Addressing Nursing Shortages: Options for States

By Sydne Enlund| June 2022


As essential frontline workers, nurses provide direct patient care in just about every health care setting. They assess patient health problems and needs, develop and implement care plans, and advise patients on health maintenance and disease prevention. Nurse practitioners (those who achieve an advanced degree) can take on additional tasks with a higher level of autonomy like prescribing medications, ordering tests and diagnosing patients. Nursing careers make up the largest portion of America's health care professions.

Exacerbated by COVID-19, the nation has faced a shortage of health care professionals for years, with nurses being one of the hardest-hit professions. Nursing shortages brought on by an aging population, aging workforce, nurse burnout, long wait times for licensure approval and extended work hours not only strain health care systems but also affect patient care and overall outcomes. The shortages are particularly dire in rural and underserved areas where lower salaries and intense workloads can impact retention.

A recent survey found that nearly one-third of nurses have thought about leaving their jobs by the end of 2022, mostly due to exhaustion and burnout. The demand for health care services is predicted to increase in the coming years due to an aging population and workforce as well as higher rates of chronic disease. However, the supply of providers is not expected to keep pace with the demand.

State Action

In response to this national shortage, states have examined a variety of options to recruit and retain nurses. Specific policy levers include loosening licensing requirements, changing scope of practice laws, bolstering educational programs, and offering monetary incentives.

With many people receiving virtual care during the pandemic, licensure compacts have gained traction as a way to allow various types of health professionals to provide services to patients in other states. Compacts are formed when a certain number of states enact legislation that includes specific, uniform language or by a certain date, whichever occurs first. Thirty-seven states, Guam and the Virgin Islands have enacted the Nurse Licensure Compact legislation, with Vermont and Ohio most recently passing legislation. This compact is for registered nurses and licensed practice nurses. The Advanced Practice Registered Nurse Compact was adopted in 2020 but is not yet active. Seven states are required to enact legislation for the compact to become active, and only four—Delaware, Kansas, North Dakota and Utah—have passed legislation so far.

Among other licensing policy options available to states, Kentucky allowed the issuance of temporary work permits for registered nurses and licensed practical nurses who are graduates of a foreign nursing school and pursuing licensure in the state. The Oregon State Board of Nursing may now issue a nurse internship license and interns may perform specific nursing functions within the limits of the nurse education program they are enrolled in.

State scope of practice (SOP) laws and regulations define the roles and responsibilities for health professionals. States have taken steps to increase the types of procedures and treatments that are permitted by nurse practitioners to address the needs of an evolving health care landscape. Twenty-six states, the District of Columbia, Guam and the Northern Mariana Islands allow nurse practitioners to diagnose, treat and prescribe medications without physician supervision. During the COVID-19 pandemic, states modified their SOP provisions by waiving some types of practice agreement requirements to allow increased access to providers. During the 2022 legislative session, states began to introduce legislation that would make these provisions permanent.

To bolster education programs, Arizona appropriated $15 million to establish a nurse education pilot program to increase the number of nurse graduates by 2027. The bill also appropriated $27 million for a student nurse clinical rotation as well as a licensed or certified nurse training program to expand the capacity of preceptor training programs. Legislation in Florida created the Linking Industry to Nursing Education fund, which provides matching funds to institutions that partner with health care providers to recruit faculty and clinical preceptors and increase the capacity of nurse education programs. The bill also established the PIPELINE fund to reward school districts and higher education institutions that meet nursing education program performance metrics.

Offering financial incentives for preceptors who are training the next generation of nurses through loan repayment programs is a retention strategy many states are considering. Colorado offers an income tax credit of $1,000 to advanced practice nurses, registered nurses, and psychiatric nurse specialists, among other providers, who provide a preceptorship in rural and frontier areas of the state. Iowa established a mental health practitioner loan repayment program, which includes psychiatric advanced registered nurse practitioners. In return for five years of service, $50,000 of a loan will be forgiven.

Federal Action

The Provider Relief Fund, which is administered by the Health Resources and Services Administration (HRSA), provides financial support to providers (including nurses) who experienced lost revenues and increased expenses during the COVID-19 pandemic to maintain health system capacity. Since November 2021, HRSA has distributed approximately $13.5 billion to nearly 86,000 providers and $7.5 billion in American Rescue Plan rural payments to more than 44,000 providers.

The National Health Service Corps (NHSC) provides loans and scholarships to medical students with the goal of bringing primary care providers to underserved areas. Awardees must commit to serving at least two years in a health professional shortage area. In fiscal year 2020, NHSC’s available budget was $430 million, with more than 14,000 providers serving five programs. Nurse practitioners were the highest group of recipients, accounting for 26% of the awardees.

This resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $767,749 with 100% funded by HRSA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government.