A nurse who graduated from an accredited nursing school and then passed the national nurse certification exam cannot immediately or seamlessly practice across all 50 US states and territories. Jurisdictional red tape prevents this critical health care professional from caring for patients where and when they’re needed the most. Currently, state boundaries are blurring as workforce and patients become increasingly mobile and care delivery hinges on remote communication technologies.
Since the establishment of the United States boards of nursing a century ago, the single, state-specific nurse practice licensing model remains largely unchanged and woefully outmoded. Each jurisdiction institutes its own Nurse Practice Act (NPA) which delineates license qualifications, official titles, scope of practice, and oversees regulatory violations (National Council of State Boards of Nursing [NCSBN], n.d.a.). In 2000, the National Council of State Boards of Nursing (NCSBN) enacted the Nurse Licensure Compact (NLC) which allowed licensed practical/vocational nurses and registered nurses to also practice within participating compact states if their primary state of residence was an NLC member. In 2018, the enhanced NLC (eNLC) was implemented to reconcile jurisdictional concerns over public safety, state-level regulations, and license requirements. However, since the original NLC’s introduction twenty-years ago, only 30 states have implemented compact licensing (NCSBN, n.d.a.; Campaign for Action, 2018; Qaulivis, 2018).
Concerns over diminished state powers and whether compact delegation is constitutional remain powerful barriers against compact participation in some states. Continued apprehensions over disciplinary jurisdiction, licensing requirements, measurable impact to short and long-term staffing shortages, reduction of operational income to state boards of nursing, and the influence of unions continue to plague state participation. Promulgating these fears and the purported dangers to the public have successfully prevented the passing of NLC legislation, even in states where legislative support was strong (Kacik, 2018; Steward 2016; Qaulivis, 2018; OPPAGA, 2006).
In the 2017-2018 legislative session, Republican Senator Kemp Hannon sponsored the New York State Senate Bill S7579, which unfortunately stagnated within the Higher Education Committee (New York State, 2018). Notwithstanding, Congress should seek to resume efforts to pass the bills proposing state participation in compact licensure. Disparate NLC participation limits access to qualified nurses in chronically underserved rural areas and burdens employers with incurred costs and jurisdictional concerns over inter-state telehealth and care management services (Georgia, 2018; Kacik, 2018). It also constrains nurses from attaining better wages and working conditions due to the additional costs and requirements of acquiring and maintaining multiple state licenses; including a lengthy processing that varies from several weeks to months, with each single-state licensing requiring rounds of paperwork, verifications, exams and fees (Qaulivis, 2018; Siow & Ng, 2013).
Prior to compact licensure, temporary licenses were issued during state or federal emergencies. Lessons learned from the devastation wrecked by Hurricanes Katrina and Harvey highlight the need for a prompt and adequate supply of qualified professionals (Jimenez, n.d.). Florida and Texas, two of the southern states most impacted by Katrina and Harvey, both instituted the NLC, recognizing it as an essential strategy for acute and ongoing disaster relief.
Now, in response to the COVID-19 pandemic, both federal and state governments have enabled emergency powers and issued executive orders that ease state licensing restrictions to allow for adequate nurse staffing across state lines (NCSBN, 2020). However, short-term declarations of emergency, calls for disaster relief and executive orders, all expire and do not bridge the gap between an acute crisis response and the need for a more permanent resolution. The ability to quickly mobilize nurses and provide aid is critical, especially for the special needs population who require intensive care, but also necessary for longer term healthcare infrastructure recovery (Eisenhower, 2017). By implementing the enhanced Nurse Licensure Compact the state benefits from the more stringent and standardized licensing requirements while also improving patient access to licensed, qualified nurses, enabling prompt emergency and disaster relief, supporting workforce mobility, providing for staffing shortages, and adequately responding to changing healthcare delivery models.
Each state’s participation in compact licensure is a critical short and long term response to the current pandemic crisis. By supporting legislation that promotes state adoption of the eNLC we can help improve access to qualified nurses and respond proactively to these unprecedented, fast-changing times.
Campaign for Action. (2018). Many states, one license: The enhanced nurse
licensure compact is now live. https://campaignforaction.org/many-states-one-license-enhanced-nurse-licensure-compact-now-live/
Eisenhower Health. (2017). The importance of nurses’ help after a major hurricane.
Georgia Secretary of State. (2018). Nurse licensure compact. http://sos.ga.gov/index.php/licensing/plb/45/nurse_licensure_compact
Jimenez, S. (n.d). Nurses called to help Hurricane Harvey relief efforts. https://www.nurse.com/blog/2017/08/29/nurses-called-to-help-hurricane-harvey-relief-efforts/
Kacik, A. (2018) Providers welcome interstate licensing, while unions oppose it.
Kappel, D. (2018). NCSBN news release: Enhanced nurse licensure compact
(eNLC) implemented Jan. 19, 2018. https://www.ncsbn.org/11945.htm
National Council of State Boards of Nursing. (n.d.a). About U.S. boards of nursing.
National Council of State Boards of Nursing. (2020). States changing nurse licensing for
COVID-19 Response. https://www.ncsbn.org/covid-19.htm
New York State. (2018). Senate Bill S7579. 2017-2018 Legislative Session.
Office of Program Policy Analysis & Government Accountability (OPPAGA). (2006).
Nurse Licensure Compact Would Produce Some Benefits But Not Resolve the
Nurse Shortage. http://www.oppaga.state.fl.us/reports/pdf/0602rpt.pdf
Siow, E. & Ng, J. (2013). Internal migration of nurses in the United States: migratory
prompts and difference in job satisfaction between migrants and non-migrants.
Nursing Economics 31(3), 128-136.
Steward, T. (2016). DFL Lawmaker Bucks Nurses’ Union in Effort to Streamline
Qaulivis. (2018). Nurse Licensure Compact Analysis. https://www.qualivis.com/wp-content/uploads/2018/06/Qualivis_WhitePaperUpdate_18.pdf
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