The position statement addresses 16 different areas of concern that need to be considered and addressed appropriately to ensure a safe reopening of schools for in-person learning, including:
- Proper ventilation and circulation of air;
- Assessing community resources for alternative school settings;
- Ensuring proper social distancing;
- Standardization and availability of PPE for all staff and students
- Resources and infrastructure to support hand hygiene and mask wearing;
- Safe cleaning practices;
- Addressing the health and safety of students with special needs;
- Access to rapid testing;
- Clear guidelines for contact tracing;
- Appropriate school nurse staffing;
- Space to isolate and monitor suspected or positive cases;
- Resources for safe transportation of students;
- Safe re-entry into school protocols;
- Comprehensive education and training of staff prior to reopening;
- Disparities in access to in-person learning;
- Preserving school staff pay and benefits.
The position statement clearly describes each specific area of concern as well as how each must be addressed to ensure a safe reopening. After completing this review, the Coalition position statement concludes:
“In light of all the issues we have presented, the current lack of funding appropriated to address these issues, and the increased need for staff, PPE, testing and other resources to implement a safe reopening, at this time; we don’t believe our State is ready to pursue in-person learning safely. And until these issues are resolved, it is also not safe to have staff stationed in these schools to conduct remote learning for students. “
The Coalition calls for the state and school districts to reopen for remote learning, while taking the time to develop comprehensive plans with the infrastructure, protocols, staffing, funding and training “to safely institute in-person learning that we all know our students deserve.”
The organizations that have endorsed the document to date include: American Federation of Teachers Massachusetts, Massachusetts Association for the Chemically Injured,
Massachusetts Coalition for Safety and Health, Massachusetts Jobs with Justice, Massachusetts Nurses Association, Massachusetts Teachers Association and Service Employees International Union Local 888.
Coalition to Safely Reopen Schools
The Coalition to Safely Reopen Schools (The Coalition) is a statewide collaboration of school nurses, teachers, parents, bus drivers, cafeteria workers, librarians, school support staff, janitorial staff, labor, and community advocates. The Coalition has an overarching goal to reopen schools safely. We are working together, through sharing our collective expertise, perspective and voices to the discussions and decisions surrounding plans to safely reopen schools for in-person learning. Ours is a frontline perspective from those who will be ultimately responsible for the health, safety and the quality of education students will receive as a result of these decisions. For our members who are school nurses, they are also responsible for the health and well-being of every member of the school staff, all of whom will be placing their own well-being and that of their own families and communities at risk as a result of reopening during this unprecedented pandemic.
Like all involved in this process, we believe the return to in-person learning is the ultimate objective to meet the educational, emotional, social, and psychological needs of our students, with safety at the center of all decisions. In so doing, ensuring a safe, well planned, adequately funded, and appropriately resourced process must be the overriding priority for all. This process represents one of the most consequential decisions our communities and our State will make. Our nation is experiencing a dangerous surge in cases, and our State is now seeing a resurgence in COVID-19 exposure (Policy Lab, 2020). We are about to confront a potential second wave of the pandemic in combination with the onset of the flu season. The stakes in this process could not be higher and the outcome of our decisions truly have life and death consequences.
Our position on the reopening of schools is based on the following guiding principles:
- All decisions and plans for the reopening of schools must place the health and safety of staff and students as the primary objective and must be based on the best available science.
- The process for developing plans for reopening must include frontline staff for every school impacted, including school nurses, teachers, transportation, cafeteria, janitorial and support staff to ensure that the plans are safe and can be implemented as proposed.
- All plans proposed must be supported with the funding, staffing, and resources to ensure they can be implemented as proposed (CDC, 2020, August 21). We contend that any process that does not adhere to these principles is untenable (Deloitte, 2020).
Issues that Must Be Addressed Before Reopening Schools
In this, our initial analysis of the appropriate standards for reopening schools, we are relying on issues and recommendations proposed by a number of groups and authorities, including independent guidance published in the report: School for Health: Risk Strategies for Reopening Schools, by the Harvard T.H. Chan School of Public Health, as well as position statements prepared by the Massachusetts Teachers Association, Boston Teachers Union, National Education Association, Mass COSH and others. Keeping equity as the central focus of reopening schools is a must in order to build resilience and addresses the needs of families, and communities; particularly Black, Latino and those residents of disadvantaged communities across the Commonwealth and the country (MA Education Equity Partnership, 2020).
Below are various issues we have identified that must be addressed before any effort to reopen schools is implemented:
- Proper Ventilation and Circulation of Air – Public buildings should eliminate or minimize air recirculation (thus maximizing fresh outdoor air) to the extent possible during this global health crisis. In addition, buildings should not shut off or reduce their mechanical ventilation during before-school or after-school hours when there still may be people in the building, including students, staff, and custodians during any student programs, cleaning endeavors, teacher class preparation, sports (e.g., if students are returning to lockers), or other activities (Harvard T. Chan, 2020). For many of our schools, particularly in our urban centers, this is a major barrier to safe reopening.
Many of our schools are decades old, with long-standing issues related to indoor air quality prior to the onset of the pandemic. Many do not have HVAC systems that circulate air as needed. Many do not have windows that open. Prior to opening any school, mitigation efforts must be made to address these concerns and those efforts should be certified by an independent HVAC expert through American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). As is the case with many aspects of this process, we are concerned about the funding available to support this effort.
Accessing community resources for alternative school settings – For those situations where schools cannot be retrofitted to allow for safe reopening, it is possible for learning to occur in a variety of settings. Libraries, other public buildings, places of worship, or community-based organizations - such as those that run summer or after-school programs - would be ideal locations to “host” a small group of students. In order to make these creative learning strategies work, leaders must address the question of resources. What resources (personal protective equipment, technology, meals, etc.) do these organizations need to be able to host students? Are there other individuals or organizations in the community - such as retired educators or college students - who can provide students with one-on-one support (such as tutoring or mentorship) virtually? What plans to use their organizations or programs have parents and families already established for the fall? Assess the interest and availability of parents and other family members in the community who could act as sponsors for these programs (MA Education Equity Partnership, 2020).
- Ensuring Proper Social Distancing – Every school must be configured to support the minimum of 6 feet of social distancing, including classrooms, cafeteria, hallways, and other areas, as well as on our school buses. We are concerned to see the State, and some school districts, qualify this requirement with the phrase, “if possible, and if feasible” or worse, that “a distance of 3-feet would be acceptable”. The 3 feet suggestion was qualified with mask wearing only, but this could also increase the number of students per class, and unsafe practice. The 6-foot standard is well established, keeping space between you and others is one of the best tools that we have to minimize exposure to the virus and slowing its spread in communities (CDC, 2020). Any school that cannot meet that standard should not be allowed to reopen. Currently our understanding is each school building will be evaluated for airflow. This means the direction and speed should be considered and evaluated when deciding what intervention measure(s) would be appropriate to reduce exposure and limit the transmission of COVID-19 in closed settings. Keeping a 2-meter (6.5 ft) distance between students in a classroom may not be an effective measure without considering the air flow inside the classroom (Almilaji & Thomas, 2020).
Standardization and Availability of PPE for All Staff and Students – School systems and every school must ensure that staff and students have access to needed personal protective equipment including masks for students and all staff who don’t have them upon entering the school or bus. All staff, including but not limited to school nurses must be provided proper PPE. This includes N95 masks and face shields, as well as gloves, aprons or gowns when working closely during encounters that pose both moderate and/or high risk for transmission. The National Association of School Nurses (NASN, 2020) define those risks as:
- Moderate Risk - Tasks including those that require close contact, within 6 feet, of people who are not known or suspected to have COVID 19. These tasks include, but are not limited to first aid, oral medication administration, vision screening, hearing screening, consultation, blood glucose checks (diabetes care), metered-dose inhalers (MDI) for students/staff with asthma.
- High Risk - Tasks that require close contact, within 6 feet, people who are not known or suspected COVID-19 patients but are undergoing procedures with potential for aerosol generation or body fluid contact, such as, but not limited to open suctioning of airways, sputum induction, non-invasive ventilation (e.g., BIPAP, CPAP), manual ventilation (NASN, 2020), as well as diapering and feeding.
There needs to be, at minimum, a 90-day inventory of these materials made available and transparency regarding the process of storage and distribution of these materials. The cost of procuring these materials must be the responsibility of the school districts and not the classroom teachers or school nurses. Any reduction in the availability of PPE should result in the immediate closure of that school for in-person learning.
Resources and Infrastructure to Support Hand Hygiene and Mask Wearing – The promotion and execution of regular handwashing by students and staff is essential for risk reduction and prevention of virus spread. The CDC (2020) recommends that handwashing stations should:
- Allow users to wet and rinse their hands under a stream of running water
- Secure provided soap with a cage (liquid soap), rope (bar soap), or other device
- Have a place to catch used water
- Provide single-use hand drying materials whenever possible
Provide a waste bin to collect single-use hand drying materials (when applicable)
Unfortunately, many classrooms lack the availability of sinks to allow for regular handwashing, and most schools lack appropriate bathroom space to easily accommodate efficient handwashing with social distancing for large numbers of students. In addition to hand hygiene, ensuring that students of all ages adhere to mask wearing protocols is of the highest priority. Expecting bus drivers and teachers to be solely responsible for monitoring student compliance with these protocols is not feasible or practical. We recommend that efforts to safely reopen schools include additional staff to monitor and enforce compliance.
Safe Cleaning Practices – The CDC (2020) calls for intense cleaning and disinfection by cleaning staff. The specific procedures outlined by the agency will include a minimum of daily cleaning and disinfection of frequently touched surfaces and more frequently when possible. Railings, desks and tables, door and window handles, sanitation (restroom/toilet/latrine) surfaces, toys, teaching/learning aides, and materials used/shared by students are examples of frequently touched surfaces. We are calling for complete disclosure of the cleaning and sanitizing schedule plans for schools, including classrooms, shared spaces like gyms, cafeterias, bathrooms and offices. All methods, (such as spraying, defogging, UV) or products and chemicals utilized must be fully disclosed.
This disclosure is imperative as it will impact individuals who will be affected based on the amount of exposure. The CDC (2020) recommends that if you have asthma, you should have an adult without asthma clean and disinfect for you. Asthmatic individuals are at an increased risk to be affected by the sharp increase in disinfectants and hand sanitizer use which will dissipate into the air. There are both teachers and students who will have increased symptoms to all the extra cleaning chemicals that will be in the environment. Some individuals are more sensitive (including those with asthma), going into a heightened sanitized and chemically cleaned environment, who may experience heightened reactions and symptoms. All plans must include specific identification of all sanitation procedures (schedules), protocols (fogging, spraying/wiping, mopping) and products with Safety Data Sheet/Material Safety Data Sheet (SDS/MSDS) available for products used by school support staff, teachers and students for general sanitization and personal sanitization (hand sanitizers, wipes, soaps) in the school buildings (hallways, restrooms, classrooms, gym, cafeteria/kitchen & playgrounds) and transportation vehicles (buses & vans). Additionally, in the event that faculty, staff or students experience adverse health reactions, including physical or behavioral symptoms that may be triggered or exacerbated by the increased use of sanitization products in the buildings, a reporting, mitigation and resolution process must be identified for each school to include the identification of the specific staff positions to be involved in the process. The CDC's guidance on schools reopening also cautions that anyone using disinfectants should be properly trained in their use and wear protective gear. The dangers of allowing students to use disinfectants needs to be discouraged as they can be absorbed through skin (Wittenberg, 2020).
- Addressing the Health and Safety of Students with Special Needs – The American Academy of Pediatrics (AAP, 2020) reported, “Students receiving special education services may be more negatively affected by distance-learning and may be disproportionately impacted by interruptions in regular education.” It is well documented that this population should return to the school setting as soon as it is safe to do so. These students require additional individualized supports to receive quality education and, when needed, various additional supports provided in the school setting. All differently abled students will require accommodations specific to their specialized needs. Students need to always wear masks when unable to preserve social distancing practices, due to the frequent need for close contact with educators. Designate a safe place, preferably outside, for students needing a break from wearing a mask. The CDC also suggests wearing a see-through mask for young students or students with disabilities. Each school also needs to have, or develop, a “Crisis Response Person/Team” available to be focused on students’ mental health and wellness, having access to resources as needed. Educators and support staff will always need to wear full PPE attire; N95 mask, face shield, gown and gloves.
The health and safety needs of students with special needs including autism, hearing impaired, and those with behavioral challenges will require unique approaches in order to mitigate their risk of contracting the virus. Educational materials must be available for these students and their families prior to returning to school. Short videos, storyboards, etc. are but a few modalities that may be utilized to provide support. It is vitally important that teachers, nurses, support staff have the staffing and monitoring capabilities to assess these students, who may display behavioral changes prior to or accompanied by physical changes, associated with the onset of COVID-19 symptoms. The AAP (2020) reminds health and safety leaders that, school policies must be flexible and nimble in responding to new information, and administrators must be willing to refine approaches when specific policies are not working.
- Access to Rapid Testing – One of the most important aspects to monitor the safety of our schools and to track potential exposure and transmission is ensuring the availability of rapid testing for suspected cases. This is an area where the State and Federal Government have failed to provide the resources and infrastructure to safely reopen schools. Prior to opening for in person learning, all students and staff should undergo testing. In addition, ongoing testing needs to be done for surveillance purposes and the quality of testing needs to be monitored to minimize false negative or false positive results. (Abdelmalek & Christie, 2020). Further, were these tests available, most schools lack the staff to implement a testing program.
Appropriate School Nursing Staff – School nurses play an essential role in ensuring the health and safety of both the students and all staff in our schools. Too many schools don’t have a dedicated school nurse and those that do require that nurse to be responsible for several hundred students. If a school doesn’t have at least one school nurse, it should not be allowed to open. Given the unique demands involved in a safe reopening, an investment in appropriate school nurse staffing resources will be necessary.
Clear Guidelines for Contact Tracing – Students may still be coming to school when they should be quarantined or isolated at home if they have, or a family member, tests positive or is waiting for test results. In light of these concerns, plans for reopening must provide clear guidelines for contact tracing, including who is responsible in the school and what is the process for contact tracing; how the health department will communicate with the school about community cases that may impact the school; how the school will know if students/staff or family members of students/staff should be quarantined and/or isolated.
Space to Isolate and Monitor Suspected or Positive Cases – In the event of students and/or staff present with symptoms of COVID-19, the ability to isolate and monitor that person is essential to stop the spread of infection to other students and staff. Unfortunately, for too many school nurses, they lack the space to properly triage and isolate students. This will become more challenging during the flu season, when school nurses can see their offices rapidly fill up with students needing their attention. Managing and monitoring those students, while also having a potentially positive student without additional staff support is simply not possible. Prior to opening any school, we must ensure that school has the physical space and the level of staffing to ensure student and staff safety.
Resources for Safe Transportation of Students – Transporting students to school safely, while ensuring the safety of drivers and monitors is a major challenge. Buses must limit capacity to ensure the required 6 feet of social distancing, and all students on the bus must be monitored to ensure they have and are wearing their mask. Further, bus drivers must have appropriate PPE, and we can’t see how they can safely transport the children and monitor student compliance with social distancing and mask wearing. As with other aspects of this plan, providing staff (bus monitors) to ensure safety compliance will be necessary (Di Carlo, P, et al., 2020).
Safe Re-Entry into School – As students arrive to their school day there will also need to be staff available to monitor mask wearing and to ensure safe social distancing is maintained as students move to their classrooms.
Comprehensive Education and Training Prior to Reopening – If and when a plan is approved for reopening a school, all staff must have been provided with comprehensive education, training, and time to rehearse implementation of every aspect of the plan prior to any effort to reopen that school. Particular attention needs to be given to the putting on and taking off of PPE for all staff and students. This cannot be a one-size fits all training. Training will need to be specific to the people involved and the situation. For example, nurses or any staff that would need to use an N95 mask, would need to have additional training and be fit-tested per NIOSH guidelines (NIOSH, 2020). This education should be available in multiple languages and be delivered via written, video and audio modalities. Given that we are in late August, and most plans have yet to be finalized or approved, we find it impossible to believe that this level of education and orientation for staff can be completed to safely meet the established school reopening date.
Disparities in Access to In-Person Learning – Given the substandard condition of many inner city schools, the lack of: funding, staff support for these schools, and the fact that these school districts service minority communities hardest hit by the pandemic, we foresee a situation where the racial and economic disparities that plague these communities will be exacerbated by this process. The need to secure computers and internet access is of utmost importance for the education of these students. Wealthier, predominantly white communities having the newer schools may have the resources to reopen for in-person learning while these poorer communities will not be able to safely reopen. These are also the communities where remote learning is more difficult, placing these students and families in a double bind. To address these disparities, State and Federal funding must be directed at mitigating barriers to in-person learning for these under-resourced schools.
- Preserving school staff pay and benefits — No school employee should suffer the loss of pay and benefits due to the ongoing pandemic and the state and school district’s inability to safely reopen the schools. As we anticipate a phased approach to in-person learning, and the development of a vaccine in the coming year, we need to maintain current staff as we move towards a safe and successful reopening of our schools. All school staff who can, should be able to continue working, if even in a different capacity. The Commonwealth of Massachusetts has the second-highest per capita income in the wealthiest country in the world. Given the importance of education to our future as a nation, and the risks involved in reopening schools, instead of penalizing those who place such a vital role in this effort, now, more than ever, our public officials on all levels need to allocate and provide the funding needed to protect our students and preserve our dedicated staff.
In light of all the issues we have presented, the current lack of funding appropriated to address these issues, and the increased need for staff, PPE, testing and other resources to implement a safe reopening, at this time; we don’t believe our State is ready to pursue in-person learning safely. And until these issues are resolved, it is also not safe to have staff stationed in these schools to conduct remote learning for students. This position is further supported by recent data that shows community spread of the virus is on the rise in our State, and as the flu season looms to complicate this crisis.
Good work and planning have begun to address the multitude of issues before us. Let’s now take the time to further refine those plans and involve the frontline staff in this process, while monitoring the progression of the virus. Provide staff with the training and education so that when the time is right, we are ready to safely institute in-person learning that we all know our students deserve.
Abdelmalek, Mark and Christie, Megan (2020, May 21). “Mayo Clinic doctors find may COVID-19 antibody tests fail their quality standards”. ABC News exclusive. Retrieved from: https://abcnews.go.com/US/mayo-clinic-doctors-find-covid-19-antibody-tests/story?id=70803740
Almilaji, Orouba, Thomas, Peter (2020, July 9). “Air recirculation in the infection with COVID-10, lessons learned from Diamond Princess cruise ship”. medRxiv. Retrieved from: https://www.medrxiv.org/content/medrxiv/early/2020/07/09/2020.07.08.20148775.full.pdf. (The copyright holder for this preprint)
American Academy of Pediatrics (2020). “Covid-19 planning considerations: Guidance for school reentry”. Retrieved from: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/.
Centers for Disease Control and Prevention (2020, August 21). “Operating schools during COVID-19”. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools.html#anchor_1589931996560.
Centers for Disease Control and Prevention (2020, August 14). “People with moderate to severe asthma: Prepare for COVID-19.” Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/asthma.html.
Centers for Disease Control and Prevention (2020, July 25). “Operational considerations for schools”. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/schools.html#anchor_1595699244882.
Centers for Disease Control and Prevention (2020, July 15). “Social distancing”. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html.
Deloitte (2020). “Analysis – Executing the COVID-19 recovery: A guide for state and local governments for reopening and restoring their economies”. Retrieved from: https://www2.deloitte.com/us/en/pages/public-sector/articles/executing-recovery-covid-19-guide-for-state-and-local-government.html?id=us:2ps:3gl:consem21:eng:cons:060820:nonem:na:T1cZHFxQ:1192109723:440355730291:b:Smart_Cities:COVID_Reopening_BMM:nb.
Di Carlo, Piero, Chiacchiaretta, Piero, Sinjari, Bruna, Aruffo, Eleonora, Stuppia, Liborio, De Laurenzi, Vincenzo, Di Tomo, Pamela, Pelusi, Letizia, Potenza, Francesca, Veronese, Angelo, Vecchiet, Jacopo, Falasca, Katia, Ucciferri, Claudio (2020, June 26). “Air and surface measurements of SARS-CoV-2 inside a bus during normal operation”. bioRxiv. Retrieved from: https://www.biorxiv.org/content/10.1101/2020.06.26.173146v1.full.pdf. (The copyright holder for this preprint)
Harvard T.H. Chan School of Public Health (2020, June). “Schools for health: Risk reduction strategies for reopening schools”. Retrieved from: https://schools.forhealth.org/wp-content/uploads/sites/19/2020/06/Harvard-Healthy-Buildings-Program-Schools-For-Health-Reopening-Covid19-June2020.pdf.
Massachusetts Education Equity Partnership (2020, August). “Keeping equity at the forefront during COVID-19 school closures”. Retrieved from: https://masseduequity.org/wp-content/uploads/sites/20/2020/03/Keeping-Equity-at-the-Forefront-During-COVID-19-School-Closures-Massachusetts-Education-Equity-Partnership-March-2020.pdf.
National Association of School Nurses (2020, July 30). “Guidance for healthcare personnel on the use of personal protective equipment (PPE) in schools during COVID-19”. Retrieved from: https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72d-fff9-4ed7-833f-215de278d256/UploadedImages/PDFs/Guidance-for-Healthcare-Personnel-on-PPE-Use-in-Schools.pdf.
PolicyLab at Children’s Hospital of Philadelphia (2020, July 22) “New COVID-19 projections show risk for resurgence continues spread to Northeast”. Retrieved from: https://policylab.chop.edu/press-releases/new-covid-19-projections-show-risk-resurgence-continues-spread-northeast.
Wittenberg, Ariel (2020, August 10). “Pandemic toxic cleaners pose new risks as schools reopen”. E&E News. Retrieved from: https://www.eenews.net/stories/1063709823.
Founded in 1903, the Massachusetts Nurses Association is the largest union of registered nurses in the Commonwealth of Massachusetts. Its 23,000 members advance the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Legislature and regulatory agencies on health care issues affecting nurses and the public.