NationalInterstate Council of

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• National-Interstate Council of
• State Boards of Cosmetology (NIC)
• August 26, 2006
• Portland, Maine

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Standing the Test of Time

• Mutual Recognitionand theNurse Licensure Compact

Myra A. Broadway, JD, MS, RN Executive Director,
Maine Board of Nursing
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The year was 1903

• World Series had begun
• Wright Brothers took flight
• Ford Motor Co. was founded
• Telephone had been in existence 27yrs
• Computer would not be invented for
• another 43yrs (1946)
• NY, NJ, VA, NC passed the
  first Nurse Practice Acts in US

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Much has changed . . . except regulation
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Progression of Regulation

• Based on the 10th Amendment to
  the U.S. Constitution
• Legal authority to practice
  confined to the boundaries of the state which
  issued the license
• Evolved state-by-state to meet the needs of the
  citizens of that state

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Early Efforts to Regulate Nursing Practice

• Each state had its own requirements
• Hospitals trained their own
• States wrote their own examinations

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Times Change

• More mobility
• Nursing programs more uniform
• Nursing programs accredited by same
  organization(s)
• Eventually one test is written to be used
  nationally
• An arm is an arm is an armWe are more
  alike than we are different

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Factors Influencing a Re-Look at Licensure (Mid
1990s)

• Healthcare Delivery System Restructuring
• Managed care/capitation
• Movement away from acute care
• Mergers and acquisitions resulting in large,
  integrated health care delivery systems
• Emergence of Demand Management Call Centers and
  Telephone Triage

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Factors (continued)

• Technological Advances
• Acceptance of World Wide Web/Internet
• Telephone
• Computers
• Videoconferencing, teleconferencing
• Advanced electronic diagnostic technologies
• Robotics

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Factors (continued)

• Consumerism
• Growing expectation for health care information
• Expectations for information about treatment
  options and inclusions in decisions about their
  own treatment plan
• PEW Taskforce on Health Care Workforce
  Regulation, 1995 1998

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Factors (continued)

• Telecommunications Act of 1996
• Barrier Report to Congress 1997
• Changing health care environment
• New practice setting and technology
• Necessity of expedient access to qualified nurses

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Factors (continued)

• Increased number of nurses practicing across
  state lines
• Expectation of rapid authorization to practice
• Qualification for licensure in multiple states
  (cumbersome, costly inefficient)
• Telenursing
• Boards of Nursing need authority to regulate
  in-state practice

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The National Council of State Boards of Nursing
(NCSBN) Definition of Telenursing

• The practice of nursing over distance, using
  electronic means

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Telenursing

• Delivery of patient care by means of
  telecommunication
• Telephone
• Facsimile
• Cellular phones
• Computers
• Teleconferencing
• Videoconferencing

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Telenursing Differs from Other Telepractice

• Physician consultation generally involves a
  licensed practitioner in each state

• Telenursing generally involves the nurse being in
  direct contact with the patient, frequently in
  the patients home or by telecommuni-cative
  means

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Regulatory Issues
?

• States right or Interstate Commerce 200 years
  of case law ruled that states have the right to
  protect consumers.
• Where does practice occur location of provider
  or patient?
• Does practice by electronic means constitute the
  practice of nursing?

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Dilemma What model of nurse licensure is best
for the 21st century?

• Licensure remains state based
• Practice is not bound by state lines

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Vision Statement

• A state nursing license recognized nationally
  and enforced locally

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Policy Goal

• Simplify governmental processes
• Remove regulatory barriers to increase access to
  safe nursing care

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Delegate Assembly Actions

• 1994 - Task Force to Study Regulation
• 1995 - Regulation Task Force charged to consider
  models Telecommunications Task Force authorized
• 1996 - Study Issue (magnitude of need, impact on
  state regulatory processes)
• August 1997 - Endorsed Mutual Recognition Model
• December 1997 (special) - approved Interstate
  Compact

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Models Considered

• Reciprocity
• Fast Endorsement
• Corporate credentialing (institutional licensure)
• Ontario Model
• Mutual Recognition
• Limited License for Telehealth

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Solution Mutual RecognitionA state-based
license, nationally recognized locally enforced

• Multi State Regulation (MSR) Task Force
• Surveys, interviews, conferences
• Best model to protect public decrease barriers

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Basic Concepts of Mutual Recognition

• Allows nurse to have one license in the state of
  residence and practice in party states
• Nurse is subject to each states practice laws
  and discipline
• Practice allowed physically or electronically
• Each state must enter into interstate compact

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Panel of Legal Experts

• Mutual recognition is workable
• Reflects full faith and credit among U.S.
  jurisdictions
• Can be implemented incrementally
• Implementation could begin without uniform
  requirements

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Why is the individual in the NLC limited to one
license in the home state?

• The policy decision was made specifically to
  enhance public protection while retaining state
  based authority reducing administrative burdens

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• Determining the state of practice would be
  challenging in an era of multiple employers, at
  multiple sites across state lines through
  telenursing

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• Tracking a nurse in the event of a complaint is
  better accomplished through residence than the
  employment link

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Effects of Mutual Recognition

• Nurses
• Public
• Health Care Institutions
• Government
• Revenue

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First Compact Adopted 1783

• Nurse License Compact (NLC) is one of 200
  compacts
• Average compacts per state 27
• NLC Allows for One License in Home State

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Interstate Compact

• Formal agreement between 2 or more states to
  remedy a problem or multi-state concern (Blacks
  Law Dictionary)
• Each state enacts a compact via legislation
• Mutual recognition of those who enact the
  legislation

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• Affords states the opportunity to develop self
  regulatory adaptive structures to meet new
  challenges over time
• Example - Drivers License Model

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Examples of Interstate Compacts (IC)

• Interstate Compact for the Placement of Children
  (1960s)
• IC for Supervision of Parolees and Probationers
  (1937)
• IC for Juveniles (developed between 2000 and
  2002) in 35 states
• Dairy Compacts

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General Purposes of the Compact

• Facilitate the states responsibility to protect
  the publics health and safety
• Ensure and encourage the cooperation of party
  states
• Facilitate the exchange of information
  between party states

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Purposes (continued)

• Promote compliance with the laws governing the
  practice of nursing in each jurisdiction
• Invest all party states with the authority to
  hold a nurse accountable

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Nurse Licensure Compact Addresses

• Jurisdiction
• Discipline
• Information Sharing
• Compact Administration

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1) Jurisdiction

• Nurse is licensed in state of residence (home
  state)
• Nurse may only have one license
• Nurse is granted the privilege (via the Compact)
  to practice nursing in other party states, i.e.,
  remote states

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2) Discipline

• Complaint is filed where violation
  occurs
• Board takes action on privilege to practice and
  issues an Order
• State of licensure notified

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• Complaints in a party state are processed
  reported to the home state
• The party state may revoke the privilege issue
  a cease desist order the home state may take
  action against the license
• The party home state agree on who will
  investigate so the information is taken only once

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• The home or remote state(s) may take disciplinary
  action
• Only the home state can take action on the
  license
• The remote state (where the violation occurred)
  may take action allowed by the state
• Any party state can deny authority to practice

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3) Information Sharing NURSYS

• A comprehensive information system containing
  data on all nurses
• Coordinates existing and future nurse databases
• Used to verify nursing licenses

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4) Compact Administration

• Authorizes the formation of the Compact
  Administrators Group
• A separate body composed of participating state
  board administrators in charge of the states
  compact operations is called the Nurse Licensure
  Compact Administrators, or NLCA
• Authorizes the development of rules and
  regulations to administer the Compact

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Current Model

• Vs
• Mutual Recognition
• How do they compare?

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Initial Licensure

• Current Model
• Apply/pay fee to state(s) where expect to
  practice
• Comply with each states requirements for
  licensure (not uniform)
• Practice only in state(s) where licensed

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• Mutual Recognition
• Apply and pay fee to home state
• Comply with home state licensure requirements
• Practice in any party state

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Moving to a Party State

• Both
• Apply and pay fee to new state
• Meet requirements for new state
• Current Model
• May hold multiple licenses
• Mutual Recognition
• Only one license

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License Renewal

• Current Model
• Accountable for each states renewal requirements
  
• Renew in every state where license is held
• Mutual Recognition
• Accountable for home states renewal
  requirements
• Renew in home state only

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Lapse -- Re-Entry -- Reinstate

• Both
• Inactive status depends on laws of state
  licensure
• Current Model
• Apply to each state, according to states laws
• Mutual Recognition
• Apply to home state

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Discipline

• Both
• Action by state where patient was (or where
  incident occurred, if no patient)
• Standards used are those of disciplinary state
• Mutual Recognition
• Licensure action taken only by state of
  licensure
• Remote state may apply non-licensure penalties,
  such as fines or cease-and-desist orders

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Advantages of Mutual Recognition to Nurses

• Pay for one license
• Practice in any party state without obtaining
  additional license
• NURSYS facilitates endorsement
• Eliminates barriers to practice

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Advantages to Boards

• Public protection
• Jurisdiction over all nurses practicing in the
  state
• Unduplicated count of nurses in the country

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Major Concerns

• Sharing investigative information may violate the
  nurses right to privacy
• Licensure based on state of residence instead of
  state of practice
• Compact only applies to RNs
  LPNs
• Strike breakers in collective
• bargaining states
• Revenue loss subsequent
• increase in licensing fees

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Pros Cons
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Pros

• Drives uniform standards
• Facilitates mobility and lawful practice
• Facilitates continuity of care for consumers
• Reduces duplicative regulatory processes
• Allows state regulatory agencies to reallocate
  resources
• Discipline
• Global decision-making

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Cons

• Will take time
• Requires legislation in each participating state
• State BON rules, regulations and procedures will
  need to change

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How is the NLC Implemented?

• When enacted, a compact constitutes not only the
  law, but a contract which may not be amended,
  modified or otherwise altered without the consent
  of all parties. The legislative sponsor may
  need to be reminded that legislation must have
  substantive sameness, be identical or mirror
  the legislation in other states or the compact
  may not be binding or recognized by other states.

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Implementation
Colorado, Kentucky New Jersey are members, but
not yet implemented
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Two Words Sum Up What Is Needed to Make the NLC
Work

• FLEXIBIILTY

• TRUST

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Working Together to Enhance Public Safety

• FLEXIBILITY
• We are all in this together and solving my
  licensure issue isnt good enough if I dont
  provide you the information you need to act.

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• TRUST
• Nobody does it better

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Keys to Success
Education Collaboration
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• Communication and Collaboration are the keys to
  Compact Implementation success
• Our successes and challenges are not unique
• - A new initiative from the Council of State
  Governments
• - How can we learn from the experience of others?
• Our policies address communication
• Strategies for improving communication and
  collaboration

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Rules Highlights

• Evidence of state of residence
• Work up to 30 days after move
• Limitations on probation
• Licensee may challenge information

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Findings of States in the Compact

• The expanded mobility of nurses the use of
  advanced communication technologies require
  greater coordination cooperation among states
  in the areas of nurse licensure regulation
• 2) New practice modalities
  technology make compliance with
  individual state nurse licensure laws
  difficult complex

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• The current system of duplicative licensure for
  nurse practicing in multiple states is
  cumber-some redundant to both nurses AND states
• Nurses do not always want to give up the first
  state of licensure need advance education
  notice regarding the change

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• The message needs to be framed in many different
  ways for nurses, employers, recruiters ONE
  license for each type and no more is permitted by
  the state of residency

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• The legislation to enact the NLC must mirror
  language in all party states. Legislation
  materially different has resulted in states not
  being able to join the NLC In order to join the
  NLC, state legislators must enact the compact
  into state law or regulation.

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• What is meant by the multi-state licensure
  privilege? Multi-state licensure privilege means
  the authority to practice in any compact party
  state.
• Human Resource staff need non technical
  explanations of the compact requirements. HR
  staff also need assistance education on how to
  validate licenses from other states. Some
  mistakenly assumed they did not need to validate
  in the home state declared by the applicant

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• What determines primary state of residence?
• NLC defines primary or home state in the compact
  rules regulations.
• Sources to verify primary residence may include
  drivers license, state where federal income tax
  is paid voter registration

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• Does the NLC reduce states licensure
  disciplinary requirements?
• Under the NLC, states continue to have complete
  authority in determining licensure requirements
  disciplinary actions based on the states Nurse
  Practice Act
• The NCLA carefully studied the various licensing
  requirements agreed upon the core requirements
  all party states are to enact

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• Does the NLC affect the primary states authority
  to discipline?
• The NLC actually enhances the states ability to
  discipline through the full disclosure exchange
  of disciplinary investigative information
• Consider assigning specific investigative staff
  to the NLC complaint cases to gain experience in
  learning how to track, expedite share case
  information

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• Case law assists in better understanding how the
  compacts have been interpreted by the courts
  informs the NLCA how to better understand the
  context of the law/contract
• Examples of Compact Case Law
• Compacts are not uniform laws but contracts that
  may not be altered without the consent of all
  parties (Nebraska v Cent. Interstate Low Level
  Radioactive Wast Com.)

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Examples (continued)

• Compacts are not mere administrative agreements
  but solemn treaties between states (Rhode Island
  v Massachusetts)
• Compacts are both binding in state law a
  contract between states that no one state can
  unilaterally act in conflict with the terms of
  the compact (McComb v Wambaugh)

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Compact Development

• Challenges
• 1 Educating legislators others
• 2 Drafting language to mirror other
  states
• 3 Determining funding needs revenue
  resources
• 4 Balancing compact jurisdictions with
  member state sovereignty

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Communication

• There are obstacles
• Different Board Structures
• -- Umbrella vs independent
• -- Investigations Legal in different
  departments or agencies
• Identification of key contacts
• Resources

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Grassroots Lobbying Efforts

• Identify Key Stakeholders
• - BONs
• - Professionals
• - Employers (multi-state HMOs, travel agencies)
• - Nurse executives and recruiters
• - Organizations and associations
• -- State nurses associations specialty orgs
• -- State hospital associations
• -- Consumer groups (AARP)
• - Legislators (nurse, healthcare providers)

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Lobbying Efforts (continued)

• Educate, educate, educate
• Widespread informational campaign (include
  advantages and concerns)
• Identify message(s)
• --(i.e. efficiency, access, jurisdiction,
  technology)
• May use different message for different audiences
• Utilize media contacts

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Lobbying Efforts (continued)

• Identify key legislative sponsors
• Provide testimony (verbal written)
• Organize letter writing campaigns
• Organize telephone trees

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Emerging Issues Future Potential Compacts

• Criminal Justice Information Sharing would
  allow multi-jurisdictional access to criminal
  justice information
• Emergency Medical Assistance compact for
  interstate cooperation for medical assistance

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A New Initiative from the Council of State
Governments

• Formed the National Center for Interstate
  Compacts
• - Combines policy research with best practices
• - Designed to meet the unique needs of Compact
  Administrators
• - Promotes interstate compacts as an ideal tool
  to meet the demand for cooperative state action
• Conducted a 2004 Survey of interstate compacts in
  50 states.

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• The End!