Compact Licensure for APRNs: The Chasm We Must Bridge

You’ve probably heard the phrase “Don’t let perfect be the enemy of good.” Suggesting that sometimes our desire for perfection prevents us from doing what is good may not seem like a fit in healthcare. With patients, perfection in the form of the best care possible is our aim. However, there are other elements of nursing where, perhaps, this phrase offers guidance. Take, for example, the situation with APRN Compact licensure.

Wait, there’s a Compact license for APRNs?

Most nurses are aware of the Nurse Licensure Compact (NLC), which offers nurses a path to practice across state lines without maintaining multiple separate state licenses, similar to the way a driver’s license in one state allows us to drive in other states. The NLC was developed by the National Council of State Boards of Nursing (NCSBN) as a means to provide RNs and LPNs with licensure portability. If you would like to learn more about the NLC, NCSBN offers resources to guide nurses and employers on its use. As of December 2023, 41 jurisdictions are members of the NLC.

In 2020, the NCSBN delegate assembly voted to adopt a Compact for APRN licensure. The first APRN Compact bills were introduced in early 2021 and four states, Delaware, North Dakota, Utah and South Dakota, have since enacted the APRN Compact. In the most recent session, in 2023, seven states introduced APRN Compact legislation. In four jurisdictions, the legislation received hearings, and in three, it passed out of one legislative chamber. Multiple states have considered the APRN Compact, but as often happens with legislative and regulatory processes, it takes several tries before a bill passes. The APRN Compact will become operational when a total of seven state legislatures enact it. Interestingly, one of the roadblocks to advancing the APRN Compact is a controversy in the nursing profession.

Why is the APRN Compact controversial?

As described in this video from the American Academy of Nurse Practitioners (AANP), two elements of the APRN Compact generate significant concern. First is the requirement that APRNs who seek a Compact license complete 2,080 hours of clinical practice, which is equal to about one year of full-time practice. This is a pain point for some state and national APRN membership organizations. Requiring hours of practice seems to suggest that APRNs are not practice-ready after graduation from an accredited program. In addition, there is no evidence that requiring hours of practice for licensure improves patient safety.

This requirement is included in the APRN Compact in response to the current policy environment for APRNs across the country. A growing number of states, many of which permit independent practice for one or more APRN roles, are requiring transition to practice (TTP) periods as a pathway to independent practice. TTP periods are mandated periods of supervision, collaboration or mentorship with physicians or other APRNs before APRNs can practice independently. Unlike TTPs, the 2,080-hour practice requirement in the APRN Compact carries no supervisory, collaborative or mentorship requirements. In fact, the APRN Compact codifies independent practice by authorizing multistate licensees to practice “independent of any supervisory or collaborative relationship.” The practice hour requirement only requires the APRN to demonstrate 2,080 hours of practice experience as an APRN before applying for a multistate license. It is a practical requirement that recognizes the current APRN practice environment across the states, while making licensure mobility for APRNs a possibility.

As you consider the 2,080 practice hour requirement, remember that it does not affect existing single state licensure. APRNs will follow the same process they follow now to obtain single state licensure and then, a year later, become eligible for Compact licensure. Current APRNs who have already practiced for 2,080 hours will meet this requirement on day one and will thus be eligible for Compact licensure immediately, when it is available to APRNs in their home state. New APRNs would get a single state license and work for a year before being eligible to apply for an APRN Compact license. If they prefer, new APRNs can also seek multiple single state licenses while completing the clinical practice hours or choose to maintain multiple licenses rather than seek the optional APRN Compact license. The APRN Compact does not change current paths to practicing in multiple states. Instead, it offers a new path that is optional for APRNs to use.

The second objection to the APRN Compact concerns the plan for how it will be governed. Similar to the NLC, once the APRN Compact is operational, each state that adopts it will have an administrator serve on the Compact Commission, represent their jurisdiction as a member of the APRN Compact, and participate in the governance of the APRN Compact. The administrator, per the Compact language, is either the head of the state licensing board or their designee. Those who object to the Compact argue that the administrators should be APRNs, and many heads of state licensing boards are not.

In considering this objection, it is important to understand the role of the Compact Commission. The quasi-governmental body, which governs the operations of the Compact, does not have the authority to change state licensure requirements or scope of practice decisions, and it doesn’t have any disciplinary authority over a licensee. All of those functions remain with the state boards of nursing. As the commission’s duties are to govern the operations of the Compact, it is appropriate for the administrator to be in a regulatory role and an expert in the licensure and regulation of APRNs in their jurisdictions. Regardless, APRN organizations raise the following point: Is it fair to have a body involved in APRN licensure that may not include APRNs?

Those are big concerns. What’s good about the APRN Compact?

Separate from those two controversial elements, the APRN Compact offers many potential benefits for APRNs, particularly for APRNs working in acute and critical care. These include:

• Support for nurses who provide care remotely through tele-critical care or tele-health technology
• Flexibility for practice, especially for APRNs who work in healthcare systems that have facilities in multiple states
• Regulatory simplification, as the APRN Compact alleviates the need to apply for and maintain licensure in multiple states
• Access to clinical preceptors for APRN students (the NLC has been a huge boost to nursing education programs, which can engage clinical instructors and preceptors across state lines)
• Efficiency for APRNs who are members of military families and thus relocate often
• Cost savings for the APRN who doesn’t need multiple APRN licenses
• Enhanced ability to respond to disasters and other public health emergencies (we learned the importance of regulatory efficiency in the COVID-19 response)

Individual APRNs recognize the benefits, too. NCSBN partnered with state boards of nursing to survey APRNs about their interest in having the APRN Compact in their states. Over a two-year period, from 2021 to 2023, APRNs from five states (Arizona, Maryland, Montana, West Virginia and Wyoming) responded to surveys. 86% of respondents support having the APRN Compact in their state, and 84% report they would apply for an APRN Compact license if it were available. The latter number is not surprising, because 67% of respondents reported the need to provide nursing care or education across state lines in the last two years. These results demonstrate that despite the controversy over practice hour requirements and governance board representation, in this sample of over 8,400 APRNs, most were in favor of the APRN Compact.

So, what’s my role?

Understanding what is good about the APRN Compact and also how it is not perfect is crucial. Following are specific actions you can take to support your own practice as an APRN as well as regulatory efficiency for all APRNs:

• Get information from your state nursing association and from your state board of nursing.
• Question information from unreliable resources.
• Read about the Compact and the different perspectives, remembering that these perspectives come from organizations with different missions. A few resources/position statements to consider:
  • NCSBN APRN Compact
  • AANP and the APRN Compact Viewpoint
  • NAPNAP and the APRN Compact Viewpoint
• Talk with other APRNs, listen to their perspectives, and be ready to clarify your own.
• Advocate that all nursing parties involved work together to realize the best options.

Conclusion

I understand the position taken by leading APRN organizations that the APRN Compact is not perfect. At the same time, I see an opportunity for good. This is such an important issue for nursing, and we must work together to resolve it. Our patients deserve access to APRN care, and we know that removing barriers to practice is a key priority.

Post your comments about the APRN Compact in the space below!

Special Acknowledgement

I acknowledge and thank my co-author, Denise Buonocore, MSN, ACNPC, CCNS, ANP, CCRN, CHFN, certification practice supervisor, American Association of Critical-Care Nurses, for contributing to the development of this blog.