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United States of nursing: Changes in healthcare delivery may grow the appeal of the Nurse Licensure Compact

Wednesday September 18, 2013
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Gwen Barr wishes her nursing license worked more like her Illinois driver’s license. If it did, she could travel from state to state working as a certified registered nurse anesthetist without applying for separate nursing licenses, as she does now.
“It would make my life easier,” said Barr, who lives in Homewood, Ill. Barr works for four different agencies as a locum tenens nurse anesthetist, taking temporary jobs in facilities in various states. She currently holds licenses in eight states. Some of the agencies for which she works will help her obtain and pay for new licenses — others do not. Because she is an advanced practice nurse, some states require her to obtain an APN license as well as her RN endorsement.

“For me to get a license in a new state can take anywhere from one month to six months,” she said. Adding to her frustration is the redundancy of the application process. Each state usually requires the same information from her.

“They want to know if you’ve graduated from an accredited nursing program and if you’ve been convicted of a felony; they want you to be fingerprinted for a criminal background check, etc.,” Barr said. “I’ve been fingerprinted for six of the eight licenses I hold.”

The state of the compact

A multistate nurse licensure compact that allows nurses to work across state borders has existed in the U.S. since 2000. Unfortunately for Barr, Illinois is not part of the compact. Twenty-four of the nation’s states are part of what is officially known as the Nurse Licensure Compact. The compact was initiated by a 1997 vote of the Delegate Assembly of the National Council of State Boards of Nursing headquartered in Chicago. It is administered by the Nurse Licensure Compact Administrators.

Utah and Arkansas were the first states to become part of the NLC. Several other states quickly followed, including Texas, Idaho, Arizona, Mississippi and Maine. But no state has succeeded in joining the compact since 2009. Missouri was the last state to join after almost a 10-year struggle.

The majority of nurses and nursing associations and organizations are in favor of the NLC, according to the NCSBN. “We know from Gallup research conducted in 2006 that 88% of nurses support their state being a member of the compact, said Jim Puente, Nurse Licensure Compact associate for the NCSBN.

The benefits seem obvious:
* Nurses can work in neighboring states without having to deal with licensing paperwork and fees. Employers can recruit nurses from other states more easily.
* States can more efficiently share information about nurses who have violated nurse practice acts.
* RNs who work for telemedicine, managed care or insurance companies can speak with and advise patients who live in other states without obtaining licenses for each state.

“I really thought this was a great bill. It makes sense,” said Lori Scheidt, MBA-HCM, executive director of the Missouri State Board of Nursing and the vice chair of the NLC Administrators. “I was so baptized by fire into the legislative process. Issues came up that I had never thought about.”

Those issues include a combination of competing state political interests, such as unions; state legislatures that work grindingly slow; the quirks of individual state laws; misinformation about how the compact works; and the reluctance to change the status quo, Puente said.

Missouri was able to join the compact after quelling fears about the compact held by the nursing union and nursing association. For example, the state board of nursing convinced the nursing union that the compact would not violate union requirements if a strike occurred, by including language that the compact does not supersede existing state labor laws, Scheidt said.

In Barr’s home state of Illinois, legislation to join the compact is stalled because state legislation requires that licensed healthcare providers convicted of certain serious crimes, such as sex offenses or battery against a patient, automatically have their licenses revoked. The Illinois Department of Financial and Professional Regulation and the American Nurses Association-Illinois argue that if Illinois joined the NLC the state would not know what nurses from other compact states would be working in Illinois and whether they have had a criminal background check. Not all the states that are part of the compact require criminal background checks.

Most significant to ANA-IL is that the NLC does not require nurses who are part of the compact to notify other states in which they may decide to work about criminal backgrounds, said Sue Clark, RN, a long-time nurse lobbyist in Illinois and president of Capitol Edge Consulting, LLC.

State Rep. Sandy Pihos, who has sponsored the NLC legislation in Illinois for the past five years, said the state’s criminal background check is one of the most stringent in the country.

Growth of telemedicine validates NLC

Puente and other supporters of the compact believe momentum may be building in their favor as healthcare is reshaped by the increased use of telemedicine and managed and coordinated care. “We’ve seen an increasing interest in states wanting to join,” Puente said. Last year seven states introduced compact legislation. None of the legislation passed, but at least four of those states will reintroduce legislation in the next legislative session, he added.

The Case Management Society of America sees a change too. “Legislators are more receptive to us now that everyone is talking about coordinated care,” said Connie Sunderhaus, RN-BC, CCM, vice president of CJX Corporation and a member of the Case Management Society of America’s public policy committee. “There are discussions occurring in states such as California and Massachusetts that weren’t taking place four years ago.”

Anne Llewellyn, RN-BC, MS, BHSA, CCM, CRRN, editor in chief of Dorland Health and a member of the South Florida Case Management Network, said she will not give up her efforts to have Florida join the NLC, no matter how daunting. Her network, which has been working on getting the NLC legislation before the legislature for the past several years, is now seeking a new legislative sponsor. Llewellyn said she continues the struggle because “what we are doing now doesn’t make sense. It costs money and time that doesn’t need to be spent on obtaining unnecessary licensure when another option is available.”

The fear that states will lose the authority to control and discipline nurses working within their boundaries is another reason cited for not joining the compact, those interviewed for this story said. The Oklahoma State Attorney General issued an opinion in 2011 stating that the state could not join the NLC because it “... authorizes the legislatures of other states to determine by absolute reciprocity the qualifications of persons admitted to practice nursing in Oklahoma.”

The Nurse Licensure Compact Administrators’ Special Counsel Rick Masters, in a rebuttal statement, said the Oklahoma attorney general’s opinion appeared to be “based upon an erroneous analysis of the provisions of the Nurse Licensure Compact, which clearly provide appropriate limitations on the delegation of authority.” The rebuttal goes on to explain that nurses with compact licenses who work in other states must abide by those states’ nurse practice acts and other regulations.

NLC advice for other states

Other states considering NLC legislation can learn from Missouri’s lessons. “Don’t make our mistake by starting with a letter writing campaign,” Scheidt said. “Hold face-to-face meetings with the organizations, such as states’ nursing associations, unions, legislators and individuals who have doubts about how the compact works.”

She advises providing real-life scenarios about how the compact actually works, such as how it enhances public protection and how it affects the state’s stakeholders. “Give them demonstrations, explain the compact rules, give them a tour of the website, get them to understand what you are doing,” she said.

Whether Illinois will join the compact depends on who is answering that question. Pihos, who first started working on the legislation about four years ago, and State Sen. Pam Althoff are searching for a way to overcome the wording in the state’s legislation on criminal backgrounds. “Passing the NLC legislation may not be immediate but we are closer than last year,” Althoff said. “The bottom line is that we are working collaboratively (with other state stakeholders) to come up with a solution.”


Janet Boivin, RN, BSN, BA, is a freelance writer. Post a comment below or email specialty@nurse.com.