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.”

Chris Hinz

Chris Hinz is a freelance writer based in Milwaukee, Wisconsin.

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