Introduction

The year was 1917. The United States entered into World War I. John Fitzgerald Kennedy was born, and Buffalo Bill died. The Utah Legislature passed its first Nurse Practice Act, and regulation of nursing in Utah was born (State of Utah, 1917).

Much has changed since 1917, but the fundamental system for regulating the nursing profession has not. It is interesting to note that at the time nursing regulation began in Utah, the telephone had been invented for a little more than 40 years and the first airplane flight had taken place just 14 years earlier. Ford's Model T was nine years old, and the railroad was the most important means of transportation. The computer would be invented thirty some-odd years later. Changes in the health care environment have created changes in the delivery of nursing services. Those changes have necessitated a change in the regulation of nurses.

On March 14, 1998, Utah Governor Michael O. Leavitt signed into law the Nursing Regulation Interstate Compact. This was an historic moment for the state and for nursing regulation. Utah became the first state to adopt the interstate compact language which had been endorsed by the National Council of State Boards of Nursing (NCSBN) (NCSBN, 1997). This action was the outcome of several years of study and discussion by the Utah Board of Nursing, the Division of Occupational and Professional Licensing (DOPL), and other stakeholders. The purpose of this article is to describe the process and experience that took place and led to this historic moment. To understand how Utah was able to undertake such a legislative action, one must first understand the administrative and political framework of the state.

Background

The Utah Board of Nursing is an advisory board to DOPL. DOPL is one of seven divisions within the Department of Commerce. The statutory mandate of the Department of Commerce and hence DOPL is public protection. Section 13-1-1, of the Department of Commerce Act, reads:

it is appropriate and necessary for state government to protect its citizens from harmful and injurious acts by persons offering or providing essential or necessary goods and services to the general public.... The general public interest must be recognized and regarded as the primary purpose of all regulation by state government (State of Utah, 1998).

The mission of DOPL is to protect the public health, safety, and welfare of Utahans by appropriately administering and enforcing Utah's occupational and professional licensure laws. The Division serves two "publics." The first is the general public who seeks services from licensed professionals, and the second group is the licensed professionals. Any proposed changes to regulation must be examined for the effect on both of these groups.

Another important piece of background information is the geography of the state. The majority of health care services are found along a stretch of approximately 120 miles of the Wasatch Front. The Wasatch Front is a narrow strip of land running from Ogden from the north, through Salt Lake City, south to Provo. It is bordered between the Wasatch Mountain Range and Utah Lake and the Great Salt Lake. Although the state has several small community hospitals, not all services are readily available away from the Wasatch Front. Many describe Utah as being rural, but a better term may be frontier. Approximately one-half of the citizens of the state live along the Wasatch Front; the remaining population is found in rural/frontier areas. The Utah Legislature has an informal group referred to as the Cowboy Caucus composed of legislators from rural areas. This group is well known for their ability to get legislation passed which improves services to the rural regions of the state.

The Utah Legislature is very conservative and frugal. The state has always maintained a positive budget. The general view of the public as well as the legislature is that less government is better government. Hence, initiatives to improve or reduce governmental regulation are viewed in a very positive light. In his book The Death of Common Sense, Philip K. Howard (1994) wrote "rote devotion to sameness is not necessarily the same as responsibility in government."

Precipitating Factors for Change

There were a number of factors which supported and encouraged the decision to change the regulatory systems for nurses in Utah. Some of these factors were local issues and concerns, while others had more of a national impact. The greatest impetus for regulatory change was the need to protect the public. As the practice of nursing expands and changes, DOPL must be able to exert jurisdiction over the individuals it licenses and those who provide services to its citizens.

The traditional nurse in starch white, providing hands-on bedside care, is quickly evaporating.

The traditional nurse in starch white, providing hands-on bedside care, is quickly evaporating. Today, nursing practice includes bedside nursing, telephone triage, case management, home health visits via video conferencing, Internet consultation, and the list goes on and on. Frequently, the recipient of care and the licensed nurse are not in the same state. The regulatory system must provide the jurisdiction necessary to protect the public. Such jurisdiction would include taking action against an individual's license and/or preventing him/her from practicing. To take disciplinary action a state must either have jurisdiction over the licensee, the patient, or the practice. The Nursing Regulation Interstate Compact accomplishes this goal by establishing jurisdiction for disciplinary action to both the home state and the remote state.

Another factor is that of the current single state licensure system with nurses practicing in multiple states. Six other states border Utah. These states include Arizona, Colorado, Idaho, Nevada, New Mexico and Wyoming. A number of nurses practice across state lines. This is particularly a problem for individuals who are employed by home health care agencies. The current regulatory system requires nurses to be licensed in multiple states resulting in significant costs to the individual nurse. Also, three major regional medical centers are located in the Salt Lake Valley. Shriner's Hospital provides services for seven other western states. After discharge, patients are encouraged to contact the hospital and primary care nurse for any questions. This contact constitutes nursing practice, and most states require the nurse to be licensed in their state in order to lawfully talk to a patient located within their borders.

... nurses practicing at the bedside of regional medical centers should be licensed in multiple states in order to provide continuity of care to patients.

Hence, nurses practicing at the bedside of regional medical centers should be licensed in multiple states in order to provide continuity of care to patients. Two border states have made their licensure laws more restrictive and require licensure in their states for a health care provider to consult with another health care provider. This creates a barrier to services but has been done to assure jurisdiction and the ability to protect the public. A single license which is recognized by other states would resolve the issue of multistate practice and licensure.

Intermountain Health Care (IHC) is an agency which provides telephone triage (Ask-A-Nurse) services and is located in Utah. The administration of IHC had been informed that their nurses would need licensure in the states from which calls were coming. This would equate to three nurse licenses for approximately forty nurses and great cost to the agency. Most likely the agency would pay the additional fees of $225 for the three additional licenses for each of the approximately forty nurses.

A third factor moving Utah to change its nursing regulation system is that of duplication. During the past three to four years, a major emphasis from the governor's office and the legislature was to work smarter and do more with less. Duplication is the best word to describe the process of licensure by endorsement in each state. Generally speaking, it is easier and faster for a new graduate to become licensed than it is for a nurse with a current license in another state to be licensed. Most states require nurses who are licensed in other states to obtain official verification of licensure from every state in which they are licensed. At a minimum, they require verification from the original state of licensure (a state in which the nurse may not have worked for ten years). Under the current regulatory system, states spend countless resources, personnel and fiscal, re-evaluating credentials which have been evaluated by a sister state. When the legislature told DOPL to work smarter, the endorsement process was evaluated and determined to be redundant. What is needed is a central repository of licensure and disciplinary information so as to streamline the regulatory process. Acceptance of the Interstate Compact would mean that nurses practicing within party states would only need one license and the other states will not have to issue licenses. This will allow the reallocation of resources to enforcement activities. Also, a great deal of time and money is spent on licensure actions as a result of action from another state. It is not uncommon to find, after investigating a Respondent for a specific cause in one state, that the Respondent has had licenses revoked in other states for the same reason, e.g., substance abuse. Under the compact, with one license, only one state takes the action against the license. Again, the savings to the regulatory agency could be great.

Another precipitating factor for moving forward with the compact was the view of regulation being a barrier to the delivery of appropriate health care. In 1995, a report from the Western Governors' Association, chaired by Governor Leavitt, indicated that professional regulation was a barrier to telemedicine (Western Governors' Association, 1995). It is a strong incentive to evaluate the effectiveness of a system, when the "boss" indicates that the system is a barrier. Another report which caused DOPL to question the effectiveness of the current system was the report of the Task force on Health Care Workforce Regulation of the Pew Health Professions Commission (1995). The tenth recommendation from the taskforce reads:

States should understand the links, overlaps and conflicts among their health care workforce regulatory systems and other systems which affect the education, regulation and practice of health care practitioners and work to develop partnerships to streamline regulatory structures and processes.

This recommendation reflects the philosophical belief that regulatory agencies should work smarter and utilize outside resources.

Finally, DOPL and the Utah Board of Nursing closely monitored the activity of the National Council of State Boards of Nursing (NCSBN). In 1995, NCSBN created a taskforce to study telehealth and licensure (NCSBN, 1996). Work and study on multistate licensure and practice continues. During the 1997 Delegate Assembly, member boards unanimously voted to endorse the concept of a mutual recognition model of nursing regulation (NCSBN, August 1997). Delegates from the Utah Board of Nursing were present at that meeting and eagerly supported the motion. In December 1997, the NCSBN Delegate Assembly approved the compact language that was subsequently introduced to the Utah Legislature (NCSBN, Dec. 1997). Information from NCSBN regarding the mutual recognition model and the interstate compact was most helpful. DOPL and the Utah Board of Nursing were able to take the information and apply it specifically to Utah's issues.

Why did the Utah Board of Nursing and DOPL support adoption of the Nursing Regulation Interstate Compact? The state recognized that the practice of nursing and the delivery of nursing services is changing. Regulation needs to address those changes and ensure that the public can be protected. Also, resources are limited and need to be utilized wisely.

How the Interstate Compact was Adopted in Utah

Once the mutual recognition model of nursing regulation was identified as a solution to the shortcomings of the current regulatory system, it was necessary to adopt a mechanism to implement this model. An interstate compact was chosen as the most appropriate vehicle to make this change. An interstate compact is a contract between states. Currently there are over 200 interstate compacts in effect (NCSBN, 1998). The compact language must be adopted by the legislature of states that wish to participate. A compact can only be adopted or amended by the legislative process. A great deal of groundwork was necessary before this legislative process could occur.

The Utah Board of Nursing first started discussing multistate practice and licensure in April of 1996. The issue was discussed at virtually every meeting thereafter and continues to be discussed during monthly board meetings. The concept of multistate licensure/mutual recognition model of regulation was also discussed with a variety of stakeholders. Meetings were held with the Utah Nurses Association, and a motion was made in their annual House of Delegates to support the concept of mutual recognition. Also, Utah nursing leaders have formed a networking group called the Nursing Leadership Forum. It is composed of deans and directors of the nursing education programs and the chief nursing officer from health care facilities. Discussions were held with the Nursing Leadership Forum, and support was garnered from that group.

Another important group that supported the mutual recognition model of nursing regulation was the Utah Health Policy Commission. The Commission had appointed a technical advisory group to study telehealth issues. Presentations were made to the technical advisory group and the Health Policy Commission. Both supported the interstate compact. The Executive Director of the Department of Commerce was instrumental in securing support from the Department of Health and the governor's office.

Meetings were held with the stakeholders before the concept was adopted by the Delegate Assembly of NCSBN and while the compact language was being developed. Some of the stake holders included: Utah Nurses Association, both the Board of Directors and the Olympic Planning Committee; Health Policy Commission's Technical Advisory Groups and staff; deans and directors of the nursing education programs and health care facilities; employers; and individual nurses. Discussions centered on the need for change and the concept of mutual recognition. The stakeholders had endorsed the concept and it was possible to move forward because of this endorsement. Once language was finalized, it was disseminated.

According to Kurt Lewin an integral aspect of the change process is unfreezing. Education was utilized to successfully unfreeze attitudes about the regulatory system. Fortunately, Utah was able to move quickly from the question, why change the system that has been in place for nearly a century, to, how should it change? The precipitating factors provided a sound basis to demonstrate the need to change and precede into the moving stage of change. Since the stakeholders recognized the need for change, Utah was able to discuss the issue at a conceptual level. Hence, once language had been drafted, it was possible to drop the language into bill format and have it introduced into the legislature.

The Utah Legislature meets for forty-five calendar days starting the third Monday of January. Any government agency which will be proposing legislation must indicate its intent by the first week of December. This created a problem because the NCSBN Delegate Assembly did not meet until December 14 and 15, 1997. However, the Senate majority leader, Craig Peterson, supported the concept of mutual recognition and was willing to open a bill file by the deadline date without having the compact language. Nonetheless, it was expressly understood that the sponsor would pull the bill if he disagreed with the compact language. It was also understood that a bill would not go forward if the NCSBN Delegate Assembly did not adopt compact language. Utah would not develop their own language but would continue to work with the national organization. Fortunately, compact language was adopted, and Senate Bill 149 became a reality.

Senator Peterson agreed to sponsor the bill and was a very influential member of the Senate. The bill was assigned to the Senate Health Committee for review. A short information sheet was distributed along with letters of support from the Utah Nurses Association, Nursing Leadership Forum, and Intermountain health care. The questions raised were about nursing regulation in general and not specific to the compact. The compact language drafting process was explained with particular emphasis that the language had been reviewed by a panel of attorneys from across the country and approved by the NCSBN Delegate Assembly. One senator commented that if that many people had worked on the language it must be good.

The bill received a unanimous favorable vote and was sent to the Senate floor for consideration. The Senate passed S.B. 149 unanimously and sent it to the House where it was sponsored by the House majority leader. Again, the bill passed out of committee and then the floor with a unanimous vote of support. No one came forward during the legislative session to oppose the bill. The general reaction was supportive. Some people even questioned why it had taken so long to recognize the shortcomings of the current system. An explicit understanding during this entire process was that Utah was the first state to consider adopting the compact language. It was also clearly explained that if the compact were to be adopted, amendments may need to be made as other states precede toward adopting the mutual recognition model of nursing regulation and the compact language.

Current Status of the Compact in Utah

To become effective, an interstate compact must be adopted by more than one state. Hence, DOPL's focus since the legislative session has been with states who have expressed an interest in adopting the compact language. Three face-to-face meetings have occurred as well as numerous conference calls. The meetings have included the boards of nursing and state nurses associations. The Utah Board of Nursing and the Texas Board of Nurse Examiners have taken the lead for the boards of nursing. The Texas Nurses Association has taken the lead for the state nurses association. As a result of these meetings, clarifying amendments to the compact have been drafted. During its November meeting, the NCSBN Board of Directors approved those amendments. The Utah Board of Nursing made a motion during its October meeting to recommend that DOPL introduce the amendments to the compact language to the legislature. DOPL concurred with that recommendation. Therefore, amendments will be made to the Nursing Regulation Interstate Compact during the 1999 Legislative Session. Senator L. Alma Mansell, current senate majority assistant whip, has agreed to sponsor the bill (Senate Bill 26).

Advice to States Moving Forward with Compact Language

The success of S.B.149 was education. Starting conversations early to discuss the philosophy of regulation and multistate practice was invaluable. Utah was able to concentrate on the need for change and solutions to the identified issues. Identifying stakeholders and involving them in the discussions was also necessary. Additionally, Utah learned to expand its view of who constitutes a stakeholder. Fortunately (or unfortunately depending on how you look at it), everyone will require nursing services during their lifetime. The number and type of stakeholders involved in this issue is vast. Utilize these groups and lobbyists to champion the cause.

Be prepared to explain nursing regulation. The questions asked were surprising. A senator remarked that he was concerned with the compact because each state had its own licensure examination. When he was informed that the examination is a national examination, he indicated that the compact was a good idea. A representative thought that hospitals could grant permission for anyone licensed in another state to practice within that facility. When licensure was explained to her, she was a definite supporter of the mutual recognition model of nursing regulation. A nursing regulation 101 brief is not a bad way to start a discussion regarding multistate practice and licensure.

Keep focused on the role of regulation. Regulatory bodies are charged with the mandate to protect the public health, safety, and welfare. Promotion of professional organizations or labor issues is important, but these are not regulatory issues. Any change to the regulatory system should be for the betterment of public protection.

A concern expressed during many meetings was the adoption of identical language in the states moving forward with the mutual recognition model of nursing regulation. Anyone with experience with legislators knows that they enjoy "tweaking" or "perfecting" bills. The fear was that legislators would attempt to amend the compact language. Through this process, Utah learned that legislators understand interstate compacts and it is important not to underestimate this understanding. Providing an explanation of the drafting and approval process was sufficient.

The final piece of advice offered to states who choose to move forward with the mutual recognition model of nursing regulation is to have thick skin and continue to be bold. People are naturally resistant to change, and changing the regulatory system is a major undertaking. The Nursing Regulation Instate Compact proposes to change a regulatory system which has been in place for nearly a century. The change may not come easy. It will take visionary states to adopt the compact and initiate the change. Those states moving forward will need to continue to support and encourage one another. It is important to reiterate that to date, DOPL and the Utah Board of Nursing have not heard a complaint from a single nurse. The only concerns that have been raised have been from national nursing organizations. The nurses practicing at the bedside, over the telephone, and in the home appear to be pleased with the mutual recognition model of nursing regulation.

S.B.149 becomes effective on January 1, 2000. The nursing profession will have been regulated in Utah for 83 years, and the practice of nursing has changed a great deal during that time. The mutual recognition model of nursing regulation as implemented in the Nursing Regulation Interstate Compact provides a regulatory system which is responsive to those changes. Adoption of the compact language allows nurses to more readily participate in multistate practice while providing the jurisdiction necessary for regulatory bodies to fulfill their mission to protect the public health, safety, and welfare.

Author

Laura Poe, MS, RN
E-mail: lpoe@br.state.ut.us

Laura Poe, RN, MS has been the Executive Administrator of the Utah Board of Nursing for the past five years. In this capacity she oversees the licensure of various categories of nurses. From 1996 - 1998, Ms. Poe served as a Director-at-Large for the National Council of State Boards of Nursing's Board of Directors. Ms. Poe received her education at Brigham Young University including a dual major of nursing education and nursing administration.

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