The image of COVID-19 as it appears in emergency rooms and ICUs is not a pleasant one. Around the world, pandemic-based labor shortages have left hospitals perennially low on nursing staff. With their backs to the wall, regulators across all industries have been incentivized to take drastic measures to boost the ranks of their workforces. Many have expedited licensing processes, some by easing restrictions within their fields. In the field of nursing, several regulators have turned to a multijurisdictional charter with origins in the 1990s — the Nurse Licensure Compact (NLC).
In this article, we will look at the history of the NLC, the ways COVID-19 has led to its growth, and trends regarding its future implementation in the U.S.
The NLC’s 20th-century origins
The National Counsel of State Boards of Nursing (NCSBN) began to see inefficiencies with a state-by-state licensure system as early as 1995. That year, the Pew Commission released a report entitled Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century. The report argued that single-state licensure would continue failing to meet health care needs and expectations in the future if an alternative wasn’t proposed. According to the commission, single-state licensure was costly, restrictive, and only vaguely related to quality of care. The strengths of these arguments would reveal themselves over the next 26 years, especially in the wake of the COVID-19 pandemic.
When NCSBN first attempted putting together a multijurisdictional licensing model, they strove for a handful of primary goals. Board leaders and focus groups agreed that a better regulatory model would uphold permeable state boundaries to interstate practice. The same model, according to NCSBN, would have a clear source of legal authority with the power to make final decisions on practice and discipline across state lines. Of course, the model would also require common and reasonable standards for credentialing and practice.
Though practice was (and remains) subject to each state’s unique regulations, NCSBN created a mutual recognition licensure model in 1997 — a precursor to the NLC. Nurses with the appropriate license would be able to practice in other compact states. Ideally, the model would grow over time as legislation passed in each state to adopt it. Two years later, in 1999, the official NLC was released. The compact, focused on registered nurses (RNs) or licensed practical/vocational nurses (LPNs/VNs), created uniform rules and policies for all participating states. By 2000, Texas, Wisconsin, and Utah had become the first states to join the compact.
Eventually, NCSBN’s Advance Practice Registered Nurse (APRN) Advisory Committee sought to establish a parallel contract for APRNs under their purview. The APRN Compact was released in 2002, but after being adopted by only three states — none of which fully implemented the model — NCSBN overhauled it by adding a “Consensus Model,” which would create uniformity in practice, education, and regulation, in 2008. After several years of virtual impotence, a viable multijurisdictional model for APRNs had begun to take shape.
Trials and criticisms
The NLC, in its first heyday, was not without its detractors. For example, The Ohio Nurses Association (ONA) spoke out against adopting the compact within their state, arguing that Ohio regulators would lose control over a large part of the licensure process, that they would be unable to effectively fulfill their mandate to serve the public with this loss of power. ONA leaders also pointed out that states would have to pay NLC fees while missing out on revenue from licensure fees new nurses would ordinarily pay.
There was also the matter of disciplinary infractions. If a nurse’s infraction in one state merited a harsher penalty than in another state, how would the NLC ensure someone received the appropriate amount of disciplinary action to practice in the new state? Legal issues, too, complicated the compact, according to the ONA. In certain states, certain convictions can bar a nurse from practice entirely, while other states are more lenient. The ONA argued the NLC did not recognize or litigate these issues in any satisfactory way.
While as many as 25 states joined the NLC by 2015, they suddenly ceased, fearing some of the very same weaknesses highlighted by the ONA. Specifically, new states had a legitimate concern that the multi-state compact could not ensure competence and educational qualification well enough to protect the interest of the public. In response, NCSBN developed a new model, known as the Enhanced Nursing Licensure Compact (eNLC), in 2015. With 31 states having joined the compact by just 2019, the new model responded to many of the issues state regulators had formerly taken with the NLC.
The eNLC
The new compact made many changes and additions to NCSBN’s original model, including the addition of uniform license requirements (graduation from a program required by a board of nursing; passing of applicable license exams; extant licensure in the nurse’s home state), background checks, and extensive provisions regarding disciplinary action. For example, state regulatory boards now have the power to take action against a nurse’s eNLC license if their disciplinary charges would warrant the same treatment under a single-state license.
An example of the eNLC’s new disciplinary provisions can be found in the case of an RN (originally holding a Tennessee license) who faced sanctions with multiple states in 2016 because of an incident that occurred via telehealth practice in West Virginia. Though she held a multistate license to practice telemedicine, her APRN license in Texas afforded her certain privileges which her West Virginia license did not. Without any face-to-face contact with patients, she wrote prescriptions for patients in West Virginia despite having no relationship with them. In the wake of this incident, it was Texas that first acted against her license, which the nurse eventually surrendered of her own volition.
By July 2017, North Carolina had become the 26th state to implement the new compact. The transition toward the eNLC occurred between 2017 and 2018, over a period of about six months. As of January 19, 2018, nurses who held any type of NLC license would no longer be able to practice if their states did not switch to the eNLC. Thus, a new multijurisdictional model, one in which states had uniform credentialing standards, the ability to obtain criminal background checks on nurses, and the responsibility to report all disciplinary measures to NCSBN, replaced the old NLC.
The NLC, COVID-19, and the future
We will henceforth refer to the eNLC as the NLC, reflecting its naming on the NLC website.
More U.S. states were slowly enacting the NLC right up until the outbreak of COVID-19, which created staffing shortages that raised the stakes and forced some regulators to speed up the process. New Jersey, for example, had planned to implement the NLC over the course of 2020, but as emergency declarations allowing multijurisdictional practice for nurses swept the nation, the state took more drastic measures. State officials partially implemented the compact, and nurses from other states with NLC licensure were instantly allowed to work in New Jersey.
As of late 2020, the Nurse Licensure Compact had been enacted by 32 states. A study from the National Library of Medicine on strengthening the workforce in the wake of COVID-19 argues that the compact represents merely one step on the road to national licensure for nurses. In addition to allowing specialists to step in and help underserved communities, researchers posit that building toward national licensing generally “allows the flexibility to rapidly relocate healthcare providers where need surges (as in COVID-19 outbreaks).”
To many, the NLC represents a bold new approach to the licensing of nurses within the U.S. But this isn’t necessarily even the end goal for the idea of multijurisdictional practice. Thinking about it on a larger scale, we can understand the arguments put forth by some researchers that this compact is merely a transitional step toward national licensure in the profession. With more than half of U.S. states now having implemented the NLC, it is only a matter of time before its prevalence sparks a debate over creating and enforcing uniform licensure standards for nurses throughout the nation.
