What is the APRN Compact for Multistate Licensure? Challenges & Opportunities
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“Respect the autonomy of each state. I would eliminate the compacts and have each state board of nursing regulate nurses working in their state. This way, each state can regulate what’s important for their state. Then, I would have an expedited license. For example, incoming APRNs would get a temporary license and could go to work the next day. Once they comply with all the requirements of their new state, they would get a full license. It would no longer take months and months to get a license.”
Vicky Byrd, MSN, Chief Executive Officer of the Montana Nurses Association (MNA)
To practice as an advanced practice registered nurse (APRN), it is necessary to have a license in the state where the care is being provided. In most cases, the licenses are issued by the state board of nursing, and requirements will vary by state. The qualifications required can also vary based on specialization, such as nurse practitioner (NP), certified nurse midwife (CNM), certified registered nurse anesthetist (CRNA), or clinical nurse specialist (CNS).
Licenses are typically restricted to the state they are issued in without an interstate compact. Several professions, including registered nurses (RNs), physical therapists (PTs), and doctors, have agreements that allow license holders from a member state to work in other member states. “The National Council of State Boards of Nursing (NCSBN) owns and executes the RN compact. Their rationale for the compact is that it allows mobility for nurses to cross state lines. For example, somebody could live close to the Idaho border and potentially drive into Montana to work,” explains Vicky Byrd, CEO of the Montana Nurses Association.
To date, a compact for APRNs has yet to be enacted. The NCSBN has put efforts forward since August 2020 to move this effort forward. However, the legislature for the compact has only passed in three states, with pending bills in one more. Seven states must enact the compact for it to go into effect. Only some think the compact is a good idea, and there has been strong opposition from many national organizations, such as the American Association of Nurse Practitioners (AANP) and the National Association of Pediatric Nurse Practitioners (NAPNP). Montana’s proposed bill to join the compact was voted down on April 4, 2023.
“On paper, the compact sounds good,” says Byrd. “You just need one license, and you can travel anywhere. But it’s more complicated than that.”
Keep reading to learn more about the APRN compact, why there is so much opposition, and what the future might look like for the compact.
Meet the Expert: Vicky Byrd, MSN, RN
Vicky Byrd, MSN is the chief executive officer of the Montana Nurses Association (MNA) and has been a registered nurse since 1989. She started her career as a certified pediatric nurse and, in 2002, moved forward with her professional development and became a certified oncology nurse.
Byrd practiced as an oncology nurse until 2014, then transitioned to her nurse leadership role as CEO for MNA. At the national level, she leads the MNA members with their affiliation with the American Nurses Association, American Association of Nurse Practitioners, and American Federation of Teachers-Nurses and Health Professionals. In April 2019, she obtained her master of science in nursing, with a program study in nursing leadership and management.
The APRN Compact
In 2020, the NCSBN adopted the APRN Compact for multistate licensure. They drafted model language for state legislatures to enact. Per the NCSBN, the compact was established to “increase access to care, protect patient safety, and reduce costs while supporting state-of-the-art healthcare delivery.”
The key benefits listed for the compact include easier access to care, the ability to provide telehealth services, ease in providing disaster and pandemic relief, flexibility for military families, simpler online nursing education, and a lower cost since APRNs need to maintain only one license. The proposed compact would allow APRNs with 2,080 practice hours to practice in their home state as well as any other state in the compact.
Challenges With The APRN Compact
Not everyone thinks that the APRN compact is as advertised: “A compact will not solve your provider vacancies,” says Byrd. “When Montana opened up the RN compact, nurses did not flood into the state. It hasn’t fixed the staffing crisis.” Here are some of the top concerns and challenges with the APRN compact.
Licensing Follows The Patient
One of the outcomes of compact licensure is that the rules changed how and where providers can care for patients. “What the compact did is it changed how we practice nursing in that our license no longer belongs to us. It goes with the patient,” explains Byrd. “So if you come into my oncology clinic, I take care of your child, and you go on vacation to Hawaii, which isn’t a compact state, I would tell you that I can’t tell you how to take your nausea medicine because you’re out of state and I am not licensed to care for you there.”
She continues, “Once they’ve established care with a patient, just because they travel to another state doesn’t mean you shouldn’t be able to provide continuity of care.”
Still Need a Home License
If the APRN compact were enacted, nurses would still need to maintain a license in their home state. While this is great for traveling nurses, anyone who relocates still needs a new license. “If you pack up your family and move to Iowa because they’re a compact state, your compact license doesn’t work anymore. You must get an Iowa state license because it is your new home state. Not everyone thinks this through,” shares Byrd.
Lack Of Oversight
According to Byrd, nurses working on compact licenses don’t have sufficient oversight: “There’s no way to monitor those working on a compact license in your state. That means there’s also no enforcement. The Montana Board of Nursing doesn’t even know they have come in. They can just continue to work on their multi-state license. Many will just renew their home state license, which may not have the regulations we do. For RNs in Tennessee, they don’t need any contact hours to renew, which in Montana, you do,” she says.
Required Practice Hours
The most significant pushback to the APRN compact has been the required practice hours. To have a multistate compact license, APRNs will need 2,080 hours. “We believe in APRNs practicing to the highest extent of their education, which in Montana includes full practice authority for over four decades. As soon as our nurse practitioners graduate and get board certified, they’re ready to care for patients and do not need supervision,” explains Byrd. If Montana joined the compact, they would have more restrictions to practice as APRNs than they do now.
The AANP’s position statement says, “APRNs are prepared for safe entry to practice at the point of graduation from an accredited graduate program and after the successful passage of a national certification board examination. The inclusion of minimum practice hours as a requirement for a multistate APRN license creates unnecessary and costly regulations for all states and new challenges for the states currently working to retire similar barriers.”
The Future of the APRN Compact
Presently, the APRN compact is moving forward slowly. Currently, North Dakota, Utah, and Delaware have joined the compact, and it is pending in Arizona, Texas, Kentucky, New York, and Maryland. There must be a minimum of seven states for the compact to go into effect.
However, many want the compact to be re-written: “They need to go back to the drawing board and invite the APRNs to the table so they can voice their concerns. Let’s make it make sense,” encourages Byrd.
For Byrd, her ideal program would look very different: “Respect the autonomy of each state. I would eliminate the compacts and have each state board of nursing regulate nurses working in their state. This way, each state can regulate what’s important for their state. Then, I would have an expedited license. For example, incoming APRNs would get a temporary license and could go to work the next day. Once they comply with all the requirements of their new state, they would get a full license. It would no longer take months and months to get a license,” she says.
Kimmy Gustafson
WriterAmong her many diverse writing endeavors, Kimmy Gustafson has also lent her expertise to NPSchools.com since 2020, providing insightful and engaging content about the significant role of education in shaping our future generations of nurse practitioners. Many of her pieces include interviewing experts on timely topics such as healthcare workplace violence and moral distress.
Kimmy has been a freelance writer for more than a decade, writing hundreds of articles on a wide variety of topics such as startups, nonprofits, healthcare, kiteboarding, the outdoors, and higher education. She is passionate about seeing the world and has traveled to over 27 countries. She holds a bachelor’s degree in journalism from the University of Oregon. When not working, she can be found outdoors, parenting, kiteboarding, or cooking.