When a Sanford Health hospital in North Dakota received an influx of patients recently, the parent organization was able to send nine critical-care nurses from a hospital in South Dakota to help.
The drive took nearly four hours. But if the states weren’t part of a compact that allows nurses to practice across state lines, the licensing process to let those nurses practice in North Dakota would have taken weeks or even months .
The compact is vital to Sanford, said Meghan Goldammer, senior vice president for nursing and clinical services.
“Healthcare doesn’t stop at state lines,” she said. “Those patients in the critical-care unit in North Dakota potentially would’ve had to travel somewhere else, taking the family away from their home and livelihood.” It could also jeopardize the patient’s health, Goldammer added.
Providers like Sanford support adding more states to the interstate licensing compacts because it would allow them to be nimbler and adapt to fluctuating demand. Getting licenses for individual states is a major drain on medical professionals’ time and resources. They also contend the current system limits providers’ ability to follow up with patients in noncompact states and treat them via telemedicine since licenses are based on where the patient is, not the physician or clinician.
Sanford has an internal group of about 50 travel nurses who can move seamlessly to the states in the Nurse Licensure Compact. Currently 29 states are in the compact, with Louisiana and Kansas joining in 2019 and legislation pending in a few other states. This is particularly helpful as many of the health system’s nurses near retirement, which is expected to widen the gap between the available supply of nurses and the growing demand. It also makes a big difference for Sanford’s rural facilities, which typically struggle to attract employees.
Sanford spends less on locum tenens, or temporary nurses, and can maintain the same level of care quality and continuity, Goldammer said.
The health system can send nurses freely to each state it operates in, except for one—Minnesota.
“It would be a huge benefit if they would join the compact, especially for our patients,” she said. “When we need to send a nurse to Minnesota, it requires a nurse to apply for a separate license, which could set us back two to three months.”
But the compacts are opposed by representatives of labor unions who say that granting interstate licenses cedes control. They argue that the compacts create a loophole that invites lower-quality medical professionals with questionable backgrounds. Unions also claim that in the states where they are active, continuing education requirements, among other mandates, are more stringent than others.
“State governments believe it is their obligation to make sure someone rendering care in their state meets the state legislature’s standards,” said William Horton, a partner at law firm Jones Walker, adding that states are eager to retain their policing ability. “Keeping control within the licensing process also means those who have licenses have some degree of protection from competitors.”
In addition to nursing, there are compacts for physicians, physical therapists and advanced practice registered nurses. The physician compact, or interstate medical licensure compact, includes 24 states while the physical therapist compact has 21 states. Three states are part of the advanced practice registered nurse compact.
The nursing compact works a bit differently than the agreement for physicians. When nurses earn their interstate license, they can immediately practice in any participating state. Physicians with their interstate license still have to apply through individual states, although they can do so in a matter of days rather than three to six months. This also gives state medical boards some control.
The National Council of State Boards of Nursing implemented the nursing compact in 2000, driven by the introduction of new technology that required a more fluid licensing process. By 2015, it had 25 members. The second iteration of the nursing compact took effect in January and 24 of the 25 original states signed on, with Rhode Island not participating this time around after union pushback.
The enhanced nursing compact includes a list of uniform licensing requirements, as well as federal and state criminal background checks to ensure that the nurse has no state or federal felony convictions or misdemeanor convictions related to nursing.
Quality concerns
In highly unionized Massachusetts, worker representatives say the nursing compact has a loophole that could compromise patient safety. Joe-Ann Fergus, director of membership at the Massachusetts Nurses Association, claimed that if a nurse gets into legal trouble with one state, that person can go to another state in the compact to avoid prosecution.
Massachusetts also has more stringent continuing-education requirements than is required by the compact, and the compact would disrupt their contract negotiations, Fergus added. “It’s a solution in search of a problem. There’s no need for it in Massachusetts.”
Maryann Alexander, chief officer of nursing regulation at the National Council of State Boards of Nursing, rebutted the concerns about patient safety. Also, she said there is no evidence that continuing education improves care.
“All those years of data told us that the compact was 100% safe,” Alexander said. “There were no incidents of increased discipline of unsafe nurses across state borders.”
The defense for state-by-state licensing is weaker because accepted clinical practices have become more national in scope, Horton said.
A lot of the tension is in underserved areas where telemedicine has the potential to make a huge difference, he said. “That’s one of the speed bumps in the expansion of telemedicine,” Horton said.
Expanding the physician compact could make a significant dent in the shortage of behavioral and mental health clinical personnel, said Ralph Henderson, president of professional services and staffing for AMN Healthcare, a staffing agency. “Multistate licensure increases access to care in underserved areas,” he said. “There are so many benefits with all of the skill shortages, it’s a little crazy that all states haven’t adopted it.”
When healthcare providers wanted to pitch in to help the relief effort in Louisiana following Hurricane Katrina, they were delayed due to confusion over liability issues. Louisiana at the time was not a nursing compact member. Compact states can respond to disasters quicker, rather than waiting for a governor’s emergency order allowing licensing flexibility, Alexander said.
“The benefits outweigh the detractions,” Henderson said. “It’s getting harder and harder to resist.”
The National Council of State Boards of Nursing will work with five states during their upcoming legislative sessions as they weigh joining the nursing compact; Minnesota is one of the states involved.
Eighty percent of nearly 21,000 nurses surveyed by the Minnesota Board of Nursing were in favor of their state joining the compact.
Yet it’s unlikely any legislation will be passed in the upcoming session, said Kate Johansen, the director of government relations for Mayo Clinic.
Newly elected Gov. Tim Walz isn’t likely to rock the boat, she said, especially since the compact is opposed by the Minnesota Nurses Association, which endorses many of the state’s public officials.
Since Mayo is a healthcare destination, nurses and doctors are limited in terms of their follow-up care of patients who live in noncompact states, Johansen said. “We deliver care in ways that are more mobile than ever,” she said. “Anything that helps streamline care is really the goal we should be pursuing. The nursing compact is tested.”
The outdated state-by-state licensing system doesn’t fit healthcare’s evolution, Alexander said.
“We have huge changes in our healthcare system related to education, online tools and accessibility, and yet we have this 100-year-old licensing system that many states, primarily because of their unions, are reluctant to change,” she said. “What was good for us 100 years ago is not good for us now.”
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