Running head: MULTISTATE LICENSURE IN NURSING 1

Multistate Licensure in Nursing

Kendall Lillie

University of Saint Mary

MULTISTATE LICENSURE IN NURSING 2

Abstract

This paper explores the performance of a multistate licensure in nursing. It focuses on the Nurse

Licensure Compact (NLC) and the benefits that it gives nurses. These benefits include a

reduction in overall expenses, increased mobility for the practicing nurse, convenience for those

living near state borders, as well as diminishing the variation of requirements between states.

This paper also focuses on how the implementation of a multistate licensure has worked outside

of the country and for federal US organizations. Although there are criticisms of the NLC, they

have tried to create solutions to make the system more effective and favorable for everyone.

Keywords: nurse, multistate, licensure, NLC

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Multistate Licensure in Nursing

The nursing profession has been around for centuries along with a state by state licensure

model, which forces a nurse to acquire multiple licenses if he/she wishes to work in more than

one state. The Nurse Licensure Compact (NLC) was developed to reduce these complications by

requiring a nurse to obtain only one, unrestricted license. The NLC is set up as a mutual

recognition system that lets nurses get a license in their state of residence while also allowing

them to practice in other compact states. Much like how a driver’s license allows you to travel

across the country, nurses would have the ability to practice where they please (Congress on

Nursing Practice and Economics, 2013). Before the NLC, if a nurse wanted to practice in

multiple states that individual would have to acquire multiple licenses, one from each state. This

is still true for those that are not part of the compact. Those living on the border of a non-

compact state and a compact state still have to obtain two licenses in order to work in both of

those areas. For example, Missouri is part of the Nurse Licensure Compact but Kansas is not.

Therefore, one would have to register and keep up with the requirements for both Kansas and

Missouri in order to work in both states. This is a lot of work and the reason why the Nurse

Licensure Compact was created. The NLC has successfully cut down expenses, increased

mobility and access to patients, and demonstrated convenience for those living on state borders

while reducing the variation of requirements between states.

With the current licensure model, registered nurses must follow an endorsement process

to obtain a license from another state. This procedure is not only complicated but time-

consuming and expensive. The process involves paperwork, fingerprinting, a background check,

prior employer’s notarized forms, and verifying the amount of hours the applicant has worked

(Ashton, 2016). The Nurse Licensure Compact was created with the intention of removing some
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of this hassle. With the requirement of only one license, the process only has to be completed

once. This allows nurses to spend less time getting registered and more time helping those in

need. The NLC was established in 1997 and currently has 25 participating states and counting

(CNPE, 2013). From the time that it was created, the NLC has gone through a number of

revisions to make it into what it is today. The “strengthening of compact enforcement

provisions” and the “requirement for biometric-based criminal background checks” are among

some of these improvements (Evans, 2015). The NLC has ensured they are putting their best foot

forward in regard to patient safety and nurse competency.

The existing state-based licensure model can be extremely expensive and unreasonable

for those trying to acquire and/or maintain multiple licenses. The NLC was designed to remove

that burden for both the practicing nurse and the employment organization who may share some

of the cost (NCSBN, 2017). For example, there are a large number of nurses who live in the four

corners region which includes Arizona, Colorado, New Mexico, and Utah. The application fee

for Arizona alone is $300 while Utah, New Mexico and Colorado are around $100 each. There

are also license renewal periods, which vary from state to state and can occur annually or every

two to four years. With the renewal process comes a fee that can range anywhere from $50 to

$210. Thankfully all four states are part of the NLC, which means local nurses only have to pay

their current State Board of Nursing while having the opportunity to practice in the other

compact states (Ashton, 2016). However, you must pay for the state that you are living in. If you

live in Arizona, you have to pay Arizona’s fees. The cost of these fees vary due to outside

influences and the overall expense of living in said state. Having a system that only requires one

license eliminates unnecessary fees and the headache that comes with them.
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The NLC also increases mobility of nurses and their access to specific patients. With the

growing age of technology comes advances in healthcare, including telenursing services.

However, this become difficult when licensing gets in the way. Telenursing allows a nurse to

provide services for a patient that is not physically in front of them. This expands the profession

into areas that might have been forgotten. A good example is rural areas in which only a few

people live. They often are left without medical attention because of the immense distance

between them and the nearest hospital or clinic. Telenursing also helps with decreasing the costs

of healthcare to patients who previously could not afford it. However, a nurse must have a

license in the state that the patient lives or else they can not perform telehealth services. This

creates a barrier that the NLC is trying to break down.

Another aspect that technology and increased mobility of nurses has influenced is online

education. Online education has a history of being cost effective for both the institution and the

student. Unfortunately, the traditional scope of nursing makes this process due to the number of

licenses one must receive in order to participate. The NLC enables nurses to provide these

services without having to obtain a surplus of licenses (NCSBN, 2017). Another mobility

problem traditionally seen is the amount of time it takes to apply for and receive a license from

another state. Military spouses, along with those who have significant others that tend to relocate

often, find themselves out of work due to the untimeliness of the application process and the

delays associated with the hiring process (CNPE, 2013). With a multistate license, they would be

able to move without worry of being unemployed. The Nurse Licensure Compact enables nurses

to work without barriers caused by immobility.

A multistate licensure would be extremely convenient for nurses who live near state

borders and during strenuous times of need. When disaster hits, nurses and other healthcare
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professionals are the first ones to respond. They believe it is their duty to help in any way

possible. The NLC would allow nurses to cross state borders and perform crucial care for

patients in the event of a tragedy (NCSBN, 2017). During hurricanes, tornados, and other natural

disasters, hospitals become flooded with people in need. They require nurses who are ready to

help even if they have to drive across a state border. Allowing nurses to travel back and forth

between state borders would also reduce staffing issues and promote job opportunities. If a

hospital is short staffed, they might have to pull employees from another part of the hospital or

just try to get through the shift with less people. This often results in poor nursing procedures on

both ends because they are either inexperienced in that particular field or they are completely

overworked and trying to take care of too many patients (CNPE, 2013). Allowing out of state

nurses to come in when a hospital is short staffed would resolve that particular problem and

ensure patient safety. The NLC also promotes job opportunities especially in rural states. North

Dakota implemented the compact in 2004 due to vacant nursing positions they desperately

needed filled. Since their enactment they have discovered the benefits of increasing mobility in

the nursing labor force (Pfenning, 2016). Under the NLC, nurses are allowed to cross state

borders in times of need and help in any way possible.

According to Ashton in her article, “Compact state licensure: Take the ‘fast lane’ to

nursing practice,” there are already federal exceptions in place that correlate with a compact

nurse licensure. The Veteran’s Health Administration which employs almost 80,000 nurses and

cares for about nine million patients participates in a multistate licensure process. The Veterans

Affairs requires one active nursing license in order to be hired. This license can come from

anywhere in the United States or Puerto Rico. They also allow nurses to transfer to another VA

facility site without the loss of benefits or seniority. The Indian Health Service similarly only
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requires an active, unrestricted license from any state in order to practice under them. They care

for Native Americans as well as Alaskan communities in 35 states and employ over 2,700

nurses. Since these two organizations are federally regulated, their practice, education, and

regulations are held to the same standards throughout (2016). With these two services already in

place, it shows that America is ready for a compact licensure agreement.

A compact nurse licensure has also been proven to work outside of the United States. In

1919, the United Kingdom implemented the Nursing and Midwifery Council (NMC) which has

shown success in regulating their nursing profession (Glasper, 2017). A nurse who lives in

England is granted the same license as a nurse in Scotland or Wales. All nurses living in the

United Kingdom share the same standards of nursing practice as well as continued education

requirements and patient safety standards. Since the NMC eliminated these variations, the public

does not have to worry about regional differences because they do not exist (Ashton, 2016).

Someone from Wales could travel to England and expect the same treatment from the nursing

staff as they would in their home country. A nurse would also be able to travel anywhere in the

United Kingdom and practice as long as their license and requirements were up to date.

Every US state uses the National Council Licensure Examination (NCLEX) to test future

registered nurses on what they learned while in school. However, a lot of nursing requirements

vary greatly from state to state (Potter, Perry, Stockert, & Hall, 2017). According to the Congress

on Nursing Practice and Economics (2013), having a national nursing standard would eliminate

the variation between states regarding continued education requirements, type and degree of

criminal background checks, parameters for nurse delegation, and what constitutes disciplinary

actions. The removal of these variations would allow nurses to relocate easier and adjust to their

environment faster. However, equalizing all of these requirements is not as easy as it may seem.
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Every state has their own opinion and legislation. It is difficult to determine what method would

be most effective in measuring the competence and character of every nurse nationwide (CNPE,

2013). Although it may be difficult, a national standard is greatly needed. A nurse from

California should have the same degree of background checks and disciplinary actions as a nurse

from Kansas or New York City. They should also have the same parameters for nurse delegation

because there is an undisputed line between what an aid can perform and what a nurse needs to

execute. Continued education is what varies the most between states. Some states do not require

their nurses to complete any while other states need written documents ensuring their nurses met

their requirements (CNPE, 2013). With variation in nursing standards and requirements comes

variation in the competence and commitment of nurses nationwide.

Knowing the benefits of multistate licensure leads to the question, “why isn’t every state

part of the NLC?” A lot of criticism comes from the idea that patients might be at a greater safety

risk with a nurse’s capability of moving from one state to another so easily. This could mean that

a nurse who is being disciplined by one state board of nursing could potentially leave and

practice somewhere else without the board knowing (Ashton, 2016). In an attempt to resolve

this problem, The National Council of State Boards of Nursing (NCSBN) created a database that

alerts compact states when a license is under examination. This database allows states to

recognize nurses who are subject to discipline for their previous actions or if they are part of a

monitoring agreement (CNPE, 2013). The NLC has done everything in their power to ensure that

the patient comes first and are being treated to the best of the nursing staff’s ability.

Other critics state that the NLC will impact the revenue that state boards of nursing

receive from the registration and renewal fees that nurses must pay in order to work. However,

the National Council of State Boards of Nursing has reported that the revenue lost in this process
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has not been a concern. These compact states have discovered that by omitting the processing

cost, they do not miss the revenue from registration fees. They often end up equaling out but

what remains is the funding for disciplinary actions and investigations. Traditionally these are

covered with the extra fee cost that a nurse must pay to each state. The boards who are not

receiving revenue from licensing and other fees but have nurses practicing in their state end up

with the short end of the stick. They now have to pull money from somewhere else to cover these

expenses (CNPE, 2013). If there was a national standard for nursing, these states would not have

to worry about the cost of disciplinary actions and investigations.

Based on the evidence provided, by cutting expenses, increasing mobility and access to

patients, presenting the convenience and the ability to eliminate variation, a multistate licensure

has proven to be safe, effective, and beneficial to the nursing community. The NLC has been

around for 20 years and has impacted the nursing profession tremendously. Nurses have the

mobility and the capability to function properly in this age of technological advancement. They

have adopted well to the changing environment and have embraced every aspect. However, there

is still work to do and improvements that could be made. Compact states and nurse legislations

are constantly having conversations about what changes can be made to make the NLC even

more beneficial. Non-compact states are also discussing these benefits and considering the pros

and cons to joining the compact. It is just a matter of time before every state is involved in the

NLC and every nurse is held to the same standards.

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References

Ashton, L. M. (2016). Compact state licensure: Take the "fast lane" to nursing practice.

Nursing, 46(12), 50-54. doi:10.1097/01.NURSE.0000504677.11475.b5

CNPE. (2013). Nursing licensure portability. ANA Issue Brief. Retrieved from

http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-

Resolutions/Issue-Briefs/Nursing-Licensure-Portability.pdf

Evans, S. (2015). The nurse licensure compact: A historical perspective. Journal Of Nursing

Regulation, 6(3), 11-16. Retrived from CINAHL.

Glasper, A. (2017). NMC consultation on proficiencies to be met for registration. British Journal

Of Nursing, 26(13), 774-775. Retrieved from CINAHL.

NCSBN. (2017). About the NLC. Nurse Licensure Compact. Retrieved from

https://www.nursecompact.com/about.htm

Pfenning, S. (2016). ND board of nursing embraces the enhanced nurse licensure compact and

APRN compact. Dakota Nurse Connection, 14(4), 15-16. Retrieved from CINAHL.

Potter, P.A., Perry, A.G, Stockert, P.A. & Hall, A.M. (2017). Fundamentals of nursing (9th ed).

St. Louis, MO: Mosby Elsevier. 2.

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Appendix

I. Introduction

a. The NLC has successfully cut down expenses, increased mobility and access to

patients, demonstrated convenience for many nurses while setting a nationwide

standard and remaining safe throughout the process.

II. Cost effectiveness

a. Not having to pay for multiple licenses

b. Removing other unnecessary fees

III. Increases mobility and access to patients

a. Telenursing and online nursing education

b. Allowing military spouses to relocate without hassle

c. Travel nursing

IV. Convenient

a. Natural disasters or other tragic events

b. Short staffing and new job opportunities

V. Sets a standard throughout US

a. All nurses are treated the same from state to state

b. States still keep their power but are regulated

VI. Has been successful and safe

a. Developed 20 years ago, has 25 participating states

b. New England has same concept

VII. Conclusion