Three more states as of July 1 began allowing nurses to practice within their borders under licenses issued by certain other states, doing away with the expense and time of maintaining multiple state licenses.

The Interstate Nurse Licensure Compact-a mutual recognition of licenses developed by the National Council of State Boards of Nursing-is a potential boon to traveling nurses, tele-nurses and RNs who live in one state and practice in another.

Idaho, Maine and Mississippi bring to 13 the number of states that have implemented the compact, accepting the licenses of RNs who live in the other compact states: Arkansas, Delaware, Iowa, Maryland, Nebraska, North Carolina, South Dakota, Texas, Utah and Wisconsin.

Arizona and North Dakota will begin honoring licenses from other participating states in 2002 and 2003, respectively. Lawmakers in Illinois, Georgia and New Jersey are considering multistate licensure.

"We knew this was going to be a gradual impact vs. a light-switch type thing," said Joey Ridenour, MN, RN, president of the national council. "We were hoping for six states a year," which is about the rate at which interstate nursing is spreading.

The Virginia Board of Nursing supports mutual recognition of licenses, so much so that it asked Gov. Jim Gilmore to include it in his 2001 agenda. The General Assembly, however, put it on hold last session, citing cost.

A financial analysis estimated that by joining the compact, Virginia would lose $250,000 a year in license fees from out-of-state nurses, said Nancy Durrett, MSN, RN, the state nursing board's executive director. Many of those Virginia-licensed RNs live in Maryland and North Carolina, populous neighboring states that have joined the compact.

"We have to resolve where we're going to get $250,000 a year before it's going to move forward," Durrett said.

The financial picture is but one hurdle in the decision to join the compact.

In Illinois, the compact has passed the House and awaits debate in the Senate, said bill sponsor Rep. Patricia Bellock, R-Westmont. The debate is expected to center on ensuring that nurses who practice in Illinois under another state's license meet all the criteria that Illinois sets for its resident RNs, Bellock said.

Interstate licensing offers convenience and savings for nurses who maintain more than one license. Some do because they practice in two or more states; others have moved from a state but keep that state's license current because they already have gone through the bureaucracy of obtaining it.

The philosophy behind multistate licensing, though, has less to do with convenience and savings, and more to do with monitoring RNs.

"Our board really views this as a way to enhance our discipline information," said Kristin Hellquist, the national council's associate director of policy and external relations. "As a member of the compact, [states] can share discipline information more comprehensively and more freely within this accord. That's certainly a benefit for public protection."

When it adopted the interstate compact in 1999, the Texas Board of Nurse Examiners sent a primer to its RNs explaining key provisions. Among them is that "the compact creates a coordinated licensure information system … which will include information on the licensing and disciplinary history of each nurse."

Notably, the interstate compact changes disciplinary action from state of practice to state of residence, an acknowledgement that a nurse may not have a license issued by the state in which she is practicing. The compact does, however, allow states to restrict or revoke a nurse's privilege within its borders, regardless of the licensing state. Home states may take disciplinary action against a license based on a violation in another state, the primer said.

It also said that when a nurse changes residence-from a compact state to one that does not participate-her former state's license remains valid, but without the interstate privilege.

The handling of information and complaints is a sticking point for some professional organizations.

The Association of Women's Health, Obstetric and Neonatal Nurses and the American Nurses Association do not endorse the concept of multistate licensing because of information and discipline issues.

"It's not clear that a nurse's home state board would follow up as energetically on a complaint from a remote state because of the difficulty and expense associated with doing that," said Gail Kincaide, executive director of the women's health group.

Furthermore, because nurses are not required to register when they begin practicing across state lines, "it's conceivable that it's going to be difficult for consumers to identify or file complaints about a nurse's practice with the appropriate board of nursing," Kincaide said. "Also, recognize that there are differences in state law regarding confidentiality and privacy requirements, and concern that perhaps then there would be inconsistent treatment of licensure records across state lines."

An independent branch of the National Council of State Boards of Nursing manages the database of nurses from participating states.

Linda Carson, JD, the ANA's nurse practice counsel, called multistate licensure "premature," pointing to the logistics and varying standards of legal defense inherent in multistate practice. An RN facing discipline may have to appear far from her home state for a hearing and satisfy different standards for defense: clear and convincing evidence in one state and a preponderance of evidence in another, Carson said.

Utah, the first state to adopt the Interstate Nurse Licensure Compact in 1998, had little interaction under its provisions until July 1 when Idaho came online, said Laura Poe, MS, RN, executive administrator of Utah's nursing board. It's unknown how many Utah RNs have been using their license to practice in other compact states, Poe said, but more than 200 nurses living in Idaho are practicing in Utah under their Idaho licenses.

In July 2002, the burden of separate state licenses will disappear between Utah and Arizona.

Ridenour, president of the National Council of State Boards of Nursing and executive director of Arizona's board of nursing, said, "I anticipate the large labor states will be the last to sign on" because the ability of nurses to move between states without the time and paperwork to license themselves there can affect the negotiation of labor contracts. "In states where there is a large union contingent, obviously there's a disadvantage for those states to get excited about this."

Patient care tends to transcend license requirements in emergencies, however, Ridenour said. "I think if any state were truly to have potential harm to the public because there was an earthquake or some natural disaster or union activity, we would figure out how to get people licensed."

Ridenour said that a few years ago when North Dakota suffered heavy flooding, "They brought nurses over from Minnesota and did what was right for the public. They said, "We need you to come over and take care of these patients who are acutely ill, and we'll figure out the licensing when you get here.'"

Aside from developing the Interstate Nurse Licensure Compact model and an initial public education campaign, the council's role is informational, not promotional, Hellquist said. "We would never actually seek to introduce something that's outside the boards of nursing," she said.

"There obviously are 15 states that feel wholeheartedly that this is the way to go. Some states do feel passionately that this is not a concept they wish to pursue at this time. It's not mandated. It's not like they've all been given 10 years to complete this.

"I think, quite honestly, some states are just waiting to see how it works," Hellquist said.

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Compact timeline

A chronology of the Interstate Nurse Licensure Compact, from its origins with the National Council of State Boards of Nursing to today:

1997:
The National Council of State Boards of Nursing researches and drafts model legislation establishing mutual recognition of nursing licenses.

1998:
NCSBN delegates endorse the model for states to consider.

March 1998:
Utah adopts the compact, effective January 2000.

February 1999:
Arkansas adopts, effective July 2000.

April 1999:
Maryland adopts, effective July 1999.

June 1999:
Texas adopts, effective January 2000.

July 1999:
North Carolina adopts, effective July 2000.

December 1999:
Wisconsin adopts, effective January 2000.

February 2000:
South Dakota and Nebraska adopt, effective January 2001.

March 2000:
Iowa adopts, effective July 2000.

April 2000:
Mississippi adopts, effective July 2001.

June 2000:
Delaware adopts, effective July 2000.

August 2000:
Maine Gov. Angus S. King Jr. enacts the compact by executive rule, effective July 2001.

February 2001:
Illinois introduces multistate licensing
legislation.

March 2001:
Idaho adopts, effective July 2001; North Dakota Gov. John Hoeven enacts the compact by executive rule, effective in 2003; Georgia introduces legislation.

April 2001:
Arizona adopts, effective July 2002.