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How Nurse Licensure Compacts Can Ease Chronic Nursing Shortages

Analysis  |  By Carol Davis  
   June 19, 2023

NLCs are 'one tool in the toolbox' for broader workforce discussions, NCSBN official says.

Nurse Licensure Compacts (NLCs) may be “one tool in the toolbox” to help ease chronic nursing shortages reaching into every state and practically every health facility, says Nicole Livanos, director of state affairs at the National Council of State Boards of Nursing (NCSBN).

The compact allows RNs and licensed practical/vocational nurses (LPN/VNs) to have one multistate license, with the ability to practice in person or via telehealth, in both their home territory/state and other NLC states.

The NLC has been operational for more than 20 years, though a new and modernized version of the language was drafted and approved by boards of nursing in 2015. Since then, 38 states and two territories—Guam and the U.S. Virgin Islands—have enacted the NLC legislation.

HealthLeaders spoke with Livanos about the benefits of the NLC, why some states haven’t enacted it, and how it could help with nurse staffing shortages.

This transcript has been lightly edited for brevity and clarity.

HealthLeaders: Washington is the latest state to enact the NLC. What finally pushed it over?

Nicole Livanos: Washington has been attempting to enact the NLC and had numerous efforts since around the time that the first compact was enacted, so we’re thrilled with Washington's enactment. This sends a broader signal to the other states that are not yet in the NLC that the NLC can be part of broader workforce discussions in looking at how to shore up the existing nurse workforce, how to modernize the existing workforce, and how to make sure that your state remains competitive when recruiting nurses.

In Washington this year in particular, lawmakers were looking at several issues dealing with the nursing workforce, and NLC was seen as part of that solution to a lot of the workforce challenges that Washington was facing.

HL: How likely are the remaining states to follow suit?

Livanos: As director of state affairs, I am hopeful, and I know that the work that we're doing is working. We are encouraged to see that, especially coming out of the pandemic, states are looking at and addressing the real issue of the nursing workforce shortage, seeing the data that's coming out, and seeing how it's impacting at the individual facility level, at the patient level, and at the nurse level.

The states that we might have thought would be number 49 or 50 are seriously taking into consideration the NLC and the benefits that it can provide. And again, it's a tool in the toolbox and so many times we are seeing it proposed alongside other nursing workforce packages.

HL: Why are the rest of the states holding out from joining the compact?

Livanos: Over the past several years, we have had 40 jurisdictions that had 40 unique challenges—that's the beauty of state government—and the remaining jurisdictions have unique challenges to each of them, so it’s not a “one size fits all.” However, there are two common denominators between many of these states.

One is that there are still states that are not familiar with and have not started to adopt healthcare licensure compacts, whether it be for nurses, or physical therapists, or physicians, etc. There are some states—Hawai‘i, Connecticut, Alaska—that have either just begun enacting interstate compacts in the last year or so, or they're still exploring and learning about how these will impact healthcare in their state.

The other common denominator between some of those states is that they have opposition from nursing union leadership. Many different unions represent nurses, and each state has its own challenges and concerns that those unions would raise. Some nursing unions have expressed concern about how the NLC may impact their bargaining power during times of strike when facilities have to bring in nurses quickly to care for the patients.

There are other concerns about public safety in bringing in nurses from other states and whether an unsafe nurse can continue traveling between states to avoid disciplinary action and being caught. We are very comfortable with the safeguards within the compact that were built and drafted by boards of nursing whose mandate is to protect the public. We know that those safeguards work and that the NLC provides additional requirements for boards of nursing for them to share information across state lines to ensure that type of scenario does not happen and is properly managed.

HL: From a hospital or a health system’s perspective, what are the benefits of NLCs?

Livanos: For those that may have telehealth or they may be looking to grow a telehealth program, the NLC offers the opportunity to create nursing jobs for those roles where they can reach patients across state lines.

We travel across state lines all the time and a provider needs to be licensed in the state where we, the patients, are located, so the compact allows for these facilities to ensure that they can take care of their patients, no matter where their patients are in the country.

HL: What does a nursing compact state mean for nurses?

Livanos: We know that nursing is not purely traditional nursing at the bedside. Nurses are case managers that communicate with patients that cross state lines all the time, so if they're not in a compact state, they need to obtain and maintain up to 50 licenses to properly care for the patients that they are assigned to.

The NLC provides two opportunities. One is to relieve the nurse of the burden of holding and maintaining licenses, which might be every year or on a two-year cycle depending on that state’s board of nursing.

The other is to look at what a nurse can do when they have a multi-state license versus a single-state license and the opportunities it opens up to them to be a travel nurse or if they want to join and remain competitive in a telehealth workforce.

The U.S. Department of Defense is a huge supporter of compacts and has invested in drafting a lot of them because of the benefits to military families when they're relocating every two years. If their spouses are nurses, they're having to obtain and maintain multiple licenses each time they move, which creates a financial burden not only in having to get the license, but also a delay in when they're able to get to work because they need to wait for new licensure every time they move to a new jurisdiction. So, we know it's not a “one size fits all”—every nurse could benefit from the NLC in a lot of different ways.

HL: All governors issued executive orders to allow nurses to freely work across state lines during the pandemic crisis, but a crisis remains in nurse staffing. Could expanding the NLC to all 50 states help alleviate some of the high costs of travel nurses?

Livanos: Again, the NLC is a tool in the toolbox, so while there is a nursing shortage of this magnitude, the NLC isn't going to suddenly create nurses, but it is going to allow facilities that might have an acute shortage in one of their units to recruit a nurse for that unit or shift around their resources if they're an interstate facility and moves nurses between different states.

We saw during COVID where 34 states at the time that had the NLC operational were able to have an immediate workforce to call upon when hotspots were appearing in different states across the country, whereas those that weren’t in the NLC had to rely on these executive orders. They all operated it in slightly different ways; some were blanket waivers, while others required temporary licensure or registration requirements or that you work within a certain type of facility in responding to COVID.

It created this patchwork regulatory environment, which did not promote the ease of mobility that the NLC provides for.

“The NLC can be part of broader workforce discussions in looking at how to shore up the existing nurse workforce, how to modernize the existing workforce, and how to make sure that your state remains competitive when recruiting nurses.”

Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.


38 states and two U.S. territories have enacted the NLC.

For hospitals or health systems with telehealth, the NLC can create nursing jobs that reach patients across state lines.

The U.S. Department of Defense supports the NLC because of the benefits to military families when they relocate.

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