Almost 1 in 10 nurses who were issued new licenses last year waited six months or more, an NPR analysis found. Nurses say patient care suffers as these delays make staffing shortages even worse.



An NPR investigation finds one reason why hospitals are struggling to find enough nurses. We know about the nursing shortage through waves of the pandemic. What we did not know is a barrier to filling those jobs. Nurses right out of school and nurses who move to new states often want to help out but cannot because they're waiting on state licensing boards, which can take months to process their applications. Our team of reporters working this story includes Austin Fast with NPR's investigations team. Good morning.

AUSTIN FAST, BYLINE: Good morning, Steve.

INSKEEP: Also Jayme Lozano of Texas Tech Public Media in Lubbock, Texas. Welcome to you.

JAYME LOZANO, BYLINE: Good morning, Steve.

INSKEEP: And Brett Sholtis of WITF in Harrisburg, Pa. Welcome back.

BRETT SHOLTIS, BYLINE: Hey. Thanks for having me, Steve.

INSKEEP: So we've got a little bit of a nationwide survey here. And, Brett, let's start in Pennsylvania. What's the situation where you are?

SHOLTIS: Well, in Pennsylvania, hospitals and nurses unions say there just aren't enough nurses to meet the need right now. And it's not just nurses saying that. A recent survey of hospitals found that more than 1 in 4 nursing jobs were vacant in November and December. Long waits for licenses is one reason for that shortage. And so at the start of the pandemic, average waits were seven weeks. Here, they've more than doubled to 15 weeks, and some people wait much longer.

INSKEEP: And is it the same in Lubbock, Texas, Jayme?

LOZANO: Yes, actually. We have some people who were waiting as little as, you know, maybe three weeks, but we have several who were waiting over 400 days. So that's not a great processing time.

INSKEEP: Wow. So we're talking about someone who is qualified as a nurse, may even have been a nurse in a different state, but they have to get relicensed when they move, and it takes more than a year to get that license, even though there's a crisis?

LOZANO: Unfortunately, yes, that's what we're seeing.

INSKEEP: And why would that be in Texas?

LOZANO: Well, in Texas, it's for a couple of reasons. The biggest being that right as the pandemic started, I should say, the state board of nursing had to trim its budget, and it didn't have as many people working there as they normally would like. But on top of that, they also had to learn how to do everything remotely because of the pandemic. And Mark Majek - he's the director for the Texas Board of Nursing - he says that figuring out that process really delayed their workload.

MARK MAJEK: You can always say, great, there's more nurses coming to Texas, but you still have to do the criminal background check, verify their license from other states and, in our case, even other countries.

LOZANO: The Texas board is working to hire additional staff, but that is tough since the governor asked all state agencies to cut their budgets because of COVID.

INSKEEP: OK, so a wait of months in Pennsylvania, a wait that can in some cases be more than a year in Texas. Austin, is that normal across the country?

FAST: Unfortunately, it's happening in a lot of states. So as part of this investigation, I asked every state's nursing board for records to see when all their nurses submitted an application and when those nurses actually got that license issued. We got records from 32 states. We're talking almost a quarter of a million nurses just in 2021. And more than a third of all those new nurses licensed last year waited over three months. Many waited half a year or longer. And again, this was happening as hospitals were struggling to cover shifts.

INSKEEP: I want to be fair here. You've got a state licensing board. They want to follow the law. They also want to make sure that a nurse is, in fact, qualified in the way that they say. What is a reasonable amount of time for them to take to confirm someone's license?

FAST: Yeah, that was a really tricky question for us to answer because every state has its own laws, so it's a little bit different in every state. But what the records show us is that it's possible to go faster. We saw Colorado was processing these same types of licenses, and they were doing it in 19 days. And there was another large state, Illinois, which averaged 30 days. So it can be done quicker.

INSKEEP: Brett Sholtis, what are you hearing from nurses themselves?

SHOLTIS: Nurses in Pennsylvania are frustrated, especially when the board is often blaming them for the delays. Here in Pennsylvania, the state spokesperson says a lot of the first-time applicants are leaving off critical parts of the application, like test scores or proof of their education, and that's adding more time. That's probably true. It's certainly true in some cases. But a lot of the nurses we spoke with say they did everything right and still saw delays. For example, Reeny Pereira already had a Maryland license when she moved to Pennsylvania last summer, but it took more than five months to get her Pennsylvania license.

REENY PEREIRA: The guy was so rude. And he was like, yeah, any additional documents is going to take another 12 weeks. I was like, I already waited 12 weeks. You're asking me to wait another 12 weeks?

INSKEEP: What does this mean on a day-to-day basis for hospitals, Jayme?

LOZANO: Well, over here in Texas, it really means that all hands are on deck. Tammy Williams - she leads the nursing staff at University Medical Center here in Lubbock. She told me that she has been a nurse for almost three decades and that this is the hardest time that she's ever had trying to find nurses.

TAMMY WILLIAMS: It's painful, right? Because at UMC, we don't close beds. And so regardless how many nurses we have, that means then that we have to get our leaders, educators, other people to help staff and take care of those patients.

LOZANO: But it's still clearly not the best solution because these people are helping, but they can't do what a nurse can. So it could lead to a lower quality of care.

INSKEEP: Is there evidence that this is, in fact, affecting the quality of care for individual patients?

SHOLTIS: Nurses say the delays can hurt patients. You know, it's part of this whole feedback loop of staffing shortages. The delays add to staffing shortages. Staffing shortages can lead to worse care. Nurses know this, and they get burnt out and sometimes even traumatized by it. Nurses quit, and that also adds to those staffing shortages. So, you know, nurses say it's just really frustrating to be dealing with all that and then also be battling the nursing board, when they really want to be focused on patients. Here's Reeny Pereira again.

PEREIRA: The state really needs nurses, but you're delaying us to even work there. There's a lot of travel nurses that want to come to Pennsylvania and want to work, but it's just - this whole process is just - it's ridiculous.

FAST: This is Austin. And it doesn't have to be ridiculous. Nurses moving to California, for example, have to send fingerprints in on paper cards, which can take months to process. And other states that do it digitally, they obviously go a lot faster. And that's just one example. The bottom line here is there are states that prove it's possible to license nurses faster, and meanwhile, nurses in those slow states will just keep waiting.

INSKEEP: Austin Fast with the NPR investigations team, Jayme Lozano of Texas Tech Public Media and Brett Sholtis of WITF in Harrisburg, Pa. - thanks to all of you for your work.

SHOLTIS: Thanks, Steve.

LOZANO: Thank you.

FAST: Thank you so much.

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