1. Shaffer, Franklin A. EdD, RN, DSc
  2. Sheets, Vickie JD, RN


The first state board of nursing came into being in 1903. It was not until about 1980, however, that the last state passed legislation mandating licensure for all RNs. Traditionally, RNs had been licensed to practice only within their state licensure and were required to be re-licensed for every other state in which they wished to practice. This article examines multistate licensure and how this practice will open up wider opportunities for today's registered nurses.


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IMAGINE BEING ABLE to practice wherever your career takes you-with no legal hassles. Imagine traveling from state to state, knowing that your license is valid. Imagine, especially if you work in a border town, answering the help line with no worries about the caller's state of residence. The National Council of State Boards of Nursing has a solution: mutual recognition for nursing licensure.


Currently, licensure for registered nurses (RNs) is administered through each individual state's board of nursing, and while there are different continuing education requirements, practice acts, and regulations, all states require that RN candidates graduate from a state-approved school of nursing (a few states allow equivalent educational preparation). Candidates must also successfully complete the National Council Licensure Examination (NCLEX-RN(R)). While the structure, level of independence, and composition of state boards of nursing differ, most include both members of the nursing profession and consumers, appointed by the governor in most jurisdictions. The purpose of the boards of nursing is to protect the public.


Passing the NCLEX-RN(R) Examination indicates that the nurse has the competencies necessary for entry-level nursing practice. RNs must pass it, and all states have the same passing standard, regardless of the type of program from which the nurse has graduated.


While Florence Nightingale did not approve of licensing and fought it vigorously during her lifetime, early nursing pioneers in the United States saw the need for nursing education standards and pursued governmental regulation of the profession. The first state board of nursing came into being in 1903. It was not until about 1980, however, that the last state passed legislation mandating licensure for all RNs. (Texas and Indiana held out for decades but, in the end, both passed the legislation, with Indiana being the last state to require it.)


Traditionally, RNs had been licensed to practice only within their state of licensure and were required to be re-licensed for every other state in which they wished to practice. As nurses and their spouses became more mobile-and particularly as nurses' incomes became important sources of family income and security-nurses demanded a simpler process for moving their practices across state lines. State boards of nursing offer nurses the opportunity to endorse (or be sanctioned) to other states and become licensed if they already have proof of licensure in one state. Licensure by endorsement requires the nurse to apply to each state and present proof of his or her licensure. This is cumbersome and does not address contemporary needs. Figure 1 is a sample of a resource listing of the 1998 licensure requirements for three states. A complete listing for all 50 states is available from Cross Country TravCorps, Boca Raton, Florida.

Figure 1 - Click to enlarge in new windowFigure 1. Sample resource listing of licensure requirements.

Not only are today's nurses more mobile, but communication technologies are rapidly changing the face and practice of nursing. Telehealth is one example. Call-a-nurse programs and hotlines of various types present a legal problem, particularly for those nurses working near state borders. If the caller is in another state, is the nurse practicing nursing where the nurse is or where the patient is? This is no small matter, given liability exposure for both the nurse and the nurse's employer. It also presents regulatory challenges. Which state grants the nurse authority to practice? To which state's regulations and expectations must the nurse adhere? To which state does the nurse apply for continuing authority to practice through licensure renewal? To which state's standards will the nurse be held?


Moreover, health care providers in one part of the country frequently consult in cases hundreds, even thousands of miles away. With the aid of videoconferencing, fax, and e-mail transmissions, practitioners can participate in operations, review laboratory data, and even perform a virtual physical exam. Telehealth is a major factor in forcing state and federal regulatory bodies to reexamine their antiquated regulatory systems.


All these factors and more prompted the boards of nursing to examine the feasibility of going beyond the current regulatory practices. At the National Council of State Boards of Nursing's Delegate Assembly in August 1997, delegates unanimously adopted the following recommendation: "the National Council of State Boards of Nursing endorses a Mutual Recognition Model of Nursing regulation and authorizes the board of directors to develop strategies for implementation[horizontal ellipsis]." The reasons for endorsing the development of a mutual recognition model (providing a process similar to how driver's licenses are recognized in multiple states) follow:


* New practice modalities and technology are raising questions regarding issues of current compliance with state licensure laws.


* Nursing practice is increasingly occurring across state lines.


* Nurses are practicing in a variety of settings and using new technologies that may cross state lines.


* Expedient access to qualified nurses is needed and expected by consumers, without regard to state lines.


* Expedient authorization to practice is expected by employers and nurses.


* The current practice of requiring nurses to present the same licensure qualifications to multiple states for comparable authority to practice is cumbersome and neither cost-effective nor efficient.



The mutual recognition model of nursing licensure endorsed by the national council is based upon an agreement among states, called an interstate compact, to recognize nursing licenses from other states. According to Black's Law Dictionary: "An interstate compact is an agreement between two or more states established for the purpose of remedying a particular problem of multistate concern." Thus an interstate compact for nurse licensure is an agreement among states to coordinate certain activities associated with nurse licensure and is designed to reduce multiple licensure requirements, enhance information sharing, and establish mechanisms for disciplinary actions associated with interstate practice. An interstate compact supersedes state laws and may be amended only by agreement of all party states. Through these compacts, nurses already licensed in one compact state would be allowed the privilege of practicing in any other state that has signed the compact, as long as the nurse acknowledges that he or she is subject to each state's practice act and discipline. Practice across state lines would be permitted, wherever the nurse and patient happen to be and whether the practice is "in the flesh" or via a high-tech device. Thus nurses would have only one licensing record, presumably making it easier to track individual nurses. This model supports the public's protection, increases access to nursing care, and makes nurses' lives a little easier.


The compact provides for the head of the nurse licensing board, or his or her designee, from each board participating in the compact to be a member of the Nurse Licensure Compact Administrators (NLCA.) The NLCA is responsible for compact administration and the exchange of information among compact states.


The NLCA and the national council are supporting states that adopt the compact. The compact calls for a centralized licensure information system to be operated by a nonprofit organization comprised of state boards of nursing. The national council has developed such an information system. Nursys was pilot tested in 1999 and implemented in March 2000. Nursys provides significant safeguards to protect the licensee's privacy. The information provided via Nursys will be useful to the profession. Health care facilities will also benefit because nurses will be more mobile, and the centralized database provides institutions with a one-stop source to verify a nurse's qualifications to practice. The interstate compact became effective when two jurisdictions enacted it into law. On March 14, 1998, Utah governor Michael Leavitt signed Senate Bill 146, the Nursing Regulation-Interstate Compact Bill, with an effective date of January 2000. By this action, Utah became the first state in the nation to adopt into law the concept of the mutual recognition of nursing licenses. In February 1999 Arkansas became the second state to sign this bill into law. As of September 1, 2000, ten additional states have entered the compact. Arkansas, Delaware, Iowa, Maryland, Mississippi, Nebraska, North Carolina, South Dakota, Texas, and Wisconsin have adopted the compact. Maine has been authorized to implement the compact by rule. In addition, Idaho has proposed legislation under consideration and several other states are in the early stages of legislative development. An updated map of state compact bill status is available at


Today's technology, combined with strong consumer and nursing support, makes it difficult to find reasons to oppose mutual recognition. But there are concerns. From the national council's point of view, some of the money generated by nurses who pay for their renewals in more than one state will be lost, and the administrative costs of state-level negotiations pertaining to the compact will require additional funding of board operations. The cost of the database for tracking and coordination will be an added expense. The national council and individual boards are currently looking for new funding sources for this program.


The Nursing Community Responds

Reaction by nursing organizations to the concept of mutual recognition has been mixed. Several groups, including the American Association of Occupational Health Nurses, Inc.; the American Association of Poison Control Centers, Inc.; and the Air and Surface Transport Nurses Association have expressed support for the compact.


However, some nursing groups, including the American Nurses Association (ANA); the Association for Women's Health, Obstetric, and Neonatal Nurses; and the National Association of Pediatric Nurse Associates and Practitioners have expressed serious concerns, which include:


* licensure linked to state of residence


* lack of uniform licensure requirements


* confidentiality and information sharing


* discipline issues


* potential for increased licensing fees


* separate compact and timeline for advanced practice nurses


* access to laws, rules, regulations, and other practice-related information


* facilitation of strike breaking



Each of these concerns has been carefully considered by the NLCA (the governing group for implementation of the compact) and the national council. The implementation of mutual recognition has benefited from numerous discussions with the ANA, a number of its state associations, other nursing groups, and the practice community. While compacts have been used for years to resolve a number of interstate issues, this is the first time such an approach has been used in the regulation of professionals. Whenever a new concept is put into practice, there are challenges. The unexpected becomes, in a sense, expected. The NLCA meets regularly, via telephone conference, and has developed rules, policies, and procedures. The compact states are in frequent consultation as the day-to-day implementation of mutual recognition has begun.


The NLCA and the national council continue to work toward the goal of establishing mutual recognition nationwide. For tomorrow's practitioner, mutual recognition promises to open more doors for working in a seamless global community. The authors believe that nurses need to be prepared to capture the opportunities. Every nurse can begin preparing by assembling his or her own professional development portfolio, consisting of the important documents relative to requirements for licensure, certification, performance evaluations, and lifelong learning. More resources are becoming available to help nurses develop a career portfolio. Each nurse can become involved with efforts within their state to promote mutual recognition. Find out what your nursing board's position is on mutual recognition and begin making your opinion known on this issue.


The future is here-and mutual recognition offers new opportunities for nurses to practice in new ways.