This background document describes the concept of Multistate Licensure and addresses some of the major current issues surrounding the Nurse Multistate Licensure Mutual Recognition Model adopted by the National Council of State Boards of Nursing (NCSBN) in August 1997. It poses some of the policy options available to the profession of nursing and ANA in addressing these issues. As you know, the NCSBN approved the legislative compact language for adoption by individual states at a special Delegate Assembly held in December, 1997; NCSBN adopted "final" language in a version dated January 9, 1998. This final language followed over two years of discussion and debate among the state boards of nursing regarding the idea of addressing multistate practice through some change in the process by which nurses are licensed. This discussion has focused on the need for such a change, the mechanism through which such a change could take place, and the content of such a mechanism.

In March, 1998, Utah became the first state to adopt the NCSBN compact language for Mutual Recognition RN licensure. Proposals for 1999 legislation to enact it are under consideration in several other states. Also in March, 1998, the National Association of Pediatric Nurse Associates and Practitioner (NAPNAP) commissioned a legal memorandum raising numerous questions about the compact. NAPNAP distributed this memorandum to governors and attorney generals in all fifty states. This action, in turn, was met by public responses from NCSBN defending the compact proposal. More recently, ANA received a legal memorandum exploring the compact proposal and pointing out several concerns, including a lack of clarity in some key areas which are described later in this document.

Much of the impetus for examining multistate practice emerged from nursing's work on telemedicine/telehealth and on the issues that utilization of electronic media for the delivery of health care services poses for nursing practice. Many of NCSBN's materials addressing multistate practice continue to focus on telehealth practice. NCSBN's proposal is not limited to telehealth practice, however, and other reasons for expediting multistate practice have been offered as well-for instance, the growing influence of multistate health care systems and the increased mobility of registered nurses (who may often practice in more than one state, and/or practice in a state other than that in which they reside or are currently licensed).

The current model for state-by-state licensure requires nurses to be licensed in each state in which they practice. For nurses who practice in more than one state or who seek to move the location of their practice from one state to another, this requires multiple licensure.

Chief arguments for creating a mechanism for multistate practice include:

• The current system is duplicative and expensive for individual nurses, who must provide documentation and pay a fee for licensure in each additional state.
• For nurses who practice in several states concurrently (such as providing telephone advice, or practicing via computer, activities through which a nurses' practice may touch all U.S. states, territories and the District of Columbia), licensure in every jurisdiction in which the nurse practices is impractical. Most nurses (and/or employers) faced with this situation may currently not consider or seek licensure in additional states. This means that many nurses who practice across state lines (and those nurses' employers) are not complying with existing licensure laws, posing a major challenge to discipline and to enforcement of state practice acts.

Mutual Recognition: Current Policy Issues

In its final version, the compact allows for "mutual recognition" of nursing licensure among party states (i.e., states that agree to the compact). Nurses licensed in one party state are authorized to practice in all party states. Licensure is granted by the nurse's state of residence, regardless of the state(s) in which the nurse actually practices. A Coordinated Licensure Information System (CLIS), to be administered by a "non-profit organization composed of state nurse licensure boards" (presumably, the NCSBN or a subsidiary), would collect, store and make available information on nurses and applicants.

A number of documents, memoranda and reports have already explored many of the issues that arise from the compact—both as conceived and as drafted in its current, "final" form. This memorandum will not restate all of these. Instead, it groups and summarizes some of the major issues and suggests policy options for ANA to follow.

1. What problem(s) does the compact seek to resolve?

There is still not adequate clarity as to what the compact is intended to do. This is, of course, a threshold issue—not merely for justifying the sweeping changes in nursing licensure that the compact contemplates, but also in order to evaluate the compact's adequacy. The compact has been described as a means to address the challenge of telehealth practice, to adapt to increasing mobility of the nursing workforce and to take into account the growth of multistate health systems. It has also been described in more global terms as a bold initiative to meet the rapidly evolving nature of health care delivery and nursing practice. None of these descriptions is mutually exclusive, but without as precise a description as possible as to the goals of creating a process for multistate practice, it will remain extremely difficult to achieve consensus within nursing as to whether this compact—or any other mechanism—meets those goals.

While clarity on specific problems and the resultant specific goals that compact is designed to resolve—is critical, the shape and pace of discussion within NCSBN and between NCSBN, ANA and other concerned groups does not suggest that it has succeeded in clarifying the issues. The issues themselves appear to have become mobile: for example, NCSBN emphasizes the imminent need for a multistate compact in order to facilitate telenursing, but when challenged on how well the compact achieves this goal, the emphasis shifts to physical mobility of nurses between states. ANA will need to set out its own position on problems in state-based nursing practice that may be addressed by a multistate mechanism (such as a compact) in order to come to a formal position on the NCSBN compact language or to develop an alternative mechanism to address those problems.

2. Facilitating telehealth practice

As noted above, much of the initial and continuing interest in multistate practice has come from concern about telehealth nursing practice. Communications technologies provide a means for health care professionals to practice across state lines. In many instances, this may mean providing services in states in which the professional does not hold a current license. Many telehealth employers and nurses may not regard the provision of telehealth services as "practicing," or may consider it impractical to obtain licenses in all jurisdictions in which patients who receive there services are located. This has posed a potential problem of widespread unlicensed practice and presents a challenge for boards of nursing in states where patients receive services from nurses located in another state. Mechanisms for regulating such practice, including asserting jurisdiction over out-of-state nurses, are often unclear.

An interstate compact such as that proposed by NCSBN (and adopted by the Utah legislature) provides one potential mechanism for regulating telehealth nursing practice, including the assertion of jurisdiction by the state in which services are delivered. As ANA's legal opinion notes, the purposes of the compact—including assertion of jurisdiction over nurses practicing across state lines—can only be met once a significant number of states have signed on to the compact, which is not likely to occur for some time. An interstate compact signed by a small number of states will be of limited assistance in addressing telehealth nursing practice that spans the entire country. It would provide a means for regulating telehealth practice in party states (assuming the nurse is also a resident of a party state), but not in others; in non-party states, issues of regulation and jurisdiction will continue: nurses arguably should obtain licenses in those states, but the same concerns about non-compliance (and unlicensed practice) that currently exist will continue in non-party states.

Moreover, while the compact provides a means for a home state to assert jurisdiction (including taking disciplinary action) over a nurse licensed in a remote state, it does not provide a means for identifying or tracking these nurses. A state board can know who is authorized to practice in the state—every nurse licensed in a party state would be authorized to practice in every other party state, unless a state has taken action to remove a nurse's authority to practice in that state—but it will not know who actually is practicing. Currently, state boards may not know who among its licensees is currently practicing in the state. However, a nurse will generally not be licensed in a state unless she is practicing, has practiced, or plans at some point to practice in that state. Under the compact as currently formulated, the universe of nurses who may be practicing in a party state will not be limited to those who have applied for and received a license in that state, but rather will include every nurse licensed in every party state.

The problem posed by an interstate compact that depends on overwhelming participation by states is considerable—it means a vastly less effective mechanism for regulating telehealth practice. Moreover, it is worth asking whether such a substantial reworking of the entire system of nursing licensure in order to regulate a relatively small and distinct sector of the nursing workforce is the most appropriate means of addressing the challenges posed by telehealth nursing practice. Alternative approaches could include an interstate compact focused specifically on telehealth practice (such a compact would still require broad state participation in order to be effective, but this might arguably be more achievable for a more narrowly tailored compact), federal legislation to address interstate telehealth practice, or state legislation to provide a mechanism for authorizing limited practice (i.e., by electronic rather than physical presence) by out-of-state nurses.

3. Facilitating physical mobility

Another argument that has been put forward for an interstate nurse licensure compact is to facilitate physical mobility for nurses. Some nurses work in neighboring states; some practice in more than one state concurrently; some work for multi-state systems that may choose to deploy employees to sites in different states depending on the employers' changing needs. Others may choose to move to other states (neighboring or not) in order to change employment or for personal or family reasons.

Currently, a nurse must be licensed in any state in which she practices. If the nurse practices in more than one state, the nurse must hold a license in each; if the nurse changes the location of her practice, the nurse must obtain a license in the new state. This means paying a fee, filling out forms, providing require documentation, and often waiting for several weeks (or longer) for a new license to be issued.

The NCSBN compact would address these issues to some extent by requiring a nurse who resides in a state that is party to the compact to hold only one license in order to practice in any or all party states. Its effectiveness as a uniform nationwide licensure system, of course, would be limited by the extent to which states sign on to the compact. (The same issues of identifying which nurses are practicing in the state, discussed in the above section on telehealth practice, would also apply here).

Unlike telehealth practice, issues of physical mobility of practice are more often shaped by geography: an Arkansas nurse may seek to practice in Texas; a Massachusetts nurse may concurrently treat patients in Vermont or New Hampshire; a New Jersey nurse may hold a second job in New York. Nurses may also migrate between distant states but, with the exception of traveling nursing agencies (which have thus far accepted the burden of obtaining licenses for their employees as part of the cost of doing business), individual nurses do not generally change practice locations across distant states on a regular basis.

Again, the question may be asked as to whether a uniform multistate compact is the most effective or appropriate means of addressing the issues posed by the physical mobility of nurses. The "hassle" and delay of applying for duplicate licenses could, at least in concept, be addressed by establishing expedited means for processing applications for licensure by endorsement. (Some states currently perform better in this regard than others). NCSBN has previously attempted to develop such expedited processes. As pointed out in ANA's legal opinion, the ANA Model Practice Act also proposes such expedited licensure for nurses currently licensed in other states.

Two-state or regional interstate compacts—e.g., Arkansas-Texas, New York-New Jersey-Connecticut, New England states—could provide a more "tailored" means of addressing issues of physical mobility and interstate practice in specific geographic areas. Such compacts could be more carefully structured to reflect practice variations or other concerns specific to states in a specific geographic region. They might thus prove a more effective means of facilitating interstate practice and mobility in regions in which such practice and mobility tend to take place. A "uniform" compact signed on to by a small number of geographically disparate states, for instance, would likely have far less impact on nurses' mobility than a compact negotiated by and agreed to by four adjoining states.

4. State-of-licensure issues

Under the compact, the nurse would be licensed in her state of residence. NCSBN argues that this is the most effective way to prevent nurses from "shopping" for a state of licensure based on factors such as licensure standards, fees, disciplinary standards or processes, etc., and that it would also facilitate tracking and locating nurses for purposes of undertaking disciplinary action. Others have already discussed some of the problems posed by this approach, both conceptually and practically. For instance, a nurse might need to change her state of licensure when she moves to a new state, even if her employment does not change; the employer would need to track changes in residence among nurse employees or risk allowing unlicensed practice; a nurse who practices in multiple states and who moves from a party state to a non-party state would need immediately to obtain licenses in all of her states of practice; etc.

It is also not clear whether basing licensure on residence will effectively prevent "shopping" for the state of licensure. Nurses who are relocating, including international nurses moving to the U.S., could still choose a state of residence based on its licensure standards, disciplinary processes, or cost of licensure. For that matter, a nurse could claim residence in a state based on these factors, whether legitimately or not, in which case the burden would fall on someone else (The state of residence? The state of practice? The Coordinated Licensure Information System?) to detect and prove an illegitimate, or merely incorrect, claim of residency.

Nursing is a practice discipline. There are compelling reasons to fix some rights, privileges and obligations—voting, driving, paying taxes—to an individual's place of residence. Practicing nursing, however, may have literally nothing to do with the nurse's residence. Of all of the discussions of this issue, the most practical solution has been posed by the General Counsel for the Texas Nurses Association, who has suggested that licensure be based on the state in which the nurse primarily practices, unless she does not practice, in which case licensure would be in her state of residence.

5. Bifurcating nursing practice

The compact would provide multistate recognition for the practice of RNs and LPNs, but not for APRNs. The compact does provide (Article III, section (d)) that "a multistate licensure privilege to practice registered nursing granted by a party state shall be recognized by other party states as a license to practice registered nursing if one is required by state law as a precondition for qualifying for advanced practice registered nurse authorization." In other words, the APRN's authority to practice as an RN (which is almost always necessary as a precondition to practicing as an APRN) is recognized by all party states, but the compact does not grant authority to practice as an APRN in remote states. NCSBN is currently considering a separate compact to address APRN practice.

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. ANA has generally approached nursing as a continuum of practice. It has rejected proposals to establish separate, or "second" licensure for APRN practice as mechanistic, rigid, and ultimately stifling for nursing practice generally. The RN/LPN compact, and particularly the establishment of a second APRN compact, would rigidly separate the practice of "basic" and advanced practice nurses. It could also lead to considerable practical difficulties for APRNs who practice (and/or reside) in states which have adopted one compact and not the other.

6. Effect on revenues and licensure fees

The impact of adopting the compact on board revenues and on nurse's licensure fees has been addressed in several discussions of the compact, but there remains little specific information on this question. If NCSBN's figure of 12% of nurses holding multiple licensure is correct, then arguably boards of nursing would suffer an average of at least a 12% reduction in revenue (presumably, the average figure could be higher, depending on how many of that 12% of nurses hold licenses in more than two states). The figure would be higher in those states in which greater numbers of nurses hold licenses while practicing (or residing) in other states. Without more specific data on multiple licensees, the states in which they are licensed, the states from which the greatest numbers move, and the states to which they move, it is impossible to have any clear sense of the immediate financial impact on state boards of nursing of the elimination of duplicate licensure.

Faced with a reduction in the number of licensees (and license applications), boards of nursing could find themselves with sharply reduced revenues and a need to reduce services and/or increase licensure fees. In addition, boards are likely to find themselves with additional financial obligations to the newly established Coordinated Licensure Information System (CLIS). The extent of those obligations is unknown.

Certainly, these are issues for which nurses in each potential party state may feel entitled to information before their state signs on to the compact. Changes in board revenues and financial obligations are likely to effect both the boards' functioning and the licensing fees paid by individual RNs. ANA and the SNAs are vitally interested in strong, well-functioning boards of nursing. These boards are charged with playing a key role in protecting the public by ensuring safe nursing care. They do this not only through their licensing and disciplinary functions, but also through interpreting and enforcing the state nurse practice acts. Both the nursing profession and the public need boards of nursing that are adequately funded and have sufficient resources to function effectively. In fact, in many states, the SNAs have provided key support in lobbying and building support among nurses for adequate funding for boards of nursing, including necessary increases in licensure fees. Many SNAs may find their ability to build support for funding and fee increases for the state boards where revenues have sharply decreased as a result of signing on to the compact to be limited, particularly if nurses in the state view the board's financial difficulties as self-imposed.

7. Implementation and rulemaking

Separate rules to accompany the compact will be needed in order to implement it and to flesh out some of the details currently missing from the compact language. Party states will, in essence, have the option of adopting agreed-upon rules (the exact process for determining these rules is not entirely clear, but the rules would clearly need to be developed on a uniform basis) or, in essence, not participating in the compact. This means that important details on the compact, and how it will be operationalized, are not yet available, and that states will need to "take or leave" implementing rules once they are developed. The adoption of these rules will presumably take place through each state's rulemaking process which varies from state to state.

8. Issues with the CLIS

The compact calls for establishing a Coordinated Licensure Information System to be operated by a non-profit organization comprised of state boards of nursing—presumably the NCSBN or a subsidiary. Other discussions of this system have pointed out several questions and concerns. Key concerns for ANA and the SNAs should include the privacy and confidentiality of information held by the CLIS, including the question of which entities other than state boards of nursing will be entitled to CLIS data. This is not a minor or obstructionist point. The rapid explosion of communication technologies has already posed a significant challenge to a number of governmental and non-governmental bodies regarding public access to information. (ANA has already heard from several state nurses associations regarding public access—by telephone or computer—to board information on licensees, including home addresses.)

ANA's legal opinion notes the compact provides that states may designate information that may not be shared with "non-party states or [unspecified] other entities or individuals"—in other words, evidently data may be shared with a range of entities and individuals unless a state designates those who may not receive information. Nurses deserve some assurances regarding the range of information that will be available through the CLIS, and to whom it will be available. In addition, will information be available for research by other organizations.

Another point of concern is the extremely broad immunity granted to the CLIS under the compact. 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") are protected from liability "for any act or omission in good faith while engaged in the performance of their duties under this Compact. Good faith in this article shall not include willful misconduct, gross negligence, or recklessness." (Article IX).

Such broad immunity granted to a non-governmental body, particularly one whose actions are so critical to both patients and nurses, is one that merits careful attention. State administrative agencies—even where they are afforded some degree of immunity from legal action—are accountable to the public. Their members and officers are generally political appointees; their budgets and administrative processes are determined (or, at least, subject to oversight) by public bodies. As a private, national entity, the CLIS has no such public accountability. The immunity provision would relieve it almost entirely of legal accountability as well.

9. Concerns regarding discipline

Other discussions of the compact have noted some of the issues posed by boards' disciplinary powers and procedures. Nurses could find themselves subject to multiple investigations and disciplinary proceedings arising from the same incident. Moreover, all party states—"home" and "remote" are granted broad powers regarding discipline, including the power to issue subpoenas. Nurses could be required to bear the cost of investigation and disciplinary proceedings.

It is not clear what the result of the availability of parallel disciplinary processes is likely to be. How much weight is afforded by a remote state to an adverse action by the home state? By the home state to an adverse action by a remote state? What kinds of incidents lead a remote state to "limit or revoke the multistate licensure privilege of any nurse to practice in their state" (Article III(b))—will these be the same kinds of incidents that lead to suspension or revocation of licensure in the home state? What is the relationship between the two kinds of actions?

ANA's legal opinion also points out a lack of clarify regarding whether a party state in which the nurse does not practice may limit or revoke a nurse's authority to practice. The opinion suggests that constitutional due process considerations would prohibit it from doing so, notwithstanding the compact's lack of clarity on this question. Presumably, a nurse could face limitation of her ability to practice in a remote state but, if her home state failed to take action against her license, she would be free to practice in another party state. Given different disciplinary procedures and processes in different states, and the apparent possibility under the compact for concurrent disciplinary proceedings in the home state and a remote state based on the same incident, this outcome is probably not so far-fetched. (ANA's legal opinion also discusses a number of other jurisdictional issues on which the compact is unclear.)

ANA and the SNAs remain vitally interested in strong, effective disciplinary systems. Whether this is accomplished by creating parallel and duplicative investigative and disciplinary proceedings is open to question.

10. Employer role in nursing practice

By creating a system whereby nurses may be licensed in one state but authorized to practice in several, the compact poses special challenges for nurses in understanding nurse practice acts and regulations in each state in which they practice. How this may be achieved is not clear. State boards of nursing generally keep licensees informed of changes in practice requirements, new board policies, etc., through mailings to them. How will nurses who are authorized to practice in a given state, but not licensed, access this information—since they will be essentially unknown to the remote state board?

The basic parameters of nursing practice may not differ markedly from state to state, but some aspects of practice do. In particular, the utilization of unlicensed assistive personnel (including authority to perform tasks, certification or licensure, the responsibilities of the nurse and the employer) can vary considerably between states. Interpretations of the ways in which employers may or may not utilize UAP are often points of disagreement between boards of nursing, employers and state nurses associations. A nurse who is practicing in a party state in which she is not licensed may find herself particularly dependent on the employer's interpretation of the law and without ready access to the board's or SNA's positions.

The nurse's ability to function as an effective patient advocate—on this or on other issues in which she may find herself in conflict with the employer—may be compromised by this lack of access. ANA is concerned with establishing mechanisms for ensuring that nurses have access to information about state practice acts, regulations, labor laws and other informational resources that the employer may not make readily available. It will also be more important than ever to monitor employers' compliance with all applicable licensing laws, to ensure that some employers do not seek to take advantage of out-of-state nurses' lack of access to current information and board policies on utilization of unlicensed personnel and other relevant issues.

The use of increased mobility of nurses under the compact for purposes that may be contrary to public policy, or to public safety, should be a continued source of concern. This issue has already been raised with regard to use of out-of-state nurses as strikebreakers. This is a significant omission and an important issue for ANA and the SNAs.

Mutual Recognition: Policy Options

ANA and the SNAs continue to face a range of possible policy options in addressing multistate practice and the NCSBN compact. In their broadest form, these options have previously been identified: we can oppose the compact; we can propose changes in it; or we can propose an alternative compact.

If ANA agrees that addressing multistate practice is an important goal, opposing any action at all may no longer be a viable option. The compact has been proposed in a "final" form, has been adopted by one state and is under consideration by others. In any event, ANA will need to decide soon between outright opposition to the compact, uncritical support, or support for an amended or alternative proposal.

Whether we can propose changes in the NCSBN compact—at least, in a cooperative manner—remains to be seen. NCSBN has already adopted "final" language; if it is not amenable to changing the compact, it will be impossible for both organizations to move together on an amended compact. ANA can point to many compelling reasons why NCSBN should want to work with it on this issue, but the call is essentially NCSBN's at this point.

ANA will identify elements that need to be in an amended compact or, if necessary, in an alternative compact; the choice between these two options (an amended joint NCSBN-ANA compact or an alternative compact) will essentially be determined by the outcome of discussions between the two groups as to whether joint language is desirable and achievable.

Does nursing need a single instrument for interstate practice? Or should we look at mechanisms tailored to address specific identified problems—for instance, a nationwide compact for telehealth practice, and a series of two-state or regional compacts to enhance physical mobility?

ANA Legal Opinion on Interstate Compact

ANA commissioned a Washington law firm to prepare a legal analysis of the NCBSN Multistate Licensure Compact. Their memorandum focused on the legal issues posed by the compact. A summary of some of the major points of that memorandum follows. Readers may examine the memorandum itself in its entirety.

• The legal analysis primarily focuses on legal issues posed by the compact; it does not draw conclusions on policy considerations.
• As an interstate agreement concerning an area that has traditionally been a matter of state regulation (professional licensure), the compact would not require congressional consent.
• The compact does provide a means of addressing interstate nursing practice. There are other means of doing this as well, including expedited endorsement of out-of-state licensure.
• The goal of "single licensure"—that is, of a nurse needing to obtain only one license in order to practice in any state—would not be achieved for some time under the compact, until a substantial number of states enacted it.
• The compact provides some advantages over the present licensing system by creating a more convenient system for nurses who practice "telenursing," and by allowing for a more efficient information exchange. It does not appear to provide a significant advantage for those nurses who may practice physically in only a few states.
• Basing licensure on state of residence (as proposed by the compact) rather than state of practice poses some legal issues regarding jurisdiction and due process. While traditional professional licensing requirements typically focus on the location of the licensee's practice, basing licensure on state of residence appears to satisfy legal requirements with regard to these issues. Deciding the state on which to base licensure is a policy choice for all parties involved. The issue of which state is the state of licensure under the compact is primarily a policy (not a legal) decision.
• Language in Article III of the compact creates some confusion regarding definitions of nursing between states, the practice of nursing other than providing patient care, and inconsistent use of terms regarding party, home and remote states.
• The disciplinary system outlined by the compact utilizes the existing system(s) in each state. While there is no change regarding nurses' substantive rights, the compact does create 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 proposed Coordinated Licensure Information System (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 the 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 the CLIS are left open by the compact.
• The CLIS also 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 be not be shared, non-party states and "other entities and individuals" will normally have access to information held by the CLIS.
• The compact language is unclear as to whether a party state that is not the nurse's home state and is not a state in which the nurse is practicing may take adverse action against that nurse. Constitutional due process considerations support the conclusion that it may not, but the compact is confusing on this point.
• In answer to questions that have previously been raised, the legal analysis notes that:

a. Implementation of the compact could probably be made contingent on the occurrence of some event, such as the start-up of the CLIS.

b. The compact could include language stating that it specifically does not supersede other state laws. For example, there is currently such language in the Driver License Compact.

c. While the compact is adopted on a state-by-state basis, it must be substantially identical from state to state. "Add-on" or other provisions adopted by individual states would have to be minor ones that would not create significant differences in the operation of the compact as enacted by various states.

Based on this analysis and consultation with experts and SNA representatives, several key elements in a interstate compact are called for.

Required Compact Elements

The following points are ones that NCSBN's Compact does not adequately address. Specific elements to be addressed in an amended or alternative compact are:

1. Definitions of "Home," "Party" and "Remote" must be clarified and the language of Article III changed to reflect the clear definitions related to party state.
2. A compact should include, or be accompanied by, proposed implementation regulations/guidelines (i.e., developing and proposing these regulations should occur before, not after, proposal and adoption of the statutory compact language).
3. A compact or implementing regulations should include clear parameters for security of information collected by CLIS, including clear limits on which information may be shared with which entities and parties.
4. Immunity provisions for CLIS and its administrators must have a means established for accountability and oversight of its administration and its actions and the existing immunity must be scaled back.
5. A compact should not specify the precise group that will administer the CLIS. The task should be open to bid by organizations other than NCSBN (or a subsidiary). There must also be a means of reconciling the CLIS's processes with any existing state laws and procedures regarding who is responsible for collecting, maintaining and distributing licensure and disciplinary information regarding state licensees.
6. Parallel investigations and disciplinary proceedings for the same incident, and the expanded powers of the boards of nursing, including the power to make the nurse bear the cost of investigation and discipline, must be reconsidered.
7. A compact(s) should address "basic" RN practice and advanced practice in a single document, recognizing that these represent a continuum of nursing practice.
8. Only final BON orders information, not investigative information is to be included in the CLIS.
9. Means must be established to ensure that nurses practicing in a remote state have ready and ongoing access to practice-related information, including current board of nursing policies. A mechanism for all nurses practicing ( this is in addition to all residing in the state) in the state to be known to the BON must be in place.
10. The compact (or compacts, or other mechanism) should provide for licensure in the nurses' state of primary practice, unless she is not practicing, in which case the nurse would be licensed in her state of residence.
11. Employers must be held accountable for ensuring that they utilize staff who are licensed (or otherwise authorized to practice) under state law.
12. A compact must not be used to circumvent or contravene existing public policy as expressed by the laws or policies of each state; this includes laws on use of strikebreakers and striker replacement.

Additionally, ANA's President and Executive Director have engaged in recent dialogue to share all issues described here.

SUMMARY

Changes in the licensure system will potentially affect every nurse in this country. Dramatic and sweeping changes in nurse licensure such as that proposed by the interstate compact. require the collaboration of the profession. ANA remains committed to working closely with the SNAs, as well as with nursing specialty groups, to ensure that changes in nursing licensure reflect the evolving needs of consumers and the profession.

APPENDIX

Frequently Asked Questions and Answers:

Q1. How does a state enter into the Interstate compact?

A1. By passing legislation that adopts the compact language already passed by other compact party state(s). No state is forced to enter into the compact but if they chose to do so, each state must pass the same language or have all other party states go back and change what is in place.

Q2. How will the individual RN be affected by adoption of the NCSBN compact?

A2. H/she will only hold license in their state of residence but will be held to the state practice acts of all states in which they practice. Disciplinary action against the license will be taken only by the state of residence (license). It is unclear if fees will be raised since the BON will incur a loss in revenue.

Q3. What will be the financial loss to BON if revenues are generated only in state of RN residence?

A3. Unknown at this time. Border states may lose because the RN only holds license where they live, not the state that they cross (electronically or physically) into to work. e.g. DC, Maryland, Virginia—Many RNs cross borders to work in DC; they will hold only 1 license, not 3 if all states enter into the compact.

Q4. How does the Interstate compact address tracking which RNs are actually working in the state?

A4. It is silent on this issue. The only RNs known to the BON will be those who live in the state or who have a complaint filed against their practice.

Q5. Is this model, in fact, a form of national licensure?

A5. This type of interstate compact sometimes require federal impetus or are preceded by federal statute; however, according to NCSBN, federal action is probably not needed for nursing regulation because this would not impinge on a federal interest or adversely harm a non-participating state.

Q6. Do interstate compacts allow exemptions?

A6. No. You either agree to the terms or you do not. Law cannot be overridden without law change. Compacts cannot be overridden without compact change.

Q7. In the mutual recognition model if there is no license to revoke, what could a state do with a violator of safe practice?

A7. Possibly fine, bring a criminal judgement or cooperate with the state providing the license to provide information for disciplinary action.

Q8. What is the reaction of RNs who have heard about the Mutual Recognition Compact?

A8. They are reported to be happy with having the ability to get a license in another state facilitated, looking forward to less expense since they will pay for only 1 license fee, believe holding only one (1) license is simpler and look to having their due process protected.

Q9. How are APRNs covered in the current Mutual Recognition model?

A9. This compact is silent on APRNs. In states where APRNs are considered as a separate category, there is no impact. NCSBN is developing a separate Mutual Recognition Model for APRNs with uniform requirements in the compact language. Advanced practice specialty nursing groups, ANA, the National League for Nursing, the American Association of Colleges of Nursing and others have held meetings to advise the NCSBN task force on key professional issues.

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