Mutual recognition erases state boundaries on nursing licenses

Enables telenursing, practice in other states

Imagine the inconvenience of having a driver’s license that was good only in your state of residence. If you wanted to drive the roads of a neighboring state, you’d have to arrange to get a second license. That is something like the situation in which many occupational health nurses and nursing professionals in other specialty areas found themselves until recently.

Historically, nursing licenses, like medical and other professional licenses, have permitted nurses to practice in their states of residence where the licenses are issued — not very convenient for an occupational health nurse employed by a company that has locations in six states.

But a growing number of states — 18 so far, with another dozen or so contemplating legislation — have passed laws permitting nurses to practice in states in addition to their states of residence under a mutual recognition model, the nurse licensure compact (NLC). (See chart for list of states that already have passed NLC legislation.)

Go where work leads

The compact allows for ease in getting nurses where they’re needed in times of emergency — after hurricanes and other natural disasters, or in the wake of man-made disasters. But more frequently, it will allow nurses to practice their profession in areas that once were off-limits, according to Don Bollmer, director of business affairs for the American Association of Occupational Health Nurses (AAOHN).

AAOHN has been a supporter of the NLC, urging passage of the compact so nurses residing in compact states would be able to practice in other compact states without applying for separate licenses.

"We have a member in Texas who works for a refinery that has facilities in Alaska," he explains. "She has had to be licensed in Alaska and in Texas, but what she is finding is that technically she can’t really practice in Alaska because she’s not a resident."

According to information supplied by the National Council of State Boards of Nursing (NCSBN), the mutual recognition model of nurse licensure allows a nurse to have one license in his or her state of residency, and to practice in other states (both physically and electronically), subject to each state’s practice laws and regulations. Under mutual recognition, a nurse may practice across state lines unless otherwise restricted.

"Mutual recognition of a license increases nurse mobility and facilitates delivery of health care by innovative communication practices, such as telenursing," says Katherine A. Thomas, MN, RN, executive director of the Texas Board of Nurse Examiners. Texas enacted the NLC in 2000. "Additionally, it will better promote the public health and safety by encouraging cooperative efforts among the party states in nurse licensing and regulation.

For a nurse to take advantage of mutual recognition, each state in which he or she wants to practice must enact legislation authorizing the NLC. States entering the compact also adopt administrative rules and regulations for implementation of the compact. The nurse also must apply to the nonresident state for recognition of his or her license.

Once the compact is enacted, each compact state designates an NLC administrator to facilitate the exchange of information between the states.

Since 1998, the NLC has included RNs and licensed practical or vocational nurses (LPN/VNs). In 2002, the NCSBN Delegate Assembly approved the adoption of model language for a licensure compact for advanced practice registered nurses (APRNs), which may be implemented only by the states that have adopted the RN and LPN/VN NLC. In 2004, Utah became the first state to enter the APRN compact.

The legislation makes all licensed nurses in the compact states eligible to practice in other compact states, with employers responsible for verifying their licensure status through their home states and/or the basic licensure information and disciplinary history provided through NCSBN at www.ncsbn.org.

Some nursing specialties always have had a need to move between states, but occupational health nursing is relatively new to that world, Bollmer says.

"Occupational health nurses once were very facility based, and now they’re not," he says. For example, in addition to providing telehealth and case management services across state lines for their employers, nurses who operate as consultants likewise want the freedom to move across state lines, he points out.

Questions about licenses

The NCSBN began the process of creating a nurse licensure compact in 1996 at its national assembly, when delegates voted to investigate different mutual recognition models and report their findings. That was followed a year later by a unanimous endorsement for pursuing mutual recognition on a state-by-state basis.

Understandably, nurses and state nursing boards have questioned the implementation and effect of the NLC on the way licenses are granted and recognized, and how states will handle violations and disciplinary actions.

According to information provided by NLC spokeswoman Dawn M. Kappel, questions have arisen regarding:

What is the effect on licensure requirement? Even if a state enacts the NLC, it retains complete authority to determine its licensing requirements and disciplinary actions according to its Nurse Practice Act;

Which state’s practice laws apply? A nurse who practices in compact states is required to comply with the nurse practice laws where he or she is treating a patient, just as a driver licensed in one state is required to follow traffic laws in any state in which he or she drives.

How are violations handled? Complaints against nurses are handled in the state in which the violation allegedly took place, and are reported to the states that issue their licenses. According to the NCSBN, many compact states investigate complaints in the state where the alleged violations occur, and then transfer the information to the state board that licensed the nurse (his or her state of residence), so that disciplinary action is taken only once.

However, the Nurse Practice Acts of most states (including non-NLC states) authorize nursing boards to take action based upon action taken in another state, meaning that a nurse who has his or her license disciplined in one state is likely to also face action in all other states of licensure, just as under the traditional system of single state licensure.

A coordinated licensure information system has been developed to enable the sharing of information between compact states; all information involving any action is accessible to all NLC states, and some of it is available to noncompact states.

Is a nurse’s license automatically recognized by compact states if his or her state adopts the NLC? No. The licensing authority in a compact state where an application is made may choose not to issue a license to an out-of-state nurse if the applicant does not meet that state’s qualifications for granting a license.

More states targeted

About 13 states are debating whether to adopt mutual recognition legislation. AAOHN, along with state boards and other nursing associations, is urging them along.

"We have targeted three states, where we have large, active membership numbers but where there was not licensure compact legislation, and where we thought [AAOHN] members would be traveling across state lines regularly," Bollmer points out.

The states AAOHN is concentrating efforts in are Georgia, Illinois, and Michigan.

Georgia will not introduce compact legislation this year, Bollmer notes, so efforts are going toward persuading Georgia legislators of the benefits of mutual recognition.

The state has two boards of nursing — one for registered nurses, and one for licensed practical nurses, and the two boards share one "very overworked" staff, he explains.

"We are working with the boards of nursing as well as with our members and leadership in other interested organizations to educate the board members about what this is and why it’s necessary to get their blessing before moving on to the legislature," Bollmer says.

Illinois has legislation on the licensure compact on its way to committee. Michigan, like Georgia, is still a year or so away from introducing legislation, he estimates. "All in all, it’s progressing nicely."

[For more information, contact:

  • Don Bollmer, Director, Business Affairs, American Association of Occupational Health Nurses, 2920 Brandywine Road, Suite 100, Atlanta, GA 30341. Phone: (770) 455-7757. E-mail: don@aaohn.org.
  • Katherine A. Thomas, MN, RN, Executive Director, Texas Board of Nurse Examiners, 333 Guadalupe #3-460, Austin, TX 78701. Phone: (512) 305-7400.]