Three hours spent on hold. That's how long Courtney Gramm waited one day, all so that she might get her license from the state of California to work as a nurse.
That morning was just a snapshot from a long ordeal. "Panicked, anxious, frustrated, mad even," Gramm describes how she felt as she called over and over. "I just couldn't get any information out of them."
Gramm waited seven months for her nurse practitioner license at a time when COVID-19 cases were skyrocketing across the U.S. and hospitals were desperate to keep nurses on staff.
Her story is a familiar one for nurses throughout the country. Nursing boards, meant as a safeguard, have become an obstacle, preventing qualified nurses from getting into the workforce for months when basic vetting should take only weeks.
An NPR examination of license applications found that nurses fresh out of school and those moving to new states often get tangled in bureaucratic red tape for months, waiting for state approval to treat patients.
"Huge bottlenecks" is the phrase Morris Kleiner, a licensing expert who researches labor economics at the University of Minnesota, used to describe NPR's findings.
"Patients will have much less access and will have to wait longer when they are asking for the services of nurses. And this is especially true during a pandemic," Kleiner adds, concluding that delays could lead to sicker patients or even death.
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Two years of the pandemic have pushed health care workers to the brink, with federal data showing that critical staffing shortages plagued 1 of every 4 hospitals nationwide through the omicron wave. Early retirements and employee burnout have already chipped away at the nursing workforce, and backlogged license applications can exacerbate shortages by keeping eager replacements off the front lines.
Some states have tried to mitigate these delays by issuing temporary licenses, which can get nurses working as boards process their applications. It's an additional cost, and many nurses don't apply for them. Plus, they typically last just a few months.
Betsy Snook, CEO of the Pennsylvania State Nurses Association, says her team has fielded dozens of requests per week from nurses desperate for help.
"[Nurses are] emotionally exhausted. They're physically exhausted. We add to that the frustration of not being able to get your license," Snook says. "Your mother, your father, your grandmother, your grandfather are not going to get the level of care that they should have if staffing were appropriate."
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NPR asked every state nursing board in the country for records showing when nurses submitted an application and when their license was issued over the last three years. We calculated each nurse's total processing time, along with averages for the 32 states that provided records.
The remaining boards denied NPR's request — citing state privacy laws or claiming they couldn't provide application dates — or they requested fees, including Georgia, which demanded more than $434,000 to provide the records.
Stuck in licensing limbo
Many delays are caused when simple mistakes lob a wrench into the gears of the machine: misplaced files, bad communication between states, and emails missed or ignored.
Courtney Gramm, the nurse practitioner in California, was rattled when her new boss threatened to retract her job offer. Six months after she'd moved from Florida and applied for her license, the state board told her would-be employer that Gramm still hadn't submitted her college transcripts.
"I knew that I had submitted everything that the board of nursing was asking for," Gramm says. "I was so embarrassed. It was not the first impression I was hoping to make on my new boss."
She appealed to her state Assembly member for help. Five days later, she received her license.
"My transcripts were always sitting in some email inbox," Gramm says. "No one took the time to just go in, fish them out, attach them to my application, and then process my application."
Nurses across several states told NPR their applications had been mistakenly marked incomplete. When Brenda McNeely moved to Pennsylvania, she needed written verification from each state where she'd had a nursing license.
She explains that landed her in licensing purgatory: "California says, 'We sent it.' Pennsylvania's saying, 'We never got it.' "
After six months and a call to the governor's office, McNeely finally got her license.
Freshly minted nursing graduates run into these document disputes, too. Lynn-Marie Charles teaches nursing at a Philadelphia-area community college and has watched her students wrestle with licensing delays. She fell into the trap as well while applying for her own nurse practitioner license last fall.
"Each time there's a discrepancy or you give them a call about the discrepancy, they do not review your application again for almost two weeks, so you're placed back in the queue," Charles says. "And when your number comes up again, someone will review your application. It's just a waiting game."
And any glitch can set an application back months.
A survey of Google reviews and Reddit threads about state boards suggests these nurses' struggles aren't isolated incidents. Hundreds of postings from nurses across the country allege agonizing hold times, poor customer service and lost documents, even in states NPR found to be faster at licensing.
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How long is too long to wait?
Reviewing applications does take some time. Boards typically verify nurses' education, run a criminal background check and wait for new graduates to pass a national exam.
How much time depends on the state. In Georgia, the board promises to review applications within 15 business days; in Florida, it's 30 days. California has up to 90 days.
Issuing licenses can take far longer, though.
There are all sorts of reasons why it can take so long.
Some nursing boards — including Alaska, Georgia and Texas — have blamed slow processing times on staff shortages, increased workloads and remote work. At least 10 nursing boards have posted notes online through the pandemic, pleading for patience.
California's registered nursing board has just 47 people on staff handling licenses. That's for a state with nearly a half-million RNs. That works out to 10,000 nurses for each employee to assist — whether they're applying for a first license or renewing a license or asking about continuing education requirements.
On top of all that, many states were inundated with thousands more applications last year compared to 2020 as traveling nurses followed COVID-19 waves across state lines.
Spokesperson Monica Vargas from California's boards acknowledges the sheer volume of the workload, but she also blames long waits on factors outside their control — the state Department of Justice might be running behind on criminal background checks or new graduates could delay taking the nursing test.
When to start the clock
Wait times stretch even longer than what many states say in official reports. That's because boards start the clock, in some cases, long after a nurse actually submits an application.
In Virginia, the Board of Nursing reports that it processes 99% of applications within 30 days.
But consider the case of Towson University alumna Kaede Fujiwara: The Virginia board would likely classify her license as ready within 30 days.
Fujiwara says it took more than five months to get her new license.
The reason for the discrepancy: The board doesn't start its clock until an application is marked "complete," meaning all materials are in and ready for review.
For Fujiwara, getting the board to acknowledge that her application was complete took months. Board employees repeatedly said Towson University hadn't sent proof of her clinical experiences even as school staff assured her they'd sent it. Days after Fujiwara's Virginia state delegate contacted the board on her behalf, her application went through.
She lost a job offer because of the delay. A local hospital moved on to more available nurses.
"It's frustrating. It's disappointing. It's exhausting," Fujiwara says. "I'm embarrassed, you know? I'm a nurse, and I'm unemployed in a pandemic. Like, what kind of an excuse is that?"
If you start the clock at the point nurses submitted an application, NPR's analysis of Virginia's records shows just 1 in 4 licenses were issued within 30 calendar days, well below the 99% figure.
Virginia Board of Nursing spokesperson Diane Powers acknowledged their measures are based on days from "when an application is deemed complete and the license is issued." She added, "As you can imagine, there are times when receipt of these materials moves more quickly than others."
Other states tend to highlight more flattering statistics as well. At February's meeting of the California Board of Registered Nursing, Executive Officer Loretta Melby touted processing times under 60 days, claiming "we're moving toward the 30-day mark."
Her statement is true for hundreds of complete applications but ignores thousands of "incomplete" applications.
Almost 4 out of every 5 out-of-state applications get marked as "deficient," according to the most recent data from California's website. And it's taking 160 days on average for those people to get licensed, months slower than the 30-day mark.
Some states aren't part of an interstate agreement
Many of the nurses facing long wait times have already been licensed in other states, but they're forced to start over and apply for a new license when they travel.
It's almost like a cross-country drive where travelers must stop at each state line to pass a new driver's test and then wait for it to come in the mail. Nurses' licenses were like this until 2000, when states began joining an interstate agreement called the Nurse Licensure Compact.
Now covering 35 states and Guam, this agreement allows more flexibility for nurses living near state borders and those who want to take short-term jobs in other states without waiting on another lengthy licensing process. The agreement's creators claim it improves access to health care and helps address nursing shortages.
However, several states with the most nurses have held out from joining for years, including California, New York, Illinois and Massachusetts.
Nursing boards and unions worry about losing licensing fees, which often provide the bulk of boards' funding. California's registered nursing board collected more than $66 million in fees from nurses in 2020 alone, according to state documents.
California opposes joining the agreement because its boards would lose the ability to make sure a nurse's education "meets California standards before they are licensed to practice here," Vargas writes. She also says the compact could slow down discipline of irresponsible nurses.
Plus, highly unionized states have been more hesitant to join since it might push down wages or help break strikes, according to Joanne Spetz, an economist who studies the health care workforce at the University of California, San Francisco.
"That's a purview of the state to say, 'We think that our requirements should be higher.' And that's a barrier," Spetz says. A barrier to nurses moving between states and getting licenses to work quickly.
At least 147,000 nurses reapplied in a new state last year, according to NPR's analysis, which is a serious undercount since Georgia, Florida, New York and several other states did not provide records.
Reeny Pereira was one of those nurses. She'd already been licensed for years in Maryland, but Pennsylvania, which isn't part of the Nurse Licensure Compact, wouldn't recognize that license. Pereira waited five months for a new Pennsylvania license, and she even considered working for Costco or babysitting since she couldn't take a hospital job during that time.
"If I was moving," she says, "I would definitely see if that state is a compact state, which is a little bit easier to get a license."
Pennsylvania's board told NPR that it has worked hard to reduce its application backlog while being "very transparent about its processing times." Like California, Pennsylvania has more than 10,000 nurses for each member of its licensing staff. They've created application tip sheets, and they meet with hospitals and nurses unions to help nurses apply.
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There must be a better way
Jesse Chapman, a nurse who waited almost five months last year for a Virginia license, says there must be a better way to become a nurse.
"It should be corporate, right? It should be like going to McDonald's," he says, meaning a fast, standardized process and a simple transaction. "Here are the 10 things we need, pay with a check or money order, and be done."
A few states seem to have figured out the art of short-order licensing. Nurses moving to Vermont last year got their licenses in just one day.
"Frequently, we're processing RN endorsement applications within 45 minutes of them being submitted," says Lauren Hibbert, who directs Vermont's Office of Professional Regulation.
Vermont adopted an all-digital process several years back, Hibbert says. The board created a centralized, online customer service system that allows any employee to send and receive messages from applicants if any questions pop up. Before the switch, applicants could reach out and get a different customer service rep each time, which made it tough for any employee to pick up the case's trail.
Vermont handles a fraction of the nurses that states like California, New York or Texas must manage, but Hibbert says digitalization and cross-training staff should help much larger states, too.
"Having those licensure applications move quickly through the system — having your potential workforce be unlocked faster — is in the entire state's interest," Hibbert says. "Everyone is experiencing staffing shortages. The faster we can get a nurse into the system, the better."
Vermont's processing times will slow down this year because it will now require criminal background checks rather than asking nurses to swear they have no criminal or disciplinary past. Hibbert estimates that'll add a four-week delay to Vermont's wait times, but that would still put it among the fastest states NPR examined.
Those background checks slow things down, in part, because of the old-tech ways they're processed. Vargas, the California boards' spokesperson, notes that out-of-state nurses have to submit fingerprints on physical cards, which Vargas claims can take up to three months to process. North Carolina also requires physical fingerprint cards, yet records from that board show it issued licenses almost twice as quickly.
States that don't use paper are faster. Illinois, another large state, now accepts digital fingerprints. It issued licenses more than three times faster than California.
California's nursing boards declined a taped interview with NPR, but Vargas offered pages of notes describing efforts to streamline licensing, including accepting more digital documents, creating a new online portal and preapproving nursing school curriculums.
"That should really help getting our new grads out into the workforce as quickly as possible, and the [Board of Registered Nursing] will no longer be a hindrance," said Executive Officer Loretta Melby at February's board meeting.
To fix those long hold times, California's registered nursing board invested in a new phone system last year, allowing nurses to get called back rather than waiting hours on hold.
NPR tried out that system multiple times this month, at various times of day, but each time the recording simply said, "The callback queue is currently full. Please call back at a later date," and hung up.
Courtney Gramm — the nurse practitioner who had so much trouble getting a California license — is just happy she won't need to call back again.
In January, her husband took a new Air Force post near Washington, D.C. This time, Gramm found out the Virginia Board of Nursing offers expedited processing for military spouses. The board issued her new license in less than three weeks.
Additional reporting by Brett Sholtis of WITF in Harrisburg, Pa.
Methodology: NPR requested records for all licensed practical nurses and registered nurses who applied for licensure from 2019 to 2021 from every state's nursing board. We asked for each nurse's name, city, state, license type, license duration (temporary or permanent), application type (by exam, exam-retest, endorsement, renewal, reinstatement, etc.), application status and relevant dates (application submission, date when all required documents received, license issuance date and license expiration date). Some boards provided anonymized records, citing the nurses' privacy, and Connecticut and Virginia couldn't provide details on application type.
Some boards use different terms for the same idea. For example, licensed practical nurses can also be called licensed vocational nurses, and states refer to licensed nurses applying in a new state as "endorsement" or "reciprocity." NPR standardized these terms among the 32 states' records and combined them into one data set. The first states to respond to NPR's request provided records through Sept. 23, 2021, so NPR removed all records after that date from subsequent states to standardize the timeframe. This resulted in a final data set containing more than 226,000 nurses issued new, permanent licenses in 2021.
NPR subtracted the application date from the license issue date to calculate each nurse's processing time in days. We removed 77 nurses' records showing an issue date earlier than their application date, apparently in error. NPR then grouped by state, license type and application type to find median processing times for each of the four major types and to count how many of the nurses' processing times stretched longer than three months, six months, etc.
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