Nurse Licensure Compact Lessons Learned

1. Nurse Licensure Compact Lessons Learned Joey Ridenour Arizona State Board of Nursing Marcia Hobbs Board Member/Kentucky Board of Nursing Joan Bouchard Oregon Board of Nursing

2. Factors influencing a new look at regulation developed early 1900’s • Expedient access to qualified nurses is needed & expected by the public – especially during natural disasters such a Katrina. Texas Board of Nursing processed 400-500 applications in 3-4 days; Florida Board processed approximately 200 for Charlie. • Expedient authorization to practice is expected by employers & nurses • Having to demonstrate the same licensure qualifications to multiple states for comparable authority to practice is cumbersome, inefficient and not cost effective

3. State Based Regulatory Challenges • New practice modalities & technology created issues of compliance with state licensure laws • Practice is not bound by state lines when call centers & triage systems render care whereby some nurses hold 20 or more licenses

4. Policy Goal Simplify governmental processes and remove regulatory barriers to increase access to safe nursing care.

5. Models Considered • Reciprocity • Fast endorsement • Corporate credentialing (institutional licensure) • Canadian Models • Limited License for Telehealth • Mutual Recognition

6. Mutual Recognition A state based license, nationally recognized & locally enforced.

7. Different Terms –Same Concept • Mutual Recognition • Multistate Licensure • Interstate Practice

8. What is the Mutual Recognition Model? • Nurse Licensure Compact (NLC) is one of approximately 200 current compacts. • Nurse Licensure Allows a Nurse to have One License in State of Residency & practice physically or electronically in other compact or party states • Nurse is subject to each state’s practice laws & discipline • Concept is not new – thousands of nurses working in federal facilities practice on the basis of being licensed in one state. • Lesson: Nurses do not always want to “give up” the first state of licensure & need advance notice regarding the change .

9. What is an interstate compact? • Agreement between two or more states established for the purpose of remedying a particular problem or multistate concern. (Black’s Law Dictionary) • NLC allows states to regulate cross border issues in a manner that preserves the national interests without federal intervention or preemption. • NLC may be amended by all party states agreeing to & then changing individual state laws • Lesson: The legislation to enact the NLC must “mirror” language in all party states. Legislation materially different has resulted in states not be able to join the NLC.

10. What is meant by the multistate licensure privilege? • Multistate licensure privilege means the authority to practice in any compact party state. • Lesson: Human Resource staff need non technical explanations of the compact requirements. Does not take away the responsibility that employers must validate the nurse is licensed in the home state declared by the applicant.

11. What determines primary state of residence? • NLC defines primary or home state in the compact rules & regulations. • Sources to verify a nurse’s primary residence may include: driver’s license, federal income tax return or voter registration. • Lesson: Nurse’s accepting employment in a party state (not declaring a new primary state) many times complete the new application & pay the fee. An adjustment period may be needed where fees are refundable.

12. Why was residency (not practice location) determine the jurisdiction? • The policy decision was made specifically to enhance public protection while retaining state based authority and reducing the administrative burden • Determining the state of practice would have been difficult in an era of multiple employers, at multiples sites across state lines & through telenursing • Tracking a nurse in the event of a complaint is better accomplished through residence that the employment link • Lesson: The traditional nurse licensure system was built upon state of practice starting in 1903 & takes time for the link to now be state of residence.

13. Why is an individual in the NLC limited to one license? • Reduces the barriers to interstate practice • Improves tracking for disciplinary purposes • Promotes cost effectiveness & simplicity for the licensee • Acts as an unduplicated listing of nurses for planning for disaster preparedness • Lesson: The message needs to be framed in many different ways for nurses, employers, recruiters: One license per each license type – RN or LPN/LVN- and no more is permitted by the state of residency.

14. Does the NLC reduce the state’s licensure requirements? • Under the NLC, states continue to have complete authority in determining licensure requirements & disciplinary actions based on the state’s Nurse Practice Act • The Nurse Licensure Compact Administrators have carefully studied the various state licensing requirements & agreed upon core requirements that all party states are to enact • Lesson: The NLCA will at some future point also need to consider core requirements for discipline based on evidence on “best practices” that protect the public from unsafe practitioners.

15. How does the NLC address varying scopes of practice? • The nurse is held accountable for complying with the state laws/regulations at the time patient care is rendered. • Accountability is similar to driver’s license model (driver’s license compact) where one must obey the laws while driving in that state • Lesson: All nurses need to know the state’s scope of practice as this is not unique to the NLC.

16. Does the NLC affect the primary state’s authority to discipline? • The NLC actually enhances the state’s ability to discipline through exchange of disciplinary investigations & information to better determine the appropriate course of action in disciplinary cases. • Lesson: Consider assigning specific investigative staff to the NLC complaint cases to gain experience in learning how to expedite & share case information.

17. How are disciplinary violations reported in the NLC? • Complaints in a nonresident compact state are processed and reported to the home state. • The party state may issue a cease & desist order for the nurse & the home state may take disciplinary action against the license. • Some party states choose to investigate the complaint in the state the incident occurred and transfer the information to the home state so the information is taken only once. • Lesson: NCSBN/NLC is planning to host an investigator conference to provide networking to explore how to improve the investigative processes.

18. Licensure/Discipline Information -- NURSYS® • A comprehensive information system with data on all nurses • Historically used for discipline & verification • Complete system activated 1/1/2000

19. How is the NLC administered? • A separate body composed of participating state board administrators in charge of the state’s compact operations is called the Nurse Licensure Compact Administrators (NLCA) Lesson: Need to anticipate & include current NLCA fee of $2,000 year in budgeting process.

20. Are Advanced Practice Registered Nurses included in the NLC? • APRN’s have a separate APRN Compact model legislation and implementation guidelines. APRN’s were not included in the NLC because of the wide variability in the regulation of advanced practice that needed to be considered. • A state must be operational under the NLC before entering the APRN Compact. • Lesson: Need to consider an RN application process that allows for recognition of RN License in party state for APRN compact licensure.

21. APRN Compact Implemented Two States • Utah & Iowa State Law APRN Compact

22. ARNP Compact Challenges • Less Uniformity • Categories vary • Many titles • Prescriptive Authority Varies • Relationship with Medicine Varies

23. APRN Compact Provisions • Scope of Practice – Consistent with the State where Practicing • State Based Prescriptive Authority Required for • Controlled Substances Certificate • DEA numbers

24. How is the NLC implemented? • In order for a state to join the NLC, state legislators must enact the interstate compact into state law or regulation. NCSBN drafted an outline entitled Strategies for Implementation of the Mutual Recognition Model of Nursing Regulation in 1997. • Lesson: The legislative champion for the NLC may need to be reminded that the legislation must be identical or mirror the legislation in the other states or the compact will may not be recognized by the party states.

25. Lessons Learned • Cross- state licensure is a broader issue than issues related to nursing. • Legislative negotiations for the NLC often run an arduous & long course. • Study of time frame for enacting 65 compacts in 1960’s was approximately 5 years. • The very purpose of the NLC is to provide for allocation of governing authority between states which does not allow for individualism in passing dissimilar enactments.

26. Arizona Arkansas Delaware Idaho Iowa Maine Maryland Mississippi Nebraska Enacted Compact Stateswww.ncsbn.org • New Mexico • North Carolina • North Dakota • South Dakota • Tennessee • Texas • Utah • Virginia • Wisconsin

27. Status of Additional States Awaiting Implementation • New Jersey • New Hampshire (Revised Language Signed) • South Carolina (Signed 5/26/2005) • Will address revising compact language 2006: Indiana

29. NLC Supporters • American Organization of Nurse Executives (AONE) • ATA & Red Cross (formal letters pending) • Staffing & Travel Nurse agencies/registries • Occupational Health Nurses • Nephrology Nurses • Telehealth Community • Citizen Advocacy Center (CAC) • State hospital associations

30. NLC Non Supporters • ANA & some state nursing associations • Unions

31. Compact Information website: http://www.ncsbn.org Nurse Licensure Compact (section) khellquist@ncsbn.org or 312.525.3665

32. QUESTIONS???? & ANSWERS….