Licensure: Defending Personal Initiative in an eNLC World

“Too many nurses,” they said. “And they aren’t practicing the way we think they should. It must be all those independent nursing schools!” And so nurse licensure and nursing school accreditation were born.

Give those early physicians and professional nurse organizers their due: numbers of schools and nurses did fall precipitously.

That was 120 years ago. Today, we have chronic wait lists for nursing schools and nurse shortages in every state, documented by decades of study. The U.S. must graduate 1.1 million new nurses just to keep from deeper shortages.  Health Professional Shortage Areas (HPSAs) exist in every state, totaling 17,986 nationwide as of April 7, 2019. $18 Billion is being poured into the system by active grants from one federal agency alone.

Does licensure make shortages better, or worse, and why should entry-level nurses care? More importantly, what can they do about it?

As the first line of care, nurses confront the nursing shortage head on. We have the most to gain by reversing the trend to worse shortages and intolerable working conditions. Moral distress (also known as burnout and compassion fatigue) is taking more of our peers away from us in an incredibly vicious cycle. The nurses who break this cycle will be doing a difficult and good thing for themselves, their peers, and their patients.

Individual nurse initiative and autonomy relates to today’s shortage of nurses.

Personal initiative has been defined as the ability to assess and initiate things independently; professional autonomy includes the authority to make decisions and the freedom to act in accordance with one’s professional knowledge base.

Initiative is essential to becoming a professional nurse. It takes initiative to get into nursing school, and even more to complete graduation requirements and successfully pass State Board Licensure Exams.  

Initiative is vital for each working nurse to meet every patient need with excellence, and to retain that job – or find  a new one – in order to remain within the profession when the going gets tough.

Because let’s not kid ourselves: you know it’s tough out there.

No matter how the shortage is marketed as opportunity or a job-seeker’s market, a shortage means that more than likely you will work shifts you didn’t want, with people you don’t particularly like, under conditions you wish you could change but can’t.

You want to do the right thing, but what happens when working conditions (employer policy, short staffing, conflicting time demands) cripple your ability to serve your patients’ best interests?

That’s where autonomy comes in. There’s not much autonomy as a student; it’s the prize dangling out there as reward for graduating, passing the NCLEX, getting past orientation, and becoming a competent nurse.

Autonomy is key to the heart of healthcare:  the patient-professional relationship. Effective patient care, advocacy, and communication—all demand personal initiative and autonomy of the professional nurse.

Sometimes, nurses require more initiative just to advocate for their own professional autonomy. That’s why you need to understand the dark side of licensure.

Licensure: a barrier to initiative

Nurse licensure is thought to ensure public health and safety. Nurses maintain their licenses with pride, as a symbol of hard-earned achievement.

Still, licenses act behind the scenes as a barrier to job entry and continuing in the profession. Laws and regulations for licensure are susceptible to “mission creep,” and should receive close scrutiny in any market exhibiting shortages.

Licensure has grown well beyond the early state restrictions on use of the RN title.  Additional encumbrances include fees, educational maintenance requirements, scope of practice limits, and in some cases, criminal background checks for basic nurse licensure.

State licensure fees are generally reasonable, though politics can intrude. One state leveraged Advanced Practice RN (APRN) interests against other licensed nurses in order to double basic license fees to cover budget overruns of the regulating agency. State fiscal analysis projected the net increase would bring over $10.8 million in additional state revenue per renewal cycle. I wrote about it here.

Continuing Education mandates take precious time from nurses, though the financial expense can sometimes be avoided with free online CEU sources. Interstate reciprocity agreements allow nurses licensed in one state to practice in another.

Accountability for the whole system follows traditional lines within each state: regulators are subject to state law and oversight from state legislators, who answer to nurses and the general voting public at regular elections.  

Who will Rule the Rulemakers?

That all changes with the 2018 Enhanced Nurse Licensure Compact, or eNLC, which is even farther from traditional licensure than its precursor, the NLC.

The eNLC creates an independent commission, and empowers it to make rules for nurses in all participating states. Unlike state licensing agencies and federal regulators, this commission is not accountable to voters, elected representatives, governors, Congress, the president, or even state or federal regulators. Absence of oversight sets the commission up for improper influence from nursing schools or hospital systems (for example) who seek advantage over their competitors.

Contributing to the Shortage

The eNLC imposes nationwide criminal background checks.  True, some people with a history of criminal conviction should be excluded from positions of trust such as nursing. Some states already check background as part of licensure; elsewhere, employers check during the hiring process.

However, being labeled as a criminal has become so easy, this policy may allow trivial offenses to exclude good potential nurses from the profession. Over-criminalization has been identified as a barrier to legal employment, contributing to the school-to-prison pipeline.

Instituting another, broader layer of criminal background checks for licensure should be delayed at least until state criminal justice reform takes place.

Good news:

The eNLC diminishes individual nurse entry, initiative and autonomy; it eliminates voter voice and legislative accountability. But there is good news.

As a nurse, you have voting power within professional organizations and in public elections.

  • Professional and union leadership have not always been helpful in light of the shortage, at times even contributing more barriers to nurse entry, license maintenance, and stresses that drive more nurses out of the profession. Input from working nurses can change that.
  • Each state must pass essentially the same law to join the compact. Knowing state status can inform your job search and communication with your elected officials.



Donahue, M. Patricia. Nursing, The Finest Art: An Illustrated History (2nd Edition 1996), Mosby, St. Louis, Missouri.

United States Health Resource & Services Administration Data Warehouse, updated April 7, 2019, found under Data By Geography. Accessed April 8, 2019.

2017 Number of Candidates Taking NCLEX Examination and Percent Passing, by Type of Candidate, NCLEX Statistics from NCSBN

It’s Not Burnout, It’s Moral Injury | AMA 15, ZDogg MD, Published on Mar 8, 2019 Accessed April 8, 2019.

The Moral Distress Education Project, University of Kentucky Program for Bioethics. Accessed April 8, 2019.

National Council of State Boards of Nursing, Accessed April 8, 2019.

Nurse Licensure Compact Analysis, Hanover Research, updated June, 2018. Accessed April 8, 2019.

Overcriminalization, 2018, from the National Association of Criminal Defense Lawyers, found under Criminal Defense Issues. Accessed April 8, 2019.

Sarah E. Redfield & Jason P. Nance, The American Bar Association Joint Task Force on Reversing the School-to-Prison Pipeline Preliminary Report, American Bar Association Coalition on Racial and Ethnic Justice, Criminal Justice Section, and Council for Racial & Ethnic Diversity in the Educational Pipeline (2016), available at Accessed April 8, 2019.