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EDITORIAL Candise Flippin, MS, RN, CNOR

Military …Licensure That Transcends Borders

Ever wonder why nurses all take dards, issuing licenses monitoring licensees’ compli- the same examination but have to ance with these standards, and disciplining those have a license in every state in who engage in unsafe practices. Measuring compe- which they practice? Although it is tency through examination has been common prac- a complex issue, the various tice for decades. The first step toward ensuring that branches of the military have long all nurses have the same minimum competency level had a system for credentialing was adopting an examination that would be used by nurses with licenses from all 50 all states. The National Council of State Boards of states. Care may be in different Nursing (NCSBN) continues to develop the National venues compared with civilian life, but the same Council Licensure Examination (NCLEX) for regis- level of competence is expected from these nurses. tered nurses. State and territorial boards of nursing The tradition of nurses in the military dates back have used this examination for many decades to to more than 100 years. In the , George assist in making licensure decisions. Recently, the Washington is credited with communicating the need examination has gone global and there are at least 13 for nursing care to Congress in 1775 (Ulmer, 2001). countries outside the United States that are pilot sites Nurses are found in the Army, Navy, Air Force, and for NCLEX examinations (Pearson Education, Inc., National Guards. Congress formally established the 2006). Army Nurse Corps in 1901 (U.S. Army, n.d.) and the The state-based licensure model presents many Navy Nurse Corps in 1908 (Navy Nurse Corps Asso- challenges for , disaster responsiveness, ciation, n.d.). The Air Force Nurse Corps, the and the nursing shortage. As the world’s borders youngest of the military nursing corps, just celebrat- rapidly disappear with the evolution of the Internet ed its 60th anniversary (Pockett, 2009). Each of these and telephone technology, nursing practice has tried groups requires a registered nursing license for active to evolve with it. With the passage of the Telecom- duty employment. A license from only one state is munications Act of 1996, the Department of Com- required, although they will most likely practice in merce, Department of Health and Human Services, facilities around the world. This concept of interstate and other agencies began analyzing the impact of and beyond-state-based licensure begs the question, telecommunications on healthcare (Simpson, why does it not work that way in the civilian world? 2008). Telenursing raises concerns about whether Healthcare regulation begins with state govern- the nurse providing the care in a state or country ment under the concept of “police power.” This other than the state of licensure is practicing with- includes the power to enact reasonable laws to pro- out a license. Considering this is a felony; it is not a tect the public health, safety, and welfare (Tate & minor issue. Other areas of concern include reim- Moody, 2005). In the early part of the 20th century, bursement, risk management, and liability. states’ rights were a very hot topic. The need to police Disasters, natural and man-made, create an those who practiced resulted in states regu- incredible increase in need for qualified registered lating nursing practice through licensure (Simpson, nurses. The terrorist attacks of 2001 added a sense of 2008). The primary mission of boards of nursing is to urgency for disaster preparedness. In spite of emer- ensure public safety through safe nursing practice. gency management laws and disaster management The board’s responsibilities include establishing stan- programs, the Gulf Coast hurricanes of 2005 high- lighted significant deficiencies in the ability to deploy Candise Flippin, MS, RN, CNOR, is Director of the Medical Pro- , nurses, and other healthcare practition- gram at Fresh Start Surgical Gifts, Carlsbad, CA, and the Editor-in- ers to disaster-stricken areas. Licensure and compe- Chief of Plastic . tency ranked high in the list of challenges. Address correspondence to Candise Flippin, MS, RN, CNOR, Fresh Start Surgical Gifts, 2011 Palomar Airport Road, Suite 206, Nursing shortage concerns are causing multiple Carlsbad, CA 92011 (e-mail: [email protected]). organizations to look beyond the state-based licensure

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model. The Health Resources and Services Adminis- must enact the UEVHPA. From 2006 to 2008, only tration (2006) projected that the shortage of nurses six states enacted the UEVHPA. In 2009, one state would grow to more than 1 million by 2020, with some enacted it and another nine states introduced the states having greater issues than others. More nurses legislation. Even if all 50 states enacted the UEVH- are expected to be needed as baby boomers age and PA, it would not address volunteer healthcare pro- their need for healthcare increases (Tate & Moody, fessionals attempting to provide care to underserved 2005). To make matters worse, enroll- populations. ment is increasing slightly but not nearly enough to It is time, maybe even past time, for licensure to meet the projected demand of 90% more graduate catch up with modern technological advances. nurses (Health Resources and Services Administra- Space travel has begun to even further stretch our tion, 2006). boundaries. Nurses all take the same examination as With all the discussion of these issues, some a measure of the minimum competence for licensure progress is required to make nursing practice in as a . It is hard to believe that sys- multiple states easier while ensuring the public tems that have worked for the military for more than safety. Concerns about the rapid advances in 100 years cannot be adapted to civilian processes. telecommunications opening the door to interstate This issue of Plastic Surgical Nursing features arti- practice and nursing shortages prompted the cles detailing the experiences of some of our military NCSBN to investigate the concept of a mutual recog- nurses as well as the implications for postconflict nition model of nursing regulation in 1996. These wound management. Nurses in the military care for models allow a nurse to have one license and prac- those who volunteer to protect our way of life often- tice in multiple states. The Nursing Licensure Com- times put themselves in harm’s way. Please join me pact (NLC) became a reality in 2000 when legislation in thanking them for their special contributions to was passed into law by the first participating states, the field of nursing. but there are still only 23 states participating. The Please feel free to forward your comments to the NLC comprehensively addresses concerns about editorial board and me by writing us at Plastic Surgical administration, legislation, discipline, licensure, and Nursing, American Society of Plastic Surgical Nurses, practice. Organizations that have endorsed the NLC 7794 Grow Drive, Pensacola, FL 32514-7072, or send concept include many state nursing associations an e-mail to Candise Flippin at [email protected]. such as the American Association of Nurse Execu- tives and the American Association of Occupational REFERENCES Health Nurses, several state associations, Health Resources and Services Administration. (2006, April). the U.S. Department of Commerce, the Center for What is behind HRSA’s projected supply, demand and short- Telemedicine Law, the Telehealth Leadership Coun- age of registered nurses. Retrieved June 24, 2009, from cil, and the Citizens Advocacy Center. http://bhpr.hrsa.gov/healthworkforce/reports/nursing/ Today, all 50 states have ratified the Emergency rnbehindprojections/index.htm Management Assistance Compact, which allows Navy Nurse Corps Association. (n.d.). History of the Navy state and locally employed licensed healthcare prac- Nurse Corps. Retrieved June 21, 2009, from http://www. titioners to practice in states without having to be nnca.org/about/history.shtml licensed in the affected state. Federally employed Pearson Education, Inc. (2006, February 6). NCLEX testing to healthcare practitioners may also be deployed with- expand internationally through Pearson VUE. Retrieved out compliance with state licensure laws. In addi- June 23, 2009, from http://www.aldatech.com/oldalda/ new_nclex_international_test_cen.htm tion, § 2801 of the Public Health Services Act, 42 Pockett, C. (2009). Air Force nursing: 60 years, still counting. U.S.C. § 300hh recognized the Medical Reserve Retrieved June 14, 2009, from http://www.charleston. Corps and § 3191 of the Public Health Services Act, af.mil/news/story.asp?id123148673 42 U.S.C. § 247d-7b provided funding to establish Simpson, R. L. (2008). State-based licensure, are we regulat- Emergency Systems for Advance Registration of Vol- ing away the promise of telemedicine. Nursing Adminis- unteer Health Professionals (The National Confer- tration Quarterly, 32(4), 346–348. ence of Commissioners on Uniform State Laws, Tate, E. T., & Moody, K. (2005). The public good, regulation n.d.). These programs do not result in interstate of nursing students. JONA’s Healthcare Law, Ethics and recognition of licenses. The Uniform Emergency Regulation, 7(2), 47–53. Volunteer Health Practitioners Act (UEVHPA) was Telecommunications Reform Act, 47 USC (1996). approved in 2006 (The National Conference of Com- The National Conference of Commissioners on Uniform State Laws. (n.d.). The Uniform Emergency Volunteer Health Prac- missioners on Uniform State Laws, n.d.). The act’s titioners Act. Retrieved June 23, 2009, from http:// provisions address several areas of concern related uevhpa.org/DesktopDefault.aspx?tabindex2&tabid67 to deploying volunteer healthcare professionals from Ulmer, B. C. (2001). Army Nurse Corps celebrates 100th the private sector during disasters. Registration sys- anniversary. AORN Journal, 73(1), 8–14. tems and the recognition of current and valid licens- U.S. Army. (n.d.). The Army Nurse Corps. Retrieved June 21, es in other states are key areas of focus. Each state 2009, from http://www.army.mil/women/nurses.html

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