The National Council of State Boards of Nursing (NCSBN) adopted a revised version of model APRN Compact legislation on August 12, 2020. The intent of the compact is to allow advanced practice registered nurses (APRNs) to have a multistate license that allows practice in compact states.1 This is the third iteration of the compact. The first was adopted in 2002 and the second in 2015; however, only 3 states enacted each model into law, which fell short of the 10 states needed for implementation.2 Should NPs advocate for the compact? What are the potential benefits and barriers the compact might create?

The opportunity to practice in different states with only one license is appealing for NPs who hold multiple state licenses. COVID-19 has highlighted the need to eliminate barriers to using telehealth and to facilitate NP employment and volunteerism in response to healthcare emergencies. From a regulatory perspective, problems and potential negative impacts could arise should the compact be implemented.

Practice hours requirement

The most high-profile element of the compact under dispute is the added requirement that an APRN have 2,080 practice hours to be eligible for the multistate license. A motion at the NCSBN business meeting proposed by Washington state to eliminate this requirement failed.3 The American Association of Nurse Practitioners (AANP), the National Association of Pediatric Nurse Practitioners (NAPNAP), and the Nurse Practitioner Roundtable, which includes AANP, NAPNAP, the National Organization of Nurse Practitioner Faculties, Gerontological Advanced Practice Nurses Association, and the National Association of Nurse Practitioners in Women's Health, opposed the practice hour requirement. The organizations noted that APRNs are prepared for practice at graduation and the practice hour requirement conflicted with the APRN Consensus Model.4-6

Compact administration

Another concern is the administration of the compact, which would occur through a commission whose leadership would be comprised of one administrator from each state who enacted the compact; the head of the state licensing board or designee would be the administrator. This provision would make it highly likely that few if any administrators would be an APRN. Both the AANP and NAPNAP recommend that an APRN advisory committee be created to advise the compact's administrators regarding APRN practice.4,5

Disparities

Further analysis of the compact reveals additional important provisions to consider. For example, the APRN practicing under a multistate license would be subject to the jurisdiction of the licensing board, the courts, and the laws of the state in which the client is located at the time of service.7 As a result, the APRN could be disciplined differently than what might occur by the state in which the APRN is licensed, the home state, with more or less of an investigation, a stricter or more lenient ruling and actions on the license, and financial penalty.

APRNs practicing among compact states would be subject to different initial licensure and renewal requirements but only need to meet the requirements of their home state, the one in which the APRN resides that issues the compact license. For example, an APRN in North Dakota, which has already endorsed the APRN Compact, who applies for prescriptive authority must provide evidence of 30 hours of pharmacology education in the last 3 years.8 However, an applicant in Washington state, which has not adopted the compact, must have completed those hours in the prior 2 years (unless applying as a new graduate).9 License renewal requirements for APRNs also differ between the two states.

Continuing competency rules in Washington require every nurse-with the exception of nurse anesthetists-to complete a one-time training in suicide assessment, treatment, and management.10 This is not required in North Dakota. This disparity between states would also result in APRNs who practice under a single state license in some states having more requirements for licensure and renewal than an APRN practicing in the state under a compact license.

Prescriptive authority

One benefit of the compact relates to prescriptive authority for noncontrolled medications with no restrictions. Controlled substance prescribing would require that an APRN fulfill all the requirements for controlled substance prescribing in the state in which the APRN practices.7 This might result in an APRN prescribing more medications in a state other than their home state, although it is unlikely a state with restricted practice would adopt the compact.

While NP organizations see the practice hour requirement as restricting compact licenses, 80 medical societies and boards of medicine contacted NCSBN in 2018 asking for the removal or substantial revision of the sections that grant prescriptive authority and independent practice without a supervisory or collaborative relationship with a physician. The organizations consider these provisions as expanding scope of practice in states with contradictory laws.11

The compact also requires use of the model legislation with no material differences for enactment into law.1 States can neither opt to amend the provisions to eliminate the practice hours requirement nor make other changes. Amendments to the compact can occur only if all compact states enact the changes into law with the same language.7 The multistate license is the default, requiring APRNs to choose a single state license, effectively forcing the APRN to opt out of the compact rather than opt into it.7

One final consideration is the effect of a compact on the overall NP workforce. Should NPs be working in multiple states? Should there be an effort to stabilize the NP workforce in each state so that out-of-state NPs are not needed? In states with few job opportunities, NP programs should consider adjusting admissions to match supply with demand. And perhaps salaries should be higher to encourage retention of NPs rather than offering higher salaries to NPs who travel to another state. And where does telehealth fit with the compact and state laws?

Options for advocacy

This version of the compact requires only seven states to enact it into law.7 Before deciding whether to support or oppose the APRN Compact, APRNs should read the document1 to become familiar with the details. Once a position is decided upon, APRNs should query their state's NP organization(s) as to whether it has taken a position on the compact. APRNs should also contact their board of nursing to determine if it has considered endorsing or opposing legislation to enact the compact. APRNs should determine the extent to which they want to advocate for support of or opposition to the compact. NPs must be prepared to articulate the implications of joining or not joining the compact.

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