Nurses need our support now more than ever as they manage the frontlines in the fight against Covid-19, working long hours and risking their own well-being to care for those who are sick. With nurses’ crucial work in the national spotlight, it is time for policymakers to address the long-anticipated nursing shortage that could leave the U.S. unable to combat the next health crisis.
Predictions of a shortage of nearly half a million nurses due to retirements are highlighted even more by the realities of this pandemic. An arcane tangle of state regulations is deepening the existing nursing shortage and making it harder to fight the pandemic. It is time to sweep away these unneeded regulations and turn instead to a national standard. The Covid-19 pandemic has made it clear: America needs more nurses to meet urgent care needs, improve health care, and benefit Americans’ health.
Since the start of the pandemic, we have seen states rescind, revise, or waive regulations related to licensing nurses in response to Covid-19, showing that change is not only possible but can happen swiftly. Take telehealth as an example. Once a minefield with regulations that varied from state to state, telehealth quickly became part of the new normal. The elimination of state-by-state variability has supported a more consistent approach to delivering telehealth care across all states.
Nurse licensing and education standards similarly vary state by state, and standardizing regulations that govern state-level nursing education programs must be next.
In the late 1990s, all nurses began taking the same national licensing exam, the NCLEX. Yet even now, every state board of nursing imposes unique education requirements that a program of study must satisfy in order for its graduates to be eligible to take the exam. Even with the national licensing standard, states still demand different requirements in areas such as curriculum, faculty, and simulation. These variations add significant cost with no actual difference in the quality of licensed nurses or how their readiness to practice is measured.
National accreditation is a proven method for determining the quality of educational programs. Accreditors add value through deep expertise in curriculum design and clinical education. National accreditation signals a program’s credibility in design and delivery. It is used by every health profession in the United States — except nursing. Nursing is the only health profession whose state licensing boards engage in educational oversight. Medicine, pharmacy, and all other health fields recognize that licensing boards are not education experts.
Allowing state-by-state curriculum standards for nursing programs is a barrier to innovation and modernization in nursing education, which is woefully behind in its use of technology, including simulation and other methods that advance and optimize clinical learning. It is also a barrier to mobility for nurses. The Nurse Licensure Compact offers nurses mobility to practice across only 34 states and U.S. territories. In the others, nurses must go through a relicensing process that limits their ability to practice in telehealth or in border locations where they may be delivering care across state lines. While the National Council of State Boards of Nursing has done a great deal of work to resolve this issue through the compact, this has done nothing to address the patchwork of nursing education approvals or the inconsistency of education standards.
In California, for example, the Board of Registered Nursing must approve each faculty member and each clinical site. This process, which is not required by other states, adds bureaucracy and delay. These approvals are redundant, given that nurse faculty requirements are monitored by national accreditors. Even if a hospital or clinical site agrees to support students and signs an agreement to accept students, the Board of Registered Nursing requires additional approval through its processes. The board also retains archaic curriculum requirements, like limiting the use of simulation in education and prescribing when and how clinical education is implemented. These remnants of outdated education standards do not protect students or their patients, nor do they ensure high-quality nursing graduates.
In contrast, the Texas Board of Nursing has shown substantial leadership in removing unnecessary barriers and bureaucracy and supporting innovation. The Virginia Board of Nursing in March took the bold step of waiving final clinical hours for nursing students in their senior year to expedite their licensing and entry into the workforce. These are laudable efforts, but they don’t go far enough.
It is time to modernize the role of nursing boards and remove regulatory barriers that have outlived their value, as has been done for telehealth. By making these changes, we can begin to address the looming shortage.
We are calling on policymakers to make the following reforms:
National accreditation. All nursing education programs should be nationally accredited. Accreditors have the widest lens across the nation and are committed to evidence-based accreditation.
State approval by proxy. Any nursing program that is nationally accredited and maintains or exceeds the national NCLEX pass rate should be approved in any state through a recognition process, allowing nursing school graduates who pass the NCLEX to practice in any state.
Refocus board resources on licensees. When a program has been examined and found to meet national accreditation standards, it should not be subject to additional scrutiny by state nursing boards. The resources they spend to develop and implement additional regulations on nursing education programs would be better spent on individual nurses, addressing quality issues (including disciplinary actions), creating relicensing plans for nurses with lapsed or expired licenses, and providing novel solutions for supporting nurses in practice.
Modernize board regulations and associated statutes. Boards must update their regulations, including requiring national accreditation and participation in the nurse licensure compact and removing state-level nursing program approval processes.
The Covid-19 pandemic has laid bare the realities of why nursing workforce shortages continue to resurface. The patchwork of duplicative, unnecessary, and outdated regulations will remain a barrier to educating the nurses our country needs. These barriers also contribute to the cyclical nursing shortages that are a common occurrence. The solution is clear, and some states and governors are exercising their authority to solve shortages — in the short term. Shouldn’t a long-term solution be just as important?
Jan Jones-Schenk is the senior vice president and executive dean of the College of Health Professions at Western Governors University. Mike Leavitt is the founder of health care consulting firm Leavitt Partners and served as U.S. secretary of Health and Human Services from 2005 to 2009, administrator of the Environmental Protection Agency from 2003 to 2005, and governor of Utah from 1993 to 2003.
Individual states’ licensing years ago was differentiated because the quality of nursing education varied among the states — certain states, eg NY or CA were recognized nationally, while others were at the bottom…
It is sad to see nurses have so much regulation by people that don’t even know what we do or why we do it. I personally know of at least 24 nurses, young and old, that have retired this year due to covid and many other issues with licensing and demands made on nurses.
I talked to VA RN Recruiter (Seattle) re. applying for ICU RN position , he stated, ” We really need experienced ICU RN’s!” I applied but no Interview,ect for me ( 20+ year ICU RN). I realized what the meaning was – We want a RN with 1-2 years of experience , it’s Cheaper.” I’ve read that hospitals bring over RN’s from other countries not due to a shortage but it’s cheaper !
Dr. Jones-Schenk and Mr. Leavitt’s assessment of the state of nursing’s licensing and education standards is spot-on, as is their appeal for us to “go national.” As a registered nurse and a health care executive, I have found it embarrassing that nursing as a profession still clings to “the way we’ve always done it,” with little room for innovation. Those professions which work side by side with nurses – Pharmacy and Physical Therapy, for instance – have been able to harmonize their educational and entry-into-practice standards, and they remain among the most highly respected professions. Nursing remains stuck with an alphabet soup of degrees and licenses which confuses the public and stymies the individual licensee’s ability to progress.
How does one explain to the public “the patchwork of nursing education approvals or the inconsistency of education standards?” How is it that a Diploma in Nursing, an Associate Degree in Nursing, and a Bachelor of Science in Nursing all lead to the same licensing exam? Why are there differences? And what is the significance of those differences?
This non-standardized educational preparation of RNs has hampered nursing mobility and feeds the fears of those who resist the Nurse Licensure Compact. The few downsides of the Compact are potential loss of revenue to the states’ individual licensing boards, and a weakening of the threat of strike by labor unions.
COVID-19 is shining a light on these aspects of nursing education which do not serve the public or the profession. Let us hope it also provides the push to strengthen the nursing workforce at this time of need.
Ridiculous bureaucratic rules delaying RN licensure in Vermont
I agree completely. If I passed my boards which I did years ago. I should be able to work in any state. Nursing is the same anywhere. And it is always changing. Facility’s can offer classes to update you in your field.
I agree with the barriers to the nursing shortage but doubt states with boards will give up their revenue to streamline the process.
It is about money not excellence!
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