Maryland needs more nurses. Their licenses are caught in red tape.

Lauren Gulmert needs an internship to graduate from nursing school next spring.

But the delay in getting one has had nothing to do with her grades or training or anything else seemingly within the 21-year-old’s control. She missed the past two summers on the job because she couldn’t get the certified nursing assistant license required in Maryland.

“We’ve called every number, we’ve emailed every address; we’re back here again,” said her exasperated mother, Adrena Gulmert, on a mid-March day outside of the lone Maryland Board of Nursing office in a Northwest Baltimore shopping center.

“They said we didn’t have fingerprints, so we submitted them again, even though we already did that,” she said on their fifth trip in three years from Gambrills to the storefront. “Another $75. Now we wait. Again.”

Amid a severe national shortage of nurses and nursing assistants, Gulmert joins thousands of others in the state who have struggled to get new, renewed or transferred licenses in recent years from the board. Some, like the Gulmerts, have reported months-long delays to get through a process the board’s website says should take days to several weeks.

The bottleneck got so bad at the board — responsible for more than half of all health occupation licensing and certification in Maryland — that state lawmakers ordered the health department last year to take over administrative duties and hire a consulting firm to produce a plan for improvement.

Since then, state health officials and lawmakers say there has been progress in overhauling the board, with plans for a new user-friendly website and electronic licensing system, but there are still technology barriers and staff shortages. Though board officials now say the time needed to issue or renew a license is back to day or weeks, many nurses and assistants aren’t yet feeling the upgrades.

The biggest backlog in two decades

A September report from the consulting firm Ernst & Young doesn’t quantify how many licenses are delayed or for how long. But in 2021, the board told the legislature that there were more than 9,000 applicants who had been waiting at least 15 months for a certified nursing assistant or medical technician license, the highest backlog since 2005.

Nursing assistants, or CNAs, assist nurses with entry-level health care needs and patients with daily activities such as bathing and feeding. Maryland has been losing CNAs, a Baltimore Banner review of state data found: more than 7,000 more CNA licenses expired than were issued since 2019. There are now about 58,000 active CNA licenses in Maryland, plus about 2,000 that are temporary or expire within a year. The number that has been on the decline since 2019, and about 10.5% of CNA positions at hospitals are vacant.

Over two days in February and March, a steady stream of professionals exiting the board’s Reisterstown Road Plaza office expressed frustrations about employment, some for weeks- or months-long delays and others for snafus with documents or just having to make the drive to the singular board office.

“My new employer told me it was a long, slow process and I needed to come here in person,” said Janet Keith, who moved from Texas and needed to transfer her certified nursing assistant license. “I came from Hagerstown, and it’s like an hour away and I hope I don’t have to come back.”

Niba Anayama drove from the Washington, D.C., suburb of Silver Spring after a week’s worth of delays in renewing her nursing assistant license. “I called and nobody picks up,” she said. “It expires soon. I pray it’s renewed.”

Other people did not want to be named out of concern it would affect their licenses or employment.

One nursing assistant said her employer of 19 years let her go three weeks earlier when her boss discovered her license was not renewed in April 2022, though she could show that the board had received her forms and payment. Licenses need to be renewed every two years, so she said if this is corrected, it may expire again this April.

Another Baltimore woman said she’d applied for a nursing assistant license in January and got it in August with her name misspelled, an error she has been unable to fix.

Two other nurses contacted The Banner about their efforts to transfer their nursing licenses from other states. After months of delays, one got a job elsewhere and one spent months unemployed after having already moved to Maryland.

Hints of progress

Officials at the Maryland Department of Health point to specific moves at the board as a sign of progress, such as hiring a project manager. They also appointed a new executive director, Rhonda Scott, previously deputy director. Board members are also turning over, after the Ernst & Young report suggested ending all of their terms. Scott was not made available for an interview, though the department issued a statement acknowledging the troubles at the board and noting that Gov. Wes Moore’s administration is working closely with the board to improve the way it operates.

The board’s licensing database and website are now on new secure servers this month after having been disconnected during a December 2021 cyberattack on the health department, said Chase Cook, a health department spokesman. The department had to issue temporary licenses for a time after the attack, to be reconciled later.

A Banner analysis of state data found that the board has been doing a better job converting a temporary license to a full license. In 2020, the board converted 55% before the temporary license expired; last year, that rose to 92%.

Also underway are updates to the website and a new licensing system.

“Making information more accessible and secure is critical to support nurses in our state,” said Cook.

Cook said the board is also working on clearing a backlog of investigations into complaints made against nurses, another serious duty of the board that has lagged. The board is hiring more investigators.

The report from Ernst & Young, hired with a one-year, $247,500 emergency contract, touched on virtually every aspect of board operations. It began by saying that the board “faces long standing institutional and systemic deficiencies endemic to its operations and leadership.” Issues were exacerbated by disruptions during the pandemic, the report said, without being specific.

The report said personnel weren’t working efficiently and processes needed streamlining. Troubles were often due to technology that included “disparate, outdated, and unsophisticated system infrastructure” hampering application tracking and management, reporting and telephones.

The phones in particular had become “one of the biggest pain points,” Health Secretary Laura Herrera Scott wrote in a letter to lawmakers accompanying the report. Consultants said in eight of eight tries, they never reached a human.

The report recommended hiring new staff, replacing systems and technology, and providing lots of training.

State Sen. Clarence Lam, a Democrat representing Howard and Arundel counties, is co-chair of the state’s Joint Audit and Evaluation Committee and reviewed the consultants’ report. He said it was unusual for the health department to temporarily take over board management but was warranted, given the importance of getting and keeping nurses on the job and ensuring patient safety. Lam called the wait times for nursing licenses “unfathomable.”

Lam, who is also a medical doctor, said delays in investigating complaints about nurses is a threat to patient safety. At the current rate, it would take five years to get through the backlog if no new complaints were filed.

The report recommends raising fees for licenses, an unpopular move that Lam says will help fund improvements. He also praised another recommendation, that some new positions be filled with people experienced in management and other areas rather than nursing.

“This is not something that’s going to be fixed overnight,” he said. “They’ve taken some initial good steps, laying the groundwork for really long-overdue improvements.”

In the meantime, Jane Krienke, a senior analyst at the Maryland Hospital Association, has been working with the board to secure licenses for hospital workers and make improvements. With one in five hospital nursing positions vacant, it’s of critical importance, she said.

She agrees there has been some progress, with a recent drop in the number of nurses she’s had to assist in getting license issues resolved.

“At one point, we had daily emails for help for a multitude of staff members, and the volume has decreased,” Krienke said.

She still wants to see more progress, such as expanding agreements, called compacts, that make it easier for nurses to work across state lines. There is state legislation pending on that front, as well as a bill to remove the CNA license requirement for nursing students.

Years of waiting

Gulmert, a University of Pittsburgh nursing student, and her mother look forward to the improvements and hope staff will be more attentive.

Her journey through the licensing process began in July 2021, involving dozens of calls and emails, five visits to the board office that included one time it was inexplicably closed, four criminal background checks, three lost internships and one temporary license.

There was just one email apology and one form letter apology. There was also one email “informing us they were having computer problems, a staffing shortage, and to be patient.”

With a deadline just a few days away, Lauren Gulmert was worried that a third summer would pass without an internship in Maryland and she’d have to consider positions next summer in Pennsylvania. That would be an added cost to to live there after graduation.

“I’m mandated to get this, but can’t get this” from the Maryland board, she said.

Gulmert’s new license number finally appeared on March 14, one day before the internship deadline.

“I got it!” she screamed. She thanked her mom for her help and then stayed up submitting applications until just after 2 a.m. By 11 a.m. the next day she’d received two responses, had an interview the same day and another the next.

Her mother is thrilled that she’ll get what she’d worked toward and will stay in Maryland for the internship but said something has to change.

“This shows that because of having to wait for nearly two years, Lauren could have had these same experiences in the summer of 2022,” said Adrena Gulmert, about the latest attempt at getting a license. “Now she is playing catch-up to her peers in Pittsburgh who didn’t have to wait for a CNA certificate to practice.”

Baltimore Banner data editor Ryan Little contributed to this article.

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