BARRIERS TO PRACTICE as a telehealth nurse are different from those of a nurse working in a hospital. One state license may not be enough if a telehealth nurse has patients who live across state lines.

Historically, nurses were licensed in a single state and practiced in a single state.1 The introduction of telehealth meant that a nurse could not follow a patient from another state without holding a single state license in that state. The advent of the Nurse Licensure Compact (NLC) helped ease this roadblock, but only 25 states entered the original compact.1

In 2008, Simpson addressed how nursing licensure had not kept pace with practice.3 He cited the Telecommunications Reform Act of 1996, which developed several models to address the licensure challenges faced by healthcare and how nursing favored the mutual recognition model (see What is the mutual recognition model?). The National Council of State Boards of Nursing (NCSBN) adopted a mutual recognition model for licensure and developed the NLC, an agreement between states that allows nurses to practice across state lines with a multistate license.4

This article explores how licensure can restrict practice for nurses working in telehealth nursing, and how training and certification can help address concerns over patient safety.

Licensure regulatory reform

Licensure compact regulations have brought flexibility to telehealth nursing by allowing nurses holding a multistate license to practice in other compact states without additional licensure. In January 2018, the Enhanced National Licensure Compact (eNLC) replaced the NLC, expanding requirements for criminal background checks, initial applications, renewals, endorsements and reinstatements of nursing license within the states, and reporting between compact states within the new compact.4 The nursing board of each state maintains and regulates the practice of nursing for their state, and nurses should be aware of the different compact state nurse practice acts (NPAs). Nurses who fail to follow the NPA of any given state could face disciplinary action up to and including loss of license. Multiple states offer online courses that, for a nominal fee, help nurses comprehend the jurisprudence for each state in which they practice. The NCSBN has 20 such courses on its website.5

Why have a multistate license?

Nurses are required to be licensed in the state where the patient is located at the time service is provided. A multistate license allows nurses to practice in their home state and all compact states with one license issued by the home state. This eliminates the burdensome, costly, and time-consuming process of obtaining single-state licenses in each state of practice.6

Nurses holding a multistate license can legally practice nursing in the state in which they live as well as for patients located within other compact states. However, nurses who practice across state lines should remember that their care is regulated by the NPA in the statewhere the patient resides.

Thirty-one states had joined the NLC as of August 2019, with three more states set to join in January 2020.6 Although the aim was to have all 50 states signed on to the compact, over a dozen states still had not enacted NLC legislation as of August 2019.7 Concerns preventing states from becoming part of the nurse compact have been patient safety and a lack of clarity about which board of nursing should receive safety concerns.8 This has led to restrictions on state licensure that make practicing across state lines less cost-efficient for nurses. For example, nurses who live in New Jersey (which is not a compact state) but work in New York must maintain two licenses.

The mobility of people across state lines into noncompact nursing license states has increased the concerns of nurses in practicing nursing where the patient is located. For example, a patient could be on his or her cellphone talking with a nurse while riding in a car, and cross a state line into a state where the nurse is not licensed. If that nurse is not aware of the state the patient is in at the time of the call, the nurse may commit a breach of practice for not being licensed in that state and face disciplinary action. If a national license existed, nurses could follow the patient across the country without fear of practicing without a license in the state where the patient is located.

Specialty practice barriers

While telehealth nursing may have addressed one regulatory issue through the development and expansion of the licensure compact, questions remain about whether telehealth nursing should require certification or be identified as a specialty practice for nurses.9,10 In December 2007, the American Academy of Ambulatory Care Nursing (AAACN) discontinued the certification for telehealth nursing, and instead encourages nurses in this type of work environment to seek certification in ambulatory care. Because patients on the phone are in an ambulatory setting (their home), this provides a wider scope of practice for nurses.10

Remote workers in varying states present a licensure dilemma for preceptors and educators. As with any nursing role, those who are new to the field or an organization go through a period of onboarding that includes precepting by a peer. Out-of-state telehealth nurses may have a virtual preceptor. L'Ecuyer and colleagues researched the professional responsibilities of nurse preceptors and nursing boards' stance on qualification and education for preceptors. While the study found few consistencies in the requirements and education, 29 state boards identified that nurse preceptors must be "...licensed in the state that they are practicing."11

Ambulatory care has evolved with the advent of telehealth. In its 2017 position paper on ambulatory care, the AAACN addressed the expanding roles of nurses in the ambulatory care setting. The position paper addressed the expanding role of nurses in ambulatory care as "...care provider, care coordinator, and care partner..."12 Certification assists in the expansion of knowledge within the ambulatory care setting for nurses and the practice of telehealth nursing that follows the evolution within healthcare. The AAACN had the forethought to anticipate that nurses would need support and recognition to transition to the ambulatory setting while practicing to the full extent of their training and education. Certification in ambulatory care includes the role of telehealth nursing, adding to consistencies in knowledge and practice. The AAACN position paper identifies the need for state boards of nursing to embrace reforms to ensure that nurses can respond to the multiple needs of patients and abide by consistent practice standards across state lines.11

Ensuring competency and safety

Barriers to nursing practice across state lines extend to more than licensure and include educating, training, and precepting. Nurses should be knowledgeable about the NPA for every state in which they practice, whether with a compact or single-state license. While the eNLC is expanding across the US, there are still several states that have yet to enact legislation or have not considered being part of the compact. Certification establishes a standard in expertise within telehealth nursing and helps ensure competency in practice and safety for patients across state lines.

What is the mutual recognition model?

A core aspect of the NLC, the mutual recognition model is a regulatory model for the nursing profession where an agreement is achieved by states to allow nurses to have a multistate license in their primary state of residence and practice in another state in the compact, unless there are restrictions to practice across state lines.2

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