American Nurses AssociationMultistate Licensure Compact - Areas of ConcernThe compact does provide a means of addressing interstate nursing practice; however there are other means of doing this, including expedited endorsement of an out-of-state license. Interstate practice legislation should clearly define key terms and be precisely drafted to ensure that the primary objective to be accomplished by interstate practice is achieved. The rule-making process to implement any interstate practice legislation should be clearly spelled out in the legislation, and proposed implementation regulations of key provisions should be developed simultaneously with any legislation. 1. General Mechanisms should be in place that ensure nurses have ready and ongoing access to practice-related information, including current board of nursing policies. Mechanisms should be in place to ensure that a board of nursing knows who is practicing in its state under authority of a license granted by another state or through an interstate practice agreement. One suggestion is for the use of a registry. Any nurse practicing in a party state must register with the party state. The party state would then be able to provide the nurse with current practice-related information, including the nurse practice act, rules and regulations and board of nursing policies. 2. Basing Licensure on State of Practice The NCSBN proposed interstate compact ties licensure to the state of primary residence. Another option to be considered is to base licensure on state of primary practice. Basing licensure on state of residence rather than state of practice raises some policy problems, as well as practical problems. The current system of licensure is closer to "state of practice" than "state of residence." Thus the state of practice is more logically related to the purpose of the license. For following through on complaints and doing investigations, licensure in the state of practice is possibly more "user friendly" to the complainant, as well as conducive to the investigatory procedures. The state interest in protecting the safety of its citizen-patients is better served, because the home state (as the state of practice and most likely the residence of any complainant) will be perceived as more likely to take aggressive disciplinary action against nurses who have treated state citizens. Some common activities, such as tax-paying, may be linked to state of work rather than residence. Since a number of nurses are employed by state government, which may have policies requiring licensure in the state, a link to state of practice would be very acceptable while a link to state of residence could put some, who happen to live across state borders, in an untenable situation. Basing licensure to state of residence, rather than state of practice, may increase the opportunity for employers to use mutual recognition as a strike breaking tool. 3. Coordinated Licensure Information System (CLIS) The compact calls for the establishment of a Coordinated Licensing Information System (CLIS) to be operated by a non-profit organization comprised of state boards of nursing. The development of a centralized, coordinated information system and inclusive nursing database would be helpful to the profession. However, there must be significant safeguards regarding the privacy and confidentiality of the information entered into and shared from such a system. Due to the dependence of the compact on the database, implementation of the compact should be contingent on the occurrence of the start-up of CLIS.
CLIS is extremely broad in the kind of information it collects. It allows for reporting of any adverse action and any "significant current investigative information yet to result in a remote state action." The operation of CLIS is left to the formulation of procedures at a later date by the compact administrators--meaning that a broad range of issues related to the operation of CLIS are left open by the compact. CLIS will not be an effective system without input from nursing groups, specifically credentialing entities. For example, a combining of the information in the ANCC and NCSBN databases would result in a unique and very different system permitting state-of-the-art research; some examples might be: The process for selecting an entity to conduct data collection or provide other services related to implementation of interstate practice should be open and competitive. CLIS presents numerous important issues concerning confidentiality, including who has access to the information and what limits may be placed on their access. The compact language allows states to "designate information that may not be shared with non-party states or disclosed to other entities or individuals without express permission of the contributing state." This implies that, unless a state has taken action specifically to designate information that may not be shared, non-party states and "other entities and individuals" will normally have access to information held by CLIS. Clear parameters in the compact law or its regulations must be established regarding the security of information in any database and the sharing of any licensure or disciplinary information in the database. There must be a means established for reconciling the information system's processes with any existing state laws, regulations or procedures addressing confidentiality, licensure and disciplinary information of state licensees. Other than final orders and emergency suspensions, the release of any other disciplinary information should be prohibited. 4. Discipline In general, under the compact, any party state (state participating in the compact) may take action against the multistate licensure privileges of any nurse who practices in that state; however only the home state may take action against the license itself. There is still some debate as to whether a party state that is neither a home state nor a remote state (state where the nurse is practicing, but does not have a license) can restrict or limit the right of a nurse to practice in that state, where the home state has not yet taken any action against the nurses's license. The compact creates an additional burden for nurses since they may face adverse actions from more than one state arising from the same incident. In addition, the nurse may face different kinds of procedures and have different rights under the practice acts of the states in which she or he faces adverse actions. The right of individual nurses to a fair hearing of any disciplinary action must be preserved without the nurse incurring unreasonable or unfair burdens such as financial costs in pursuing this right. 5. Supersede Existing State Law Interstate practice must not be implemented in a way that allows persons to circumvent or contravene existing public policy as expressed by a state's laws or policies, including initial and continued licensure requirements. The current compact creates some confusion regarding definitions of nursing between states. The compact must include language stating that it specifically does not supersede other state laws. For example, there is currently such language in the Driver License Compact. 6. Immunity The compact grants extremely broad immunity to CLIS. The CLIS administrator (along with party states, officials of state licensing boards or "any other authority or administrator who acts in accordance with the provisions of the compact") is protected from liability "for any act or omission in good faith while engaged in the performance of their duties." State administrative agencies -- even where they are afforded some degree of immunity from legal action -- are accountable to the public. As a private, national entity, the CLIS has no such public accountability. Before any immunity from liability is extended to non-governmental entities, there should be careful scrutiny to ensure those entities are appropriately accountable for their actions. The compact should address accountability for and oversight of administration of the multistate system and any immunity from liability for the system and its administrators should be carefully scrutinized. In addition, the compact should not identify a specific group to administer the information system; it should be open to a competitive bidding process. 7. Striker Replacement Interstate practice must not be implemented in a way that allows persons to circumvent or contravene existing public policy as expressed by a state's laws or policies, including laws or policies on the use of strikebreakers and striker replacement. 8. Exclusion of Advanced Practice Registered Nurses The compact does provide multistate licensure privilege to registered nurses but does not grant authority to practice as APRNs in party states. Excluding APRN practice from the RN/LPN compact -- and establishing a separate APRN compact -- pose important challenges for the continued development of both RN and APRN practice. The RN/LPN compact would rigidly separate the practice of "basic" and advanced practice nurses. Approaches to interstate advanced practice nursing should be addressed for consistency in connection with interstate practice for other RNs. Both basic and advanced nursing practice should be addressed in a single document (compact). There should be consistency in addressing both types of practice. 9. Effect on Revenues and Licensure Fees If NCSBN's figure of 12% of nurses holding multiple licensure is correct, then boards of nursing could suffer some significant reduction in revenue. The greater the number of nurses holding licenses in several states, the greater the revenue loss. Faced with a reduction in the number of licensees, boards of nursing could find themselves with sharply reduced revenues and a need to reduce services and/or increase licensure fees. ANA and SNAs are vitally interested in strong, well-functioning boards of nursing. 10. Role of the Compact Administrators There are numerous concerns related to the role of the compact administrators and the interim compact administrators. These concerns center around the legal authority of such a group as well as the resources required by a new entity. References:
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