The Administrative Hurdles of the Nurse Licensure Compact

The Administrative Hurdles of the Nurse Licensure Compact

Although the nurse licensure compact gives nurses and employers new workplace and staffing options, critics have concerns about the process for achieving those objectives. Chief among them is that individual nursing boards and legislative entities have been left out of the loop not only in formulating compact statutory language to fit state law, but also in other key administrative ways.

Local Input

With decision makers residing elsewhere, Ohio nursing leaders complain that the compact skirts state regulations calling for anyone involved in legislative action regarding the state reside in the state. The pact’s current structure leaves Ohioans powerless to modify the pact’s language so that it addresses their state’s unique culture while honoring its sovereignty. That includes lacking the kind of transparency—e.g., complying with open meetings and records acts—required of all other legislation. “We want to make sure that if we join any compact, Ohio decision makers are at the table contributing to its content,” says Lori Chovanak, MN, APRN-BC, chief operating officer for the Ohio Nurses Association.

Board Role

Even though critics cite the inability to craft or re-craft compact language as a non-starter, they also worry about other long-term effects on the professionals who have to ensure quality patient care. For instance, Minnesota’s nursing leaders aren’t pleased that lawmakers might have to modify existing state law to accommodate a pact they didn’t help create. Yet they’re equally concerned about the state licensing board’s powers, especially regarding licensing and tracking, being usurped overtime. “Knowing which nurses are working in the states and which requirements they’ve met is very important to patient safety,” says Laura Sayles, government affairs specialist for the Minnesota Nurses Association. “But it also matters that by joining the compact, our board’s giving up its rights to do it job.”

Collective Bargaining

Not all nurses belong to unions, but for states that have strong collective bargaining sectors, there is the real fear, say critics, that the multi-state licensing compact could interfere with their efforts to either negotiate the best agreement or even deal with a potential strike. Even though there’s additional concern that a multi-state license compact just opens doors for a mass exit of talent from lower income states to greener pastures, supporters say such hasn’t been the case.

Sandra Evans, MAED, RN, executive director of the Idaho Board of Nursing, an original pact member, and chairwoman of Nurse Licensure Compact Administrators, suggests that in the 16 years since the original pact has been in play, there’s been no evidence that the agreement has interfered with existing labor laws, stymied a union’s ability to do what it needs to do in terms of collective bargaining or even facilitated a shift in manpower. “That might be more perception,” says Evans, “than reality.”

That doesn’t mean, however, that nurse leaders aren’t apprehensive. Although patient safety is its ultimate objective, Sayles admits that as a union, MNA also must focus on the compact’s potential effect on labor issues. “Anything that allows employers to move nurses in and out without our knowledge of that movement,” she says, “is going to be of concern to us.”

Caring for Aging Parents

Caring for Aging Parents

If you’re taking care of an aging parent, you will likely face days when the tasks seem overwhelming. By acting strategically, however, you can ease the burden. In honor of National Family Caregivers Month, here are a few pointers to make your life easier.

Tap Community Resources

Your support system may center on family and friends, but it’s also critical, say experts, to tap every possible resource. Fortunately, most communities have offices dedicated to supporting older adults and their families with referral, informational, and other help. Since the Older Americans Act debuted in 1965, Congress has funneled trillions of federal dollars into state and area agencies on aging to provide an array of community and individual programs. Often in combination with other state and local funds, the money facilitates partnerships with area service providers to help seniors and their caregivers cope with all manner of aging issues. By checking with your local office on aging, chances are very good that you’ll be able to connect directly with the resources you need or at least with other groups that offer them. “Seeking out your county office is a great starting point for navigating local resources that are available,” says Meg Stoltzfus, a lifespan service manager in the Office of Work, Life, and Engagement at Johns Hopkins University in Baltimore, Maryland.

Strut the Small Stuff

There are many aspects to staying organized, but taking a few small steps can keep things under control. Although you likely can craft a list of your own, Amy Goyer, a family and caregiving expert for AARP, suggests a few starters: Focus on one task at a time to avoid procrastination. Use paperless statements and online billing to eliminate paperwork. Embrace technology of all sorts since it can streamline your world. If you’re smart phone savvy, for instance, take advantage of user-friendly apps to help track records, share schedules, and keep your caregiving circle informed and engaged. Even though you have options, Goyer recommends three: CareZone, CaringBridge, and Lotsa Helping Hands. 

Locate via a Locator

Although identifying area resources is a logical first step, don’t be shy about going national. Stoltzfus, for instance, routinely recommends Aging Life Care Association, a nationwide association of nurses, social workers, and other practitioners dedicated to the delivery of high-quality health care for elderly and disabled adults. With expertise in a variety of areas key to aging well, these geriatric care managers serve as both guides and advocates for families with various resource needs. To find an appropriate professional in your community, visit www.aginglifecare.org. “This is a fantastic resource, particularly when you’re providing care long distance,” Stoltzfus says. “It’s a way to find an extra set of hands, get resource ideas, or just provide care coordination that’s difficult long distance.”

Hire a Personal Assistant

Celebrities aren’t the only people who can benefit from a Gal Friday. Hiring a personal assistant by the hour to run errands in a pinch can free you up to concentrate elsewhere. Goyer, for instance, employs a concierge to assist her with tasks not directly related to her 93-year-old father’s Alzheimer’s care, but critical to her schedule nonetheless. Whether that involves taking her to the airport, sorting her stacks of mail, or doing whatever needs to be done at the moment, her assistant takes over the minutia so she can focus on the bigger picture. “I can hire Debbie for two hours,” says Goyer, “and she gets more done than I would get done in a week.”

Chart Your Requests

You may be missing willing volunteers because they just don’t know what needs to be done. Carol Abaya, MA, a nationally recognized expert on aging and elder/parent care issues, suggests creating a simple chart by dividing a piece of paper in three parts vertically to sort out your options. In the first column, list all the things your elder charge can do. In the middle column, add those things that require some help. Fill the third column with those tasks that he or she can’t do at all. On a second paper, note your resources, whether that includes individual siblings, agencies, or others from the community. Once you’ve identified the possibilities, match your needs with volunteers and let them know. “Many times a family member will say, ‘What can I do?’ and the primary caregiver really doesn’t know,” she says. “This is one way of dividing the chores.”

Get Legal Control

Being authorized to pay the bills and handle other business transactions are critical in ensuring someone’s safety and security. If you anticipate that your elderly parent won’t be able to care for his or her own financial or legal affairs, you need to act as quickly as possible to ensure that you can do so. Obviously, there has to be trust between the two of you, but you want the proper documentation to write checks, manage assets, and make other decisions in your family member’s best interests. That likely will involve signing a power-of-attorney. “People are often afraid that if they give a child a power-of-attorney, they’re going to lose the power to take care of themselves,” says Abaya. “But it only comes into play when they can’t handle those chores.”

After discovering that funds had been embezzled from her father, Polly Shoemaker, RN, BSN, MBA, the director of clinical systems at St. John’s Hospital in Tulsa, Oklahoma, was more than willing to get the ball rolling when he asked, “Polly, how can you protect me?” The two of them not only drew up a power-of-attorney, but also put her name on a new checking account, updated his will, and made sure that correct beneficiaries were listed on his portfolio assets. Even though being her dad’s eyes and ears on such matters was draining, Shoemaker wanted to ensure that he had signed everything pertinent so she had license and direction. “When he said to me, ‘Polly, I just want to do what’s best for you,’” says Shoemaker, “I told him, ‘Dad, it’s not about me. If you tell me what you want done, I need it in writing because we can’t go on word of mouth.’”

Practice a Little Jujitsu

Achieving progress acceptable to you and the person who needs you may require changing your approach. For starters, experts suggest making sure you make decisions with an elder, rather than just for him or her. Obviously, the dynamic will change depending on the mental and physical capabilities of the elder in your charge. Yet you need to honor this person’s opinions at the same time you pace the conversation to reflect where he or she is at that moment.

For instance, when Abaya was taking care of her own ailing mother’s real estate business, she quickly learned to limit her inquiries to one or three questions per hospital visit, just enough for the woman to process. She also made it a practice to never hire anyone without letting both parents vet the individual first. “Too often sandwich generation caregivers make decisions for an elder that are not in tune with that person’s likes and dislikes,” she says. “But we have to consider their preferences and values.”

Survival Tips for the Sandwich Generation Caregiver

Survival Tips for the Sandwich Generation Caregiver

When Polly Shoemaker, RN, BSN, MBA, looks back on early 2016, she doesn’t know how she juggled everything. As director of clinical systems at Tulsa, OK-based St. John’s Hospital, Shoemaker already had a challenging job. But when her father’s esophageal cancer took a southward turn, she not only had to carry the logistical load of his care, but also keep up with work and family. “I don’t know how I did it, but I needed to and wanted to, so I did,” she says of her struggles as a sandwich generation caregiver.

Perhaps that’s you. Like Shoemaker, you’re feeling the squeeze of being a sandwich generation caregiver. You’re in the middle, raising sons and/or daughters while caring for an elderly parent (or other aged person). Even if you don’t have children, you may still find yourself pirouetting between the need to be at work and the need not to be there because someone else relies on you.

As Amy Goyer, a family and caregiving expert for AARP and author of Juggling Life, Work and Caregiving, notes: “When you look at the demands of your time and you’re juggling all of these things with just 24 hours in the day, it’s really difficult to prioritize and get it all done.”

Admittedly, there’s no one-size-fits all strategy for handling all the facets of your life. Yet, by being organized and engaging others, you can take care of everyone—including yourself.

Be Organized (But Go with the Flow)

Getting and staying organized are the most important survival skills for managing caregiving, says Goyer. In streamlining your schedule, you not only need to prioritize structure and routine, but also implement small steps to ease your daily duties. Phone apps, for instance, can keep you on course by organizing schedules and people.

Also, keep a contingency plan in your back pocket. Whether that means changing your goals, adjusting your schedule, tapping your backup team, or even modifying your definition of success, you want a strategy for when events don’t unfold as you envisioned. “Sometimes, we sacrifice the very good because we want the perfect,” says Goyer. “But we have to make compromises and not be resentful about them.”

Shoemaker agrees, noting that in getting her father to supplement the morning and evening tube feedings that she and her husband performed faithfully, she made sure that he had his favorite brands of nutritional drink brands so he’d drink during the day. And even when it became easier for her to write his checks, she still let him sign and even deliver them so he felt included in the process. “I finally learned that something was better than nothing,” she says. “I had to bend on some things.”

Don’t Be Afraid to Seek Help

You may think you’re the best person to handle caregiving. After all, you know the human body, understand the aging process, and are savvy about procedures and potential outcomes. Who better than you to be in charge? But truth is, you can’t do everything. Asking others to step up to the plate can diffuse the physical and emotional stress of people being dependent on you—along with the guilt when things don’t get done right. As Carol Abaya, MA, a nationally recognized expert on the sandwich generation, notes: “One of the big fallacies is that because it’s your parents or family members, only you can do everything for them. You can’t, and you shouldn’t.”

Admittedly, calling on brothers and sisters when you need all hands on deck can be challenging. A family health crisis can bring up a host of issues, not to mention uncover genuine differences of opinion. And sometimes it’s just easier to give siblings a pass because they live a distance or are grappling with their own issues.

But you do yourself no favors by discounting the very relatives who also may have a stake in this person’s health. Bringing them on board can be very helpful, even if you have to brush up on your negotiation skills. If you’re rusty in approaching your siblings, making demands, or setting boundaries, you may want to join a support group to learn from others how to assign tasks and say “no.” “Even if a sibling lives far away,” says Abaya, “you have to be able to say, ‘I need you to come and take care of mom or dad for a long weekend so that I can get away.’”

As the on-call patient care coordinator for Hospice of Central Pennsylvania, Nicole Planken, RN, knows the value of having others available when you’re caring for ill patients. She’s not only seen it in her professional life, but also as the primary caregiver for her mother, who’s partially paralyzed from a stroke post-brain aneurysm, and her mother-in-law, who suffers from stage IV lung cancer.

Planken is fortunate in that her sister and aunt are both closely involved with her mom. Moreover, she credits a caring husband who has the flexibility of being self-employed to pinch-hit with their son, her mother, and her mother-in-law. What does it take to cover everything? Although Planken credits her night shift schedule for making things work, she has a few other things in her quiver: a strong faith to keep her centered, written notes to track the minutia, and naps to stay refreshed. “I never feel like it’s an inconvenience or a burden to drop everything and do what they need me to do,” she says. “The only problem is that my life consists of many two-hour naps. I need rest in between everything. It’s my biggest challenge.”

Engage Your Employer

If you’re like other nurses, you want to function at your best, even if you’re exhausted from navigating the demands of sandwich caregiving and work. You may be surprised that your employer has resources to help you maintain your good health as a person and staffer.

For instance, any time employees at Johns Hopkins University in Baltimore, Maryland need help in navigating any challenge that might affect their performance, Meg Stoltzfus, a lifespan service manager in the Office of Work, Life, and Engagement, or her colleagues, get into the mix. They provide referrals outside the institution as well as link people to various short- and long-term internal services. If school is unexpectedly cancelled, for example, the office is Johnny-on-the-spot with a “manning” service to facilitate temporary childcare at home. “We want to help employees make sure that their loved ones are getting the care that they need at home,” says Stoltzfus, “so that when they’re at work, they’re not worried or distracted but completely focused on the job.”

Whatever gold mine your human resources department yields, consider yourself lucky if you have flexibility in your job. Shoemaker, for instance, not only has an understanding boss, but she also didn’t need to be tethered to her desk when her father needed her most. As head of the clinical arm of her hospital’s IT function, she could use her laptop almost anywhere her dad was at the moment. Moreover, even though she had a two-hour commute in ferrying him to his radiation treatments, the sessions were at St. John’s so she was close at hand. Shoemaker also was confident that her husband and others, including a hospice nurse and aide, had her back at home. “I knew I had the support when I needed it,” she says.

Bring Along Your Children

Although you don’t want your children to feel shortchanged because you’re caring for Grandpa or Grandma, you also need them to buy into what you’re doing and what needs to be done. Obviously, age makes a difference as to expectations. But if they’re old enough for chores, they’re old enough to understand that in helping out, they’ll have more time with you.

“It’s important to sit your children down, explain what’s going on, and get them involved in the caregiving,” explains Abaya. “You need to say, ‘This is what I need from you, and this is what I then can do for you.’”

By tag-teaming, for instance, Shoemaker and her husband were able to cover her dad’s needs and still keep up with their son’s various activities, from academic meets to livestock showings. But they also were confident that at 12, Ethan understood the situation and could roll with the punches. He had seen his beloved “Papa James” change and knew that for the present his mother had to reprioritize the three men in her life. “For now,” Shoemaker says, “Dad had to be our primary focus.”

Save Time for Yourself

With time at a premium—and someone else’s vulnerabilities in your mind’s eye—your personal priorities and favorite pastimes likely take a back seat. However, attending to your own physical and emotional needs is not selfish; it’s simply good sense. You need to refuel routinely, especially when you’re expending emotional and physical energy in giving. “People feel guilty taking a little time and doing those little things for themselves,” says Goyer, “but it’s really just a practical issue. You have to do it, or else you won’t be able to care for others.”

Obviously, streamlining your routine and bringing resources to bear can help you make room for your personal priorities. But it’s not enough to say that you’re going to join an exercise class or take a long weekend. You want to plan so that it happens. Whatever the activity, plug the date in your app and keep it. “Scheduling is really, really important,” Goyer says.

Shoemaker, for example, is an avid walker who hikes the Susan G. Komen 3-Day Walk for the Cure every November. Even during the course of her father’s illness, she penciled in time for herself. But it wasn’t until his death in February that she finally could spend a lazy afternoon without worrying. Although Shoemaker struggled at first with the concept, today she’s at peace. “I’d take my dad back in a heartbeat,” she says. “But I know that he’s in a better place. It’s OK to be relieved.”

Final Thoughts

In the din of activity, it might be difficult to think of the positives in being a sandwich generation caregiver. But experts suggest that no matter the challenges, you’ll find them. Perhaps you’ll parlay an improved relationship or gain new perspective on yourself or this person.

For instance, even though Planken prays continually for guidance, strength, and wisdom in helping her mother navigate her struggles, she’s still impressed by the woman’s upbeat attitude. Even when Planken has had to point out how very lucky they all are that she’s alive with her mind, memory, and speech intact, it’s her mom who renews her daughter’s spirit. “My mom has always been very optimistic, and I’ve seen it clearly,” she says. “She calls me daily just to let me know that she wiggled her finger and feels incredibly better. She’s so thankful.”

As for Shoemaker, she learned that being a sandwich generation caregiver involved two versions of care: addressing her dad’s physical needs as a skilled nurse along with his emotional needs as a loving daughter. In merging the two versions, she not only kept her father comfortable, but also where he wanted to be—in their new house. “He had his dignity,” she says. “He knew he wasn’t alone in an institution. He was where he was loved.”

Should A Nursing License Be Valid in All States?

Should A Nursing License Be Valid in All States?

Your nursing license is critical real estate. It reflects the fact that you’ve successfully amassed the right credentials to practice your skills. What it may not do, however, is give you wide berth in using that experience anywhere. In fact, if you’re licensed the way nurses have been for decades—via a single state model—you’re likely constrained by geographic borders.

That could change, however, if enough state nursing boards and legislatures pass the enhanced version of a 16-year-old concept: the Nurse Licensure Compact (NLC). The NLC already permits registered nurses (RNs) and licensed practical/vocational nurses (LPN/LVNs) within 25 member states to practice (either physically or via technology) without additional credentials.

The new model goes where critics say the original version, introduced in 2000 by the National Council of State Boards of Nursing (NCSBN) fell short. By establishing uniform licensure standards and mandating extensive criminal background checks, the 2015 enhanced pact not only gives original state nursing board members additional safeguards, but in doing so also attempts to attract jurisdictions that gave the initial one a pass.

Has there been enough progress to entice new partners? And what are the pros versus the cons? Supporters say multi-state licensure is about adjusting to a changing health care landscape while critics charge that it adds burdensome requirements on nurses and licensing boards.

Even with conflicting perspectives, however, both sides put patient safety front and center. As Sharon Prinson MSN, RN, NEA-BC, clinic nurse administrator for Rochester, Minnesota-based Mayo Clinic, which supports Minnesota joining the enhanced compact, notes: “How we’ve cared for patients in the past isn’t the way we’ll do it in the future so we need to prepare for new models. The compact breaks down state barriers that are no longer relevant for providing safe, quality care.”

But Laura Sayles, government affairs specialist for the St. Paul-based Minnesota Nurses Association, which has opposed both compact versions, counters: “The big umbrella issue for us is patient safety. We believe that having a license in the state where you’re actually working so that you understand the scope of practice is very important for protecting patients and working to the best of your ability.”

Meeting Change
In hailing the compact as a necessary response to a changing health care environment, supporters point to various factors driving the multi-state licensure train in beneficial ways.

Telehealth Ready
By challenging traditional geographic boundaries, telemedicine has given providers of all stripes virtual and telephonic capabilities to triage, diagnose, and even treat patients remotely. In fact, ask-a-nurse systems were among the first to ride the telehealth wave. The same hotlines that offered callers health advice, however, raised alarms for nursing boards over licensing and disciplinary authority. Who had jurisdiction when advice crossed state lines?

NCSBN sought to clarify with an interstate compact that allowed member licensure boards to recognize each other’s nurses—and nurses to work freely despite their geography. For instance, with hundreds of nurses manning 24-7 telephone advice lines, AxisPoint Health, a Westminster, Colorado-based health care case management and care coordination company, wants to ensure that each responder holds a proper license to field calls in a timely fashion. “Patients are contacting us because they’re ill or injured and they need advice,” says Kathryn B. Scheidt, RN, MSN, MS, CONUS deputy program manager for AxisPoint. “We want to guarantee that they’re talking to a nurse within 30 seconds so that they have a positive, consistent and timely interaction.”

Professional Mobility
A compact nursing license offers workplace portability in much the same way that a driver’s license issued in one state allows you to drive in another. That may not matter to you if you practice in the state where you were born and live. But, if you long for mobility—or just need dual certification for your job—you’ll likely appreciate spreading your wings without duplicative red tape.

Before she became a nurse practitioner, for instance, Marian Grant, DNP, ACNP-BC, ACHPR, FPCN, RN, helped transport patients to Baltimore-based Johns Hopkins Hospital as a member of its medical flight team. Yet even with Maryland and nearby Delaware members of the compact, she had to secure a separate license in non-joining Pennsylvania to practice on the ground.

“Health care is such a dynamic field,” says Grant, currently director of policy and professional engagement for the Washington, DC-based Coalition to Transform Advanced Care. “Everything suggests that it’s going to be increasingly integrated across geographic boundaries. It doesn’t make sense to have 50 licenses.”

Workforce Flexibility
With health care systems cobbling together community hospitals or building across state lines to broaden their reach, the interstate compact not only gives employers access to qualified staffers, but also facilitates creative use of resources.

For instance, with clinic sites already in Arizona, Iowa, Wisconsin, and Florida—states that have joined either the original or enhanced compact—Mayo Clinic administrators have an interest in Minnesota following suit. By enabling nurses to extend their professional reach, nurse leaders believe it also would expand patient care capabilities.

Mayo Clinic’s tele intensive care unit, for example, supports other health professionals by offering physician and nursing expertise to adult ICUs. With remote monitoring a 24-7 staple, it keeps people close to their primary care providers but with access to critical care second opinions. “That extra set of eyes does not usurp what the team is doing locally,” says Prinson. “It’s there to compliment the care a patient is receiving.”

Critical Concerns
Critics say the enhanced compact short circuits nursing boards in vetting, tracking, and disciplining nurses. They’re also not satisfied with safeguards for ensuring nurses are at the top of their game.

Professional Development
Although multi-state license holders are expected to meet their state’s continuing education requirements, detractors say there are too many disparities among nursing boards to level the playing field.

It’s not that uniformity isn’t part and parcel of the enhanced compact. To encourage additional states to join the original 25, NCSBN administrators have bolstered commonality by mandating that multi-state license applicants graduate from an accredited nursing program, pass the National Council Licensure Examination (NCLEX), and undergo state/federal finger-print-criminal background checks.

The compact, however, doesn’t call for uniform continuing education—a point of contention for detractors who worry that some nurses may not be up-to-speed if their states require little or no professional development. For instance, although Ohio’s RNs must take 24 hours of continuing education every two years, it bothers leaders that other jurisdictions might not demand the same standards. “The argument has been that we all go to nursing school and we all take the NCLEX test,” says Lori Chovanak, MN, APRN-BC, chief operating officer for the Columbus-based Ohio Nurses Association (ONA), which has nixed the compact. “That doesn’t mean we continue our education in the same way, however. I took that test 20 years ago too and things have certainly changed since then.”

Although supporters acknowledge such variations, they say research doesn’t support the idea that those disparities—often nuanced—make a difference in nurse performance. Instead, the commonality in delivering stellar care is that nursing programs meet the same educational markers for accreditation. Their graduates not only get the same basic training, but also must pass the same licensing exam.

“People will say that their state standards are so much higher than other state standards,” says Sandra Evans, MAED, RN, executive director of the Idaho Board of Nursing, an original pact member, and chairwoman of Nurse Licensure Compact Administrators. “My response is ‘You must be wrong because I know that our standards are higher.’ We all think that we have the gold standard—and we probably do since we’re more alike than different.”

Licensure and Discipline
Ensuring that nurses perform skillfully and ethically is fundamental to quality patient care no matter where you live and work. But critics of the multi-state licensure compact say that job becomes ever more challenging for nursing boards and individual nurses when several states are involved.

The American Nurses Association (ANA), for instance, acknowledges that many of its problems with the original pact have been refuted. Yet officials are still concerned enough about potentially burdensome variances over licensing and disciplinary standards that they’ve rejected the enhanced version.

The ANA and other detractors, for instance, part company with compact backers concerning the definition of a practice location. The NCSBN believes it’s where a patient resides while the ANA counters that it should be where a nurse holds a primary license. But when that nurse’s judgment or skill is questioned, who investigates or takes disciplinary action—and to what end? “We just think it adds another level of confusion,” says Sayles, “as to how discipline would happen.”

Supporters counter that the compact actually strengthens a state’s hand with problematic nurses. By mandating criminal background checks, boards can secure critical information not necessarily sought by others. Although ANA points to a current mixed bag of states—within and outside the existing agreement—requiring criminal history searches, supporters believe it gives licensing boards a universal tool for protecting everyone.

Moreover, by mandating that those same boards report serious infractions to Nursys, the compact adds a licensing database safeguard not required of non-member boards. Nurses with felony convictions also aren’t multi-state-eligible nor are nurses enrolled in mental health or chemical dependency programs.

“The notion that a nurse coming from one state into another state hasn’t been scrutinized is really incorrect,” Evans says. “With the centralized data base compact states use, we can put the information pieces together for every license that we issue.”

Final Thoughts
Like the original version it’s designed to supersede, the enhanced multi-state nursing licensure compact breaks down geographic borders so that nurses can move freely with little red tape. Although seven states have adopted the compact, the agreement won’t be activated until 26 states approve the legislation or Dec. 31, 2018 is reached, whichever occurs first.

In the meantime, the conversation continues. Chovanak, for instance, is one of three ANA representatives joining three NCSBN members in considering other solutions, such as a national telemedicine license for a changing environment. “Not all states will join the compact,” Chovanak says, “so there needs to be a broader option.”

Yet supporters still see multi-state licenses as doable answers for pressing staffing and other issues. The compact not only helps solve regional and emergency workplace shortages, but also gives nurses ways to leverage their skills.

As Prinson notes: “We believe the compact will help us support the future direction of health care by promoting increased mobility for nursing professionals along with increased access to newer technology for patients. That ability will help us provide the best care possible regardless of where someone is located.”

3 Ways to Counter Moral Distress

3 Ways to Counter Moral Distress

Although countering moral distress involves various tactics, keeping your eye on a few key ones can be beneficial.

1. Prioritize professional growth.

Whatever your career strategy you can never educate yourself too much about ethical issues and moral distress. The more you know the better prepared you’ll be for addressing whatever uncomfortable scenarios come your way. You don’t have to join an ethics committee or even become a nurse ethicist to understand the topic, even though they’re both worthy goals. By mining your organization’s continuing education opportunities and keeping tabs on your professional society’s resources you can become a savvy participant. For instance, in The 4A’s to Rise Above Moral Distress, the American Association of Critical-Care Nurses (AACN) provides an extensive blueprint for helping nurses and nursing staffs create a healthier work environment. With ask, affirm, assess, and act as guidelines, the AACN’s moral distress handbook demonstrates how to recognize and overcome the stress.

2. Sharpen other edges.

In addition to a supportive work environment, you need other self-care strategies to carry you over the finish line. You likely already know the basics: Adequate exercise, nutrition, and sleep are necessary for anyone’s mental and physical well-being. But identifying confidants—a counselor, spiritual advisor, or even close friend—outside your workplace as well as other reinforcements can bolster your resolve. For instance, Katherine Brown-Saltzman, RN, MA, co-director of the UCLA Health System Ethics Center and an assistant professor at the UCLA School of Nursing, conducts workshops to help health providers address their moral distress, whether it’s already occurred or just a potential. The retreats are not only part of UCLA’s extensive ethics focus, but also a reflection of research she and her colleagues are pursuing to create healthier environments for addressing such issues. Their goal is to move beyond the links between moral distress and quality of care to prevention and coping strategies. By using ethics assessments to identify risk factors for conflict, they hope to give nursing team leaders early indicators for engaging staffers daily. “It’s quite profound how long people hold on to moral distress,” says Brown-Saltzman. “It can accumulate, escalate, and become extraordinarily isolating over time. But coming together, engaging, speaking out, and even writing can be very helpful.”

3. Be detailed.

If you want to make your point, be as prepared as possible, especially for an ethics consult or family meeting. When the topic is end-of-life, for instance, complete charting can be your best ally. It’s not only to your advantage to make sure that a formal advanced directive is noted clearly, but also that you’ve documented spontaneous conversations with the patient over his or her wishes. If this person lets you know in a moment of complete clarity, “I’m just so tired. I don’t want to do this anymore,” you have what constitutes a verbal advanced directive in many states. By detailing it, you also can make a case that your patient is ready to go, even if someone has a different plan.

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