Every state needs nurses. But when my military family moves, my license might not apply.

I realized I wanted to be a nurse in November 2002. I had traveled to Kenya and became quite ill about eight days after arriving. At the time, I was staying with a German missionary couple, Marc and Sabina. Marc was a pilot, Sabina a nurse.

As my symptoms worsened, Sabina became increasingly concerned and offered to run some labs for parasites. Desperate for any relief of my ailments, I would have given her my right arm had she asked, but thankfully all she needed was a vial of blood. It came back positive for malaria, and despite promptly beginning treatment, it would be a few days before my symptoms regressed. Sabina didn’t leave my side but for a few minutes at a time to wash my sweat-soaked sheets. She held a cold washcloth to my feverish forehead and did the humiliating task of keeping my bathroom clean.

For all her work, I had no way to pay her, and she had no expectation for a return on her good deeds. Our relationship was simple: She had a skill and I needed her care. Nothing else got in our way. 

To this day, nursing remains one of the most beautiful expressions of compassion and care that we can pass along to one another. Unfortunately, however, my experience being a nurse for the past decade has not been so simple.

Jumping over regulatory hurdles 

In 2015, I married my husband who is an active duty member of the United States Air Force. It has been one of the greatest privileges of my life to be by his side while he serves our country. His career, like most service members, requires us to frequently move. For me, this means quitting my job and starting a new one wherever, and however often, the Air Force moves us. Each new job I find to be both thrilling and tiring, but the cycle has caused me to grow in my personal confidence and my nursing skills, and for that I am thankful.

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One aspect of frequently moving that continues to be an obstacle, however, is getting licensed. Nurses (whether certified, practical, registered, or advanced practice) are required to hold a license to practice in the state where they work. The process of obtaining a license varies from state to state, but usually involves filling out an application, providing proof of education, submitting fingerprints and consenting to a background check, and paying an administrative fee to the board of nursing of that particular state. 

Courtney Gramm in Alale, Kenya in November 2002. (Photo: Family handout)

One might think these are not outrageous requirements to ensure patients are being cared for by safe, competent healthcare workers, and I would tend to agree. However, the process can be tedious and expensive, and does not carry over from one state to the next, despite sitting for nationally standardized boards.

Advances have been made in recent years to allow practical and registered nurses the ability to practice in one state using another state’s license, but currently only 34 states have this agreement.

Furthermore, there is no such compact for advanced practice nurses, such as myself. Nurse practitioners, midwives, and nurse anesthetists must obtain a new license and permission to prescribe medications in each state they practice in, and the process can be tumultuous.

California case study

Take, for example, my most recent licensing endeavor with the California Board of Nursing.

California requires applicants to have a registered nursing license before they can apply for an advanced practice nursing license. The process of applying for a registered nursing license involves submitting an application ($350), sending bachelor degree transcripts for each school attended ($20), getting fingerprinted ($49), attaching a passport-quality photo to your application ($7), and paying for a license verification check to be performed on your current out-of-state license making sure there is not a pending grievance against it ($30). After gathering and submitting all forms and fees, I received my license 12 weeks later.

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Only then, was I able to begin the application for my advanced practice license. This process involved another nursing application very similar to the registered nursing application that I had already completed ($500), a separate furnishing license application to prescribe medications ($400), more transcripts ($38), forms filled out and signed by the dean of students from the master’s program I attended verifying I took a course in advanced pharmacology and, indeed, graduated from the program (no cost, except the one it takes on your sanity to obtain information that your transcripts also convey).

Once everything was submitted, I was told processing times were 12 weeks. But 17 weeks later, I still did not have my license.

Getting ready to do it all over again

Multiple attempts were made to contact the Board of Registered Nursing, but after frustratingly long hold times, the customer service representative could never provide me with specific information about my application. Eventually I contacted my California state assembly member about my predicament, and he contacted the board of my behalf.

Six days later, after a total of 30 weeks and nearly $1,400, I received my nurse practitioner license and was finally able to begin practicing.

My husband’s military assignment to California is only 18 months long, so we’ll pack up and move again already this December.

I’ll start the whole process of applying for a new nursing license again when we receive word of where we’re going next. Another application, another several hundred dollars, another few months of waiting on that little piece of paper saying “approved.”  

Reducing obstacles and streamlining licensing by lowering costs, shortening timelines, and expanding portability across state lines is a worthy endeavor for state legislatures, and admittedly a welcome advancement for those of us frequently on the move.

Courtney Gramm is a military spouse and currently works as a nurse practitioner in Monterey, California.

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