IF YOU'RE CONSIDERING relocating, planning for a transition, or contemplating mobilizing your nursing practice in any other way, you should quickly become acquainted with the multistate nursing license. This article will discuss the history of this form of licensure, the benefits it holds for relocating nurses, and resources to help nurses learn how their state is affected.
Origin of the Nurse Licensure Compact
The National Council of State Boards of Nursing (NCSBN) is a nonprofit, independent organization founded in 1978 “to lessen the burdens of state governments and bring together boards of nursing to act and counsel together on matters of common interest.”1 There are 59 member boards, which include the 50 states and the District of Columbia, and 4 U.S. territories (American Samoa, Guam, the Northern Mariana Islands, and the Virgin Islands). California, Louisiana, and West Virginia have two state boards of nursing, one for RNs and one for LPNs/LVNs. Nebraska has a board for RNs and APRNs.2
In 2000, the NCSBN introduced the Nurse Licensure Compact (NLC) commissioned “to expand the mobility of nurses.”3 Currently 25 state boards of nursing are NLC members, with several additional states pending membership for 2016.3 A list of the 25 current NLC member states can be accessed on the NCSBN website, www.ncsbn.org. This site also lists seven additional states with legislation in progress and pending membership.
At the start, the NCSBN created a template for legislation that states would need in order to join the NLC. For membership, each state must enact the “model” legislation without any significant variation. The designs of both the NCSBN and the NLC can be compared with the Interstate Driver License Compact in which 45 of the 50 states have agreed to share information.4 Traffic code violations while driving in a compact state are thus made known to the driver's home state (with the current exception of five nonparticipating states).
How exactly can NLC membership expand and enhance licensure for nurses on the go? Member states allow an RN, LPN/LVN, or APRN to reside in one compact state and practice nursing in any, or several other compact states. A separate APRN compact offers this option to the APRN.
How to apply
To apply for a multistate license, a nurse must legally reside in one of the 25 compact states. The compact (multistate) license is valid for practice in any NLC-member state for the entire licensure period. A conventional single-state license must be obtained to practice in any noncompact state. Nurses who live in a noncompact state may not obtain compact state licensure and must apply for single-state licensure to practice anywhere out of their home state. To avoid legal pitfalls related to these licensure requirements, see Legal Matters, “Check your Local Listings,” in the October issue of Nursing2016.5
Case study: Nurse Amy
Amy is currently a licensed, full-time RN in Mississippi, a compact state. She's going to live in Georgia for 1 year, where her daughter, a single mom on active duty with the U.S. military, is expecting twins. After relocating to Georgia, Amy now resides in a noncompact state. She lives in Augusta, less than 6 miles from the South Carolina state line.
Unexpectedly, she's been offered a great position with only a brief commute to South Carolina, a compact state. Unfortunately, she can't use her current multistate license originally obtained in Mississippi because her official state of residence is now Georgia, a noncompact state.
She'd anticipated working in Georgia and applied for a single-state license by endorsement in that state. Licensure by endorsement can occur when a state board accepts an RN license already granted by another state with comparable licensure requirements.6 This application involved filling out the usual forms, updated fingerprinting, and a background check. Verification of number of hours worked throughout the past several years was also required, along with notarized forms from previous employers. The Georgia Board of Nursing also requested transcripts for completed courses relevant to the original nursing-education program.
The single-state license application has been costly and time-consuming for Amy. In order to live in Georgia and work as an RN in neighboring South Carolina, she'd need to submit yet another single-state license application, resulting in more paperwork, expense, and delays.
Amy's now resided in Georgia for nearly 3 months. She's not yet eligible to work as an RN in either Georgia or South Carolina because her former multistate license isn't accepted in either of those states. She's now missed several opportunities for a desirable job in her specialty area. Amy, whose RN licensure over many years has been active and unblemished, remains unemployed.
RNs can typically continue to practice using their former residency license for up to 30 days—and 90 days in some states. To mitigate any delays in employment due to a lapse in licensure, the NCSBN recommends nurses apply 1 to 2 months in advance of a move.3
Tough situations for travel nurses
A thorough understanding of the NLC is essential when relocating. Perhaps this is the right time for you to consider travel nursing. If you live, for example, in Maine, you can accept an assignment as far away as Idaho and begin working immediately—both are compact states. However, you can't accept an assignment in neighboring Vermont, a noncompact state. Travel nurses must apply for a single-state license to work in a noncompact state whether or not they reside there.
In another example, Mark lives and works as an RN in Colorado. He also works in the Four Corners region that includes parts of Colorado, Utah, New Mexico, and Arizona. These are all compact states. His original fee for licensure in Colorado in 2014 was $88.7 Before the introduction of multistate licensure, he would have been required to pay additional application fees for three more single-state licenses. These would have totaled $100 in Utah, $110 in New Mexico, and $300 in Arizona.8-10
Additionally, license renewal periods and fees vary widely among the 50 states, affecting a nurse's ongoing expenses. For example, Washington and West Virginia require renewal annually.11,12 Renewal periods in other states can range from 2 to 4 years. Fees for renewal may range from $50 in New York State up to $210 in Tennessee.13,14
Because all states in the Four Corners region are compact states, Mark can simply apply for one compact state nursing license in Colorado, his state of residence.3 All relevant fees are submitted only to the Colorado Board of Nursing. Mark will then be licensed to practice as an RN in any or all of the Four Corner states.
Pros and cons
Given these advantages, why don't all states participate in the NLC? Critics of multistate licensure for nurses say the system increases patient safety risks. ProPublica, a not-for-profit agency, puts forth investigative journalism in the interests of society and the general public. In July 2010, it found that nurses disciplined by the board of nursing in one compact state were able to “slip through the net” and practice in another, or several other, compact states.15,16
Because professional nurse licensing isn't centralized within the compact, sharing information, including efficient reporting regarding cases of misconduct, is left to the member states. Unfortunately, this hasn't always been done quickly or efficiently. Just as licensing isn't federalized, screening nurses for misconduct is also performed to various different standards throughout the country. For example, some states don't perform criminal background checks. Standards of practice are defined by more than 50 distinct and separate nurse practice acts.
States also differ in accreditation of nursing programs as well as in regulations involving delegation and supervision for unlicensed healthcare personnel. Definitions of misconduct are defined variously by each independent state board. Continuing education (CE) requirements for nurse licensure also vary widely among the states. For example, California requires proof of 30 hours of CE per renewal period, but Connecticut doesn't require any documentation for CE.17,18
Taking a global view
These circumstances may continue to raise new ethical questions and political controversies. The wide variation in requirements and regulations among multiple nurse practice acts implies that standards of practice in each area may also diverge and differ. In the United Kingdom, all nursing licenses are issued by the United Kingdom Nursing and Midwifery Council.19 Professional nursing is held to a single standard of practice. Nurses who live in England, Scotland, Wales, or Northern Ireland are able to live and work anywhere in the United Kingdom under a single license.19 Most significant is that all U.K. nurses are held to the same standards of practice, CE requirements, and regulations. All patient safety issues become national concerns on a central level. Patients and the public may expect that nursing practice doesn't vary from region to region.19
A similar concept is seen in the United States with federally employed nurses. The Veterans' Health Administration is the largest employer of nurses in the country. Nearly 80,000 nurses (RNs, APNs, and LPNs/LVNs) are employed by the Department of Veterans Affairs. Care for nearly 9 million patients is provided each year at more than 165 VA Medical Centers and over 1,000 outpatient sites. Only one active, unrestricted nursing license from any of the 50 states, the District of Columbia, or Puerto Rico is required for hire by the VA. Nurses may apply for work at a VA facility in any state, and may transfer to accept a vacancy at another site without loss of seniority or benefits.20
The Indian Health Service (IHS), an agency of the U.S. Department of Health and Human Services, delivers care to Native American and Alaskan native communities within 12 geographical areas in 35 states. The IHS employs over 2,700 nurses. Only one active, unrestricted nursing license from any state or territory is required for nursing practice with the IHS.21 Unlike nurses in a conventional single-state licensure system, federally employed nurses are held to the same standards of practice, education, and regulation.
To date, no formal proposals have been offered to consolidate or merge individual nurse practice acts. Each charter remains separate and independent. The autonomy and jurisdiction of each state, in this regard, is relevant and has remained supreme. Perhaps this creates a legitimate obstacle to NLC membership for some states.
How to plan for relocation
If you are, or will be, a nurse on the go, advance planning is in your best interest. Compact state licensure can be beneficial and valuable for your practice, but the concept can be perplexing if you're new to it. To avoid pitfalls like the one Amy experienced, take the time to get acquainted with the process and other factors relevant to the states involved before you relocate.
To view various FAQs, or to put forth your own questions, or make a comment, e-mail email@example.com. In addition, each state board of nursing can give specific instructions for nurse licensure applications, and will also usually advise a minimum “waiting time” for the application process. Correspondence to and from several of the state boards is now available on their respective Facebook pages.
Many nurses residing in noncompact states are increasingly motivated to expand employment options. The NLC does, in fact, increase nurse mobility. It does not, however, create more nurses, and it may imply more difficulties in workforce data collection.
Beginning with its launch in 2000, the NLC has diversified and expanded potential opportunities for nursing practice. If nurses where you live and work are enthusiastic about the advantages of NLC membership, gathering signatures and contacting the state legislature and the board of nursing are important first steps to take as nurse advocates.