As of Jan. 1, 2024, there were more than 1,000 open registered nursing positions in Nevada hospitals. Those hospitals would need to hire thousands of nurses to reach the national average of nurse-to-patient ratios, and the problem will only get worse as the existing nursing workforce begins to age out and retire.

Despite that, state lawmakers this session again failed to move forward on a bill that proponents say could help address the problem by attracting more nurses — joining an interstate compact to allow nurses to practice across state lines with a single license. 

SB34, brought on behalf of the state’s Patient Protection Commission, would have enacted the Nurse Licensure Compact along with a number of other licensing agreements for various professions, including physician assistants, audiology and speech language pathologists and physical therapists. For nurses, it proposed allowing Nevada to join an agreement giving nurses the ability to hold a license recognized by any of the 41 states and two territories within the compact — but the bill died without a hearing.

Patient Protection Commission Chair Dr. Ikram Khan said Nevada’s nursing, and more broadly, provider shortages, stem in part from negative impressions of Nevada and the state’s relatively onerous licensure processes that can discourage providers from moving to Nevada.

Khan said the commission proposed the bill after lengthy discussions and work with proponents and opponents of the compact during public meetings. The commission viewed the Nurse Licensure Compact as one way to help alleviate a long-standing nursing shortage, he said. However, after the bill is introduced, he said the commission technically has no control over what happens to the measure and can only offer input at the request of lawmakers.

“We are not a part of the ‘lobbying effort,” Khan said. “We have no idea what was the reason and why they sort of killed it at the committee level.”

Sen. Julie Pazina (D-Las Vegas), who chairs the Senate committee where the bill was referred, declined to answer questions from The Nevada Independent about why the bill died and referred questions to a spokesperson for the Senate Democratic Caucus.

A statement attributed to the caucus said lawmakers are committed to improving working conditions for nurses in Nevada and “recognizing the importance of tailored solutions rather than copying strategies that haven't yielded results elsewhere.”

“Investing in safe, well-equipped work environments, and reasonable patient-to-nurse ratios to reduce burnout should, in turn, help retain and help increase the number of nurses in Nevada,” the statement said.

But observers say it’s likely because Nevada’s politically powerful unions oppose the compact, arguing that there is no evidence it would address nursing shortages, it does not resolve the issue of overworked nurses and it could be used for union-busting purposes. 

The failure marks the third consecutive legislative session and fourth time since 2009 that the nursing compact has been proposed and failed to pass in the Legislature.

Health care industry experts have long pointed to the Nurse Licensure Compact as an option to address Nevada’s critical shortage of nurses and address licensing barriers. Nevada is already a member of interstate licensure compacts for emergency medical services, massage therapists, physicians, teachers and psychologists. 

Surveys from the Nevada State Board of Nursing have indicated that more than 93 percent of Nevada nurses favor the compact, and the State Board of Nursing and Nevada Hospital Association support the measure.

Other states with a heavy union presence, including adjacent Oregon and California, have not yet joined the compact. Minnesota also rejected joining the compact, in large part because of the state’s nursing union opposing the effort.

In Nevada, opponents have also emphasized that the compact would supersede state law and could lead to more Nevada nurses leaving to take jobs in other states that are part of the compact.

Khan said the compact is a tool to help alleviate the shortage while other efforts to increase the nursing workforce continue. Even if the compact only increased the number of available nurses in Nevada by a small percentage, he said that would be helpful.

“Obviously, we're not going to solve the bigger problem of nursing by this [compact], it is a step in that direction,” Khan said. “Everything is being done that can be done, should be done also.”

The strong presence and power of unions in Nevada are underscored by their status as the third-largest industry group of donors to legislators, contributing $1.6 million during the 2024 election cycle, and unions have long held the ear of Democrats who control both houses. Health care groups, including hospitals, made up the fourth-largest contributors to campaigns last year.

One of the most vocal opponents of the measure is the Service Employees International Union (SEIU) Local 1107, the state’s largest union for health care and public employees that has organized nurses in many of the state’s key hospitals. Union representatives declined to sit down for an interview despite multiple phone calls and emailed requests for comment.

Asked about the inability of the compact to pass in Nevada, Cathy Dinauer, a registered nurse and the executive director for the Nevada State Board of Nursing, which regulates about 70,000 nurses and nursing assistants in Nevada, pointed to the resistance by unions.

“It becomes a political hot potato,” Dinauer said.

Senate Minority Leader Robin Titus (R-Wellington) alluded to the tensions in a March committee hearing on SB182, a measure backed by SEIU that would mandate nursing staffing ratios (existing federal guidance simply recommends ratios). Various hospitals, including the Nevada Hospital Association, have opposed the measure, with one Dignity Health hospital writing that the measure “would further strain an already limited workforce, making it even more difficult to staff hospitals across the valley.”

“We have a finite amount of nurses,” Titus said, noting that the state would likely need to join the compact or pass other nurse reciprocity laws to fulfill the proposed ratio requirements outlined in the bill.

SEIU Political Director Dakota Hoskins replied that he understood, but said a nurse licensure compact was not up for discussion.

“The compact does nothing to improve working conditions,” Hoskins said. “Our position is, we're going to continue to lose nurses whether we train them locally, whether we bring new nurses in from out of state, if we do not improve the working conditions. That is the number one way to maintain and recruit new nurses.”

Though SEIU declined an interview for this article, SEIU Nevada has argued through social media posts and at the bill’s hearing that high patient-to-nurse ratios have led to nurses being overburdened with patient loads and burnout, leading to worse patient care and strain on the families of nurses.

Would the compact hurt or help?

The Patient Protection Commission (PPC), which is composed of health care advocates, providers and industry professionals, said in its semi-annual report that it brought the bill to address “ongoing challenges with building an adequate health care workforce” by removing “unnecessary licensing barriers for recruiting and retaining health care providers.” 

Report authors noted that the Nevada State Board of Medical Examiners attributed the 63 percent year-over-year increase in physician medical licenses issued in Nevada as of July 2024, in part, to the compact — more than half of all new physician licenses in Nevada are issued through the Interstate Medical Licensure Compact.

Patrick Kelly, the CEO and president of the Nevada Hospital Association, said the nursing compact would allow nurses to quickly cross state lines to assist with disaster relief and meet an ongoing need for nurses.

One example of that came in 2020, when then-Gov. Steve Sisolak issued an emergency directive allowing out-of-state nurses to work in Nevada during the pandemic.

Dinauer said the directive was helpful and set up a type of compact without the formal rules of the compact, allowing nurses to come into the state and work immediately without waiting to get a license as long as they had an active, unencumbered license in another state.

“We did not, to my knowledge, have any problems with nurses doing that. We did not have any specific complaints with regards to that happening among nurses and practice issues,” she said.

Research shows that to meet national averages, Nevada needs more than 3,100 additional registered nurses, at least 3,200 licensed practical nurses and upward of 5,500 nursing assistants — Nevada is projected to be among the top five states with the most pronounced nursing shortage by 2030. 

“Traveling nurses are becoming harder to get, and one of the reasons is because if they get a choice of assignments in a compact state or in Nevada, they go to the compact state because it's easy,” Kelly said. “They can just start work the next day, whereas here they have to fill out a bunch of paperwork to get their license, wait for the license and pay a fee. Who wants to do that when you can just go start somewhere else?”

The Patient Protection Commission report noted some unnecessary delays in processing state licenses to practice in Nevada, with some applications taking “months” to complete. That can dissuade health care providers from working in the state. It added that compacts can also enhance public protection through a data system that allows member states to share information such as disciplinary actions.

Dinauer said for nursing specifically, it takes about four to five days to receive a temporary license for nurses coming outside of the state while they wait for fingerprints to be processed. Though that doesn’t seem like a long time, Dinauer said if you’re a nurse looking to have mobility in a nursing career, waiting four or five days for a temporary license can be a long time, leading to nurses opting to just go to a compact state instead where there is no waiting period.

The separate licensure process also costs $200, which can be prohibitive, she said, noting that with the compact there’s only one fee.

What do unions say?

Though unions have claimed the measure is a way to get around organized labor by hiring new employees rather than working with unions, Kelly said other states that are part of the compact haven’t had those issues. 

In 2023, the sponsor of the licensure compact that year, Assm. Sandra Jauregui (D-Las Vegas), proposed an amendment that required hospitals to provide new nursing hires with union information and request that the new nurse meet with their union representative. The union still opposed the measure, and it failed.

Along with the nurse licensure compact, the Nevada Hospital Association has advocated for other policies aimed at expanding the state’s nursing workforce — increasing the size of nursing classes, recruiting and retaining more nurse educators and allowing part-time or adjunct teaching opportunities for nurses without a master’s or doctoral degree.

But Kelly said there’s an immediate need for nurses, and the licensure compact would help address that.

SEIU Local has contested this. 

A 2023 letter submitted by union lobbyist Marlene Lockard outlines many of the union’s arguments against the measure, including citing that the Nurse Licensure Compact “does not purport to alleviate a state nursing shortage,” would override state requirements and there’s no proof that the compact, which has been in place since 1999, has alleviated shortages in other states.

“As long as nurses are overloaded and unable to provide quality patient care they will continue to leave and find a career that provides greater rewards and satisfaction,” Lockard wrote. “This bill does nothing to work towards resolving those issues. NOTHING.”

At the commission’s hearings on the proposal and during lengthy discussions of the proposed bill, Khan stated that a California Nursing Association union made a presentation opposing the compact, citing concerns that it fell below nursing standards in state law.

Khan said he is not a proponent of lowering standards, but if the nursing board approves the national compact’s vetting process, then that should be considered, and to his knowledge, no standards are being compromised in terms of nursing quality.

Overall, research has found mixed results with some studies indicating that the compact may increase interstate movement and labor supply, while others find no substantial effect. 

Data compiled in 2023 by the National Nurses United union indicated that the Nurse Licensure Compact has had little effect on staffing levels and wages, and union representation are greater factors. A June 2016 working paper from the National Bureau of Economic Research adds that nationalizing licensing has not affected labor supply or nurse mobility.

On the other hand, findings from a 2024 survey published in the Journal of Nursing Regulation indicated that there’s a rising need for a flexible and mobile nursing workforce that can easily cross state borders. 

“The multistate license benefits crossborder nursing practice and a majority of the respondents support and welcome the adoption of the NLC,” researchers noted.

A 2023 report from The Hamilton Project, which analyzes evidence-based policy proposals, indicates that “the literature largely corroborates the causal impact of compact membership on greater mobility among nurses.”

Dinauer said the compact is designed to help ease licensing burdens and has not been presented as the sole solution to various problems within the nursing industry, but it’s a way to attract more nurses to the state.

“The issues of shortages and staffing and working conditions and environments are all issues that have been raised by the union … have nothing to do with the nurse licensure compact,” she said.

Khan said that addressing the nursing shortage in Nevada requires collaboration and compromise. 

“I may have certain opinions of my own, I may disagree with certain other opinions, but at some point you need to agree to disagree,” Khan said. “Because that's what democracy is about. You have to accept the majority position and go on.”