a license without borders

958 • AORN JOURNAL

APRIL 2006, VOL 83, NO 4 Health Policy Issues

he 10th Amendment to the USConstitution gives each statethe power to enact measuresto preserve and protect thesafety, health, welfare, and

morals within state borders. Includedin this right is the power to regulatespecific professions in a manner thestate deems necessary to protect thepublic from incompetent professionals.The regulation and licensure of nursesvaries from state to state according tothe rules set forth by the board of nurs-ing in each state. If a nurse intends topractice in more than one state, thenhistorically that nurse must be licensedby each state and according to thestate-specific requirements for educa-tion, entry into practice, competency,and scope of practice.

State-specific licensure requirementsare intended to protect individual stateinterests. In recent years, however,boundaries of nursing practice haveexpanded beyond state lines with theemergence of telemedicine, nationalnursing call centers, and increased mo-bility of nurses who work for hospitalsystems or managed care organizationsthat operate in several states.1 As de-scribed by the American Organizationof Nurse Executives,

[a]dvances in technology allow morefrequent, regular communication be-tween [nurses] and [patients] via tele-phone, e-mail, fax, and teleconference,contributing to the nursing profes-sion’s ever-widening boundaries.2

In 1997, in response to a growing con-cern in the national nursing communityregarding competing practice require-ments among different states, delegatesfrom the National Council of StateBoards of Nursing (NCSBN) unani-mously agreed to develop and endorse a

mutual recognition model of nursingregulation to “remove regulatory barri-ers to increase access to safe nursingcare.”3 The Nurse Licensure Compact(NLC) was the result of this effort. Aninterstate compact is an agreementbetween two or more states to address aproblem identified by each state that canbe resolved by a singular solution.4

When a state enters theNLC, nurses in the mem-ber state can practice inthe other member stateswithout securing separatestate licenses. This mutualrecognition model ofnurse licensure allowsnurses to secure a licensein the state of their resi-dency and still practice inother states as long asthey adhere to the lawsand regulations of theirpractice state.

MEMBERS OFTHE COMPACT

In 2000, the NCSBNofficially enacted thecompact with these par-ticipating states: • Maryland, • Texas, • Utah, and • Wisconsin.5

Nurses in these statesare permitted to practicebeyond the borders oftheir residency state if both their resi-dency and practice states are membersof the compact. Since the enactment ofthe compact, 16 additional states havejoined the NLC: • Arizona, • Arkansas, • Delaware, • Idaho,

A license without borders

H E A L T H P O L I C Y I S S U E S

Catherine Becker

TThe NurseLicensure

Compact allowsnurses to securea license in thestate in whichthey reside and

be able topractice in otherstates that have

enacted thecompact.

AORN JOURNAL • 959

Health Policy Issues APRIL 2006, VOL 83, NO 4

language for a licensure com-pact for advanced practice RNs(APRNs) for states that previ-ously had adopted the NLC.5

At this time, only Utah andIowa have passed legislationadopting the APRN LicensureCompact.6

STATE REQUIREMENTSEach state is required by the

compact to enact legislationauthorizing the recognition ofthe compact and must subse-quently develop rules and reg-ulations to incorporate thecompact into their state nurs-ing program.5 Each memberstate must designate an NLCadministrator to participate inthe exchange of informationbetween the member statesand to assist in developingmodel laws and regulationsfor enactment, implementa-tion, and continued participa-tion in the NLC.5

REACTION TO THE COMPACTSince its introduction, the

NLC has generated significantattention in terms of whetherit is truly a problem solver orwhether it has created addi-tional problems in the nursingcommunity nationwide. Theidea of a multistate compactthat would permit nurses topractice across state bordersinitially appears to be an idealsolution to the issues createdby advances in technologyand increased nurse mobility.The compact, however, is notwithout its opponents.

One of the more contro-versial aspects of the compactis the coordination of disci-pline resulting from scope-of-

practice or competency con-flicts among the memberstates. The compact requiresthat the nurse’s state of resi-dence (ie, the home state)retain the authority to disci-pline a nurse for actions con-trary to laws and regulationsgoverning the practice ofnursing in the resident state,while permitting the state ofpractice (ie, the remote state)to retain its authority to regu-late and discipline the mannerin which the nurse conductshis or her duties in that state.1

This means that the homestate can take action againstthe nurse’s license and prac-tice privileges but the remotestate is limited to disciplinaryaction only in the form of lim-its on practice privileges inthe remote state.7 This struc-ture requires that a nurse whois licensed by one statebecome familiar and complywith the laws and regulationsof the remote state in whichhe or she is practicing.

Opponents to the NLCargue that allowing both thehome state and the remotestate to discipline a nurse for asingle infraction could result induplicative investigations andconflicting rulings on thenurse’s behavior. A remotestate, for example, could issuea disciplinary sanction againsta nurse for performing a taskthat is outside of the remotestate’s scope-of-practice re-quirements but is entirely con-sistent with the nurse’s homestate’s laws and rules. “Eachnurse will bear the consider-able burden of determiningthe difference between the

• Iowa, • Maine, • Mississippi, • Nebraska, • New Hampshire, • New Mexico, • North Carolina, • North Dakota, • South Carolina, • South Dakota, • Tennessee, and • Virginia.6

The governor of New Jerseyenacted the NLC during the2005 legislative session, butfull implementation is pend-ing the development of regula-tions. Similarly, the SouthCarolina Legislature will voteon HB 4581 in 2006, to ap-prove the regulations con-cerning the NLC, which wasenacted during the 2005 leg-islative session.

The debate on the NLC willbe taken up in the 2006 legisla-tive sessions in several states.Five states consideringwhether to become membersof the NLC are • Colorado (SB 20); • Illinois (HB 3497, HB 3826,

and SB 86);• Kentucky (HB 102);• Michigan (HB 5493); and • Missouri (HB 1150 and SB

664).Each state will weigh the ben-efits, risks, and costs of adopt-ing the NLC to determine ifcompact membership wouldbe beneficial for their statenursing programs.

The original NLC was de-signed to include RNs andlicensed practical nurses(LPNs) or vocational nurses(VNs) only. In 2002, however,the NCSBN approved model



scope-of-practice regulations ineffect in each jurisdiction,”1(p29)

and this can be both cumber-some and inefficient for anurse practicing in severalstates.1

In response to the discipli-nary issues regarding thecompact, the NCSBN revealedthat “since the implementa-tion of the [compact], mostdisciplinary cases in the[member] states have beenlimited to single jurisdictions.. . . “8 The NCSBN, however,has tried to ease the burden ofdiscipline by requiring thateach compact member stateprovide licensure, discipline,and significant current inves-tigative information to a cen-tralized database calledNURSYS.7 By sharing discipli-nary information in NURSYS,states can coordinate theinvestigative and disciplinaryactions so that a nurse is sanc-tioned only once for a singleevent.4 The NURSYS databasealso is promoted as a way forall state nursing boards toaccess timely nurse licensureand disciplinary informationand be able to prevent a pre-viously sanctioned nurse frompracticing and potentiallycausing harm in their state.

An additional criticism ofthe NLC is that it could havethe effect of weakening state-specific standards for nursing.7

For example, many stateshave continuing education orpractice requirements fornurses to maintain their licen-sure, but the standards varygreatly from state to state.Nurses in a compact statemust meet only the entry-to-

practice and licensure mainte-nance standards in their homestate, but they would have theprivilege of practicing in othercompact states in which theentry-to-practice and licensuremaintenance standards maybe more rigorous.

Provisions in the compactrequire party states tounconditionally accept thelicensure standards of otherstates which could lead to a“lowest denominator” ofstate licensure standards.9

In response, proponents ofthe NLC claim that the basicgoal of the compact is “har-monious cooperation amongthe states,”1(p29) implying thatstates entering into the com-pact should respect and recog-nize the standards of practicein other states rather thandoubting their effectiveness.1

A third criticism of theNLC is related to the cost ofimplementing the compact atthe individual state level.Opponents argue that thecompact would decrease therevenues that a state board ofnursing receives from licen-sure fees.10 Under the com-pact, nurses that are licensedin their home state would notneed to pay the licensure feeof the remote state. In arecent report published bythe Office of Program PolicyAnalysis and GovernmentAccountability of the FloridaLegislature, however, a sur-vey of several state boards ofnursing indicated that theytypically experienced little tono change in licensure rev-

enues, although they didincur some expenses whenimplementing the compact,including a $3,000 annual feethat is paid to the NLCadministrators.11 Some stateswould incur a greater costthan other states in theimplementation process ifthey were forced to hire addi-tional staff members to eitheradminister the compact orparticipate in interstate disci-plinary investigations. Thesecosts would vary from stateto state, however, and aretherefore difficult to quantify.

ENDORSEMENTSDespite these criticisms,

the NLC has garnered en-dorsements from a number ofnationally recognized nursingorganizations including theAmerican Nephrology NursesAssociation, American Tele-medicine Association,American Association ofOccupational Health Nurses,and American Organization ofNurse Executives.12 Theseorganizations recognize thebenefit of the compact in lightof the advances in technologythat have expanded the reachof nursing practice beyondstate borders.13 Additionally,health care organizations viewthe compact as a possiblesolution to “the general mobil-ity of the nursing workforce,the unpredictability of naturaldisasters, and the omnipresentthreats of bioterrorism.”14

GOING FORWARDWith all this information in

mind, five state legislatureswill engage in the NLC



debate in 2006. Some statesmay be swayed by the criti-cism against the compact andchoose to retain absoluteautonomy for the regulationof nursing in their state. Otherstates may embrace the bene-fits of cross-state licensureand readily become membersof the compact. Ultimately,the practice of nursing willcontinue to evolve, and asadvancement of the NLC con-tinues, a workforce of “nurseswithout borders” will contin-ue to emerge. ❖

CATHERINE BECKERMSPH, JD

AORN LEGISLATIVE AND REGULATORY

RESEARCH ANALYST

Editor’s note: NURSYS is aregistered trademark of theNational Council of StateBoards of Nursing, Chicago.

NOTES1. A M Sulentic, “Crossing bor-ders: The licensure of interstatetelemedicine practitioners,” Jour-nal of Legislation 25 no 1 (1999) 29.2. “2005 key public policy is-sues,” American Association ofOccupational Health Nurses,http://www.aaohn.org/press_room/up

load/policy%20platform%202005.pdf(accessed 21 Feb 2006).3. “Background informationabout the RN and LPN/VNNurse Licensure Compact,”National Council of State Boardsof Nursing, http://www.ncsbn.org/nlc/rnlpvncompact.asp (accessed21 Feb 2006).4. “Frequently asked questions re-garding the National Council ofState Boards of Nursing (NCSBN)Nurse Licensure Compact (NLC),”National Council of State Boardsof Nursing, http://www.ncsbn.org/pdfs/FrequentlyAskedQuestions.pdf(accessed 21 Feb 2006).5. “Nurse Licensure Compact,”National Council of State Boardsof Nursing, http://www.ncsbn.org/nlc/index.asp (accessed 21 Feb 2006).6. “Nurse Licensure Compact im-plementation,” National Councilof State Boards of Nursing, http://www.ncsbn.org/nlc/rnlpvncompact_mutual_recognition_state.asp(accessed 21 Feb 2006).7. S E King, “Multistate licensure:Premature policy,” Online Journalof Issues in Nursing (May 31, 1999)http://www.nursingworld.org/ojin/topic9/topic9_3.htm (accessed 21Feb 2006).8. “NCSBN letter to Barbara A.Blakeney,” (Dec 4, 2003) NationalCouncil of State Boards of Nurs-ing, http://www.ncsbn.org/pdfs/ANA7Points120503.pdf (accessed21 Feb 2006).9. “ANA state government rela-tions: Background information

on interstate nurse compact,”Nursing World, http://www.nursingworld.org/gova/state/2004/interstate.htm (accessed 21Feb 2006).10. M A Hellinghausen, “Nurseswithout borders,” NurseWeek (Feb16, 1998) http://www.nurseweek.com/features/98-2/border.html(accessed 21 Feb 2006).11. “Nurse licensure compactwould produce some benefitsbut not resolve the nurse short-age,” Office of Program PolicyAnalysis & Government Ac-countability, http://www.oppaga.state.fl.us/reports/pdf/0602rpt.pdf(accessed 21 Feb 2006).12. “What organizations supportthe nurse licensure compact?”National Council of State Boardsof Nursing, http://www.ncsbn.org/nlc/rnlpvncompact_BDED1E05DD2F4468B2097B37E6B0D42F.htm(accessed 21 Feb 2006).13. “CMSA letter to Kathy Ap-ple,” (Nov 29, 2005) Case Man-agement Society of America,http://www.ncsbn.org/pdfs/CMSACompactLetter.pdf (accessed 21Feb 2006).14. “Legislative/regulatoryactivities: ANNA letter to KathyApple,” (Feb 3, 2005) AmericanNephrology Nurses’ Associa-tion, http://www.annanurse.org/cgi-bin/WebObjects/ANNANurse.woa/1/wa/viewSection?wosid=QTpJ4vhAjPs92FU3Wgt6Zj6d4JN&tName=fullActivity&s_id=1073744052&od_id=805312271 (accessed 21Feb 2006).

AORN member and former AORN ExecutiveDirector Lola M. Fehr, RN, MS, CAE, FAAN, has

been appointed to the 2005-2007 board of direc-tors of the Sigma Theta Tau International Founda-tion for Nursing, according to a Feb 9, 2006, newsrelease from the Honor Society of Nursing, SigmaTheta Tau International. The mission of SigmaTheta Tau International is to improve the healthof people worldwide through leadership and schol-arship in practice, education, and research. TheSigma Theta Tau International Foundation for

Nursing raises funds to support honor society pro-grams and initiatives, including the VirginiaHenderson International Nursing Library and nurs-ing research grants.

Fehr was AORN’s executive director from 1990to 1999. She currently is the executive director forthe New York State Nurses Association.

Honor Society of Nursing Names Foundation Board ofDirectors (news release, Indianapolis: Honor Society ofNursing, Sigma Theta Tau International, Feb 9, 2006).

AORN Member Named to Nursing Foundation’s Board

a license without borders

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