An audit of mental health questions on U.S. nursing licensure applications: Evidence to guide urgent action for change

Abstract

Background

Nurses often forgo needed mental healthcare due to stigma and fear of losing their license. The decision to access care or disclose mental health struggles is intensified when registered nurses (RNs) or advanced practice registered nurses (APRNs) discover that licensure applications ask invasive mental health questions that could impact their ability to work.

Aims

This study highlights findings from an audit of mental health and substance use questions included in RN and APRN licensure applications across the United States.

Methods

A sequential 4-step approach was used to retrieve RN and APRN licensure applications: (1) review of Board of Nursing (BON) websites, (2) communication with BON staff, (3) communication with Deans of Nursing to ask for retrieval assistance, and (4) creation of mock applicants. An embedded checklist within the Dr. Lorna Breen Heroes Foundation's Remove Intrusive Mental Health Questions from Licensure and Credentialing Applications Toolkit guided the audit. Two study team members reviewed the applications independently for intrusive mental health questions, which were designated as non-compliant with the Toolkit's recommendations and arbitrated for consensus. States were designated as non-compliant if ≥1 item on the checklist was violated.

Results

At least one RN and APRN application was obtained from 42 states. Only RN applications were obtained from five states, while only APRN applications were obtained from three states. Only 13 states (26%) fully adhered to the Took-Kit checklist.

Linking Evidence to Action

The majority of BONs did not fully adhere to the Took-Kit checklist. Guidance from national organizations and legislation from state governments concerning the removal or revision of probing mental health and substance use questions is urgently needed to cultivate a stigma-reducing environment where nurses are supported in seeking needed mental health treatment.

INTRODUCTION

Nurses face a higher suicide risk than the general population (Davidson et al., 2020), yet often forgo necessary mental health care due to stigma and fear of losing their license (i.e., license revocation; Kelsey et al., 2021). Depression, burnout, and substance use disorder (SUD) can increase the risk of suicide in nurses (Davidson et al., 2021; Zisook et al., 2022). The prevalence of depression and burnout in nurses is estimated to be 29.5%–65.5%, respectively (Melnyk et al., 2022; National Academies of Sciences, Engineering, and Medicine et al., 2019). Estimating the prevalence of SUD in nurses is challenging as legal and employment risks contribute to underreporting (Davidson et al., 2021). However, the nationally representative Nurse Worklife and Wellness study (n = 1170) found that 18% of respondents had issues with substance use (Trinkoff et al., 2022). Despite having increased rates of mental health and substance use conditions, nurses report treatment avoidance due to licensure status and employment eligibility concerns (Cares et al., 2015; Kelsey et al., 2021).

When applying for registered nurse (RN) or advanced practice registered nurse (APRN) licensure, applicants may be subjected to invasive questions regarding their mental health or substance use history (Halter et al., 2019; Schimmels et al., 2023). In the context of licensure questions, “invasive” is defined as inquiring about specific mental health treatments and diagnoses in an overly detailed and potentially stigmatizing manner (e.g., requiring proof of substance use rehabilitation or a physician letter addressing mental health and ability to practice when answering yes to having a mental health condition). Such questions aim to assess “good moral character” or “fitness to practice” and have historically been viewed as protective measures, enabling the disqualification of applicants who may pose a public safety risk (Feist & Howard, 2023). However, the use of these questions can foster stigmatization, discouragement, and anxiety, leading applicants to fear rejection or withhold information about the status of their mental health (Halter et al., 2019). Such questions are not only a driver of suicide, but also may violate the Americans with Disabilities Act (ADA; Halter et al., 2019; Schimmels et al., 2023).

Mental health and substance use questions require careful auditing for appropriateness. In 2018, the Federation of State Medical Boards (FSMB) released recommendations concerning the removal of invasive mental health and substance use questions from physician licensure applications, prompting a subsequent audit (Saddawi-Konefka et al., 2021). The Workgroup on Physician Wellness and Burnout, FSMB staff, and an array of stakeholders dedicated two years of study to formulate FSMB recommendations. According to the FSMB (2018), a state medical board should “evaluate whether it is necessary to include probing questions about a physician applicant's mental health, addiction or substance use” (p. 12). If a state decides questions concerning mental health must be included, the questions should be “non-invasive.” Specifically, these questions should not separate mental from physical health and should pertain to current impairment, not diagnoses or previous treatment. For example, “Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would otherwise adversely affect your ability to practice medicine in a competent, ethical and professional manner?” (FSMB, 2018, p. 13). The National Council of State Boards of Nursing (NCSBN) has not publically released comparable guidance. Further, a similar audit had not been conducted on nurse licensure applications.

Therefore, the purpose of this study was to conduct an audit of mental health and substance use questions included in RN and APRN licensure applications across the U.S. for the purpose of identifying states that asked invasive questions. The Remove Intrusive Mental Health Questions from Licensure and Credentialing Applications: A Toolkit to Audit, Change, and Communicate (referred hereafter as “Tool-Kit”), developed by the Dr. Lorna Breen Heroes' Foundation (2022), was used to conduct this audit as it has emerged as a valuable, easy to follow resource endorsed by the National Institute for Occupational Safety and Health (NIOSH, 2023). The Tool Kit was developed using guidance from the American Medical Association (2023) and FSMB (2018).

METHODS

Between September 2022 and May 2023, RN and APRN licensure applications were retrieved via a sequential 4-step approach: (1) Board of Nursing (BON) websites, (2) communication with BON staff, (3) communication with Deans of Nursing to ask for retrieval assistance for applications not obtained by direct communication with BONs, and (4) creation of mock applicants. Email and telephone communication were used to contact BON staff and Deans of Nursing. If no response was received after the initial contact, two additional attempts were made using each form of communication. Microsoft Excel Spreadsheet software was used to document contact information, form of communication, number of touch points, date of contact, and date of response. Once application information was received, questions relating to mental health and substance use were databased into a separate Excel Spreadsheet by state and RN and APRN status. Throughout their careers, RNs and APRNs may encounter varying types of licensure applications, such as license by examination (RN); initial APRN; reinstatement (restoration or reactivation); license by endorsement, reciprocity, multi-state, or compact; renewal; prescriptive authority (APRN); or mandatory practitioner profile questionnaire. The application types were noted during review.

The Tool-Kit's 5-item checklist with an additional sixth item facilitated the audit (Dr. Lorna Breen Heroes' Foundation, 2022). The study team added the sixth item in accordance with the FSMB (2018) recommendation to not separate mental from physical health. With the Breen Heroes' Foundation consultation, applications were evaluated on the six items, including whether they:

1. Surpass current impairment (e.g., Have you ever had a substance use disorder), contain invasive language (e.g., Provide any/all relevant information concerning your mental, emotional, or nervous disorder or condition), or request disclosure around mental health (e.g., Board may request a letter from your current treatment provider).
2. Mention time-off or breaks in practice relating to mental health or substance use.
3. Include non-supportive language (e.g., Have you been found to be a mentally ill person).
4. Ask about past treatment (e.g., Have you been admitted to a hospital for mental health treatment?).
5. Include unnecessary fine print (e.g., current impairment can be by anytime in the past 8 years).
6. Separate mental and physical health (i.e., only asks about mental health issues and not physical health).

Applications were assessed independently by two study team members (AFH & ADH) for violations based on the six items (i.e., designated non-compliant) and arbitrated for consensus. Violating ≥1 of the six items designated states as non-compliant. States that did not violate any of the six items were deemed compliant.

RESULTS

At least one RN and APRN application was obtained from 42 states (Table 1). Only RN applications were obtained from five states (Georgia, Maine, North Dakota, Tennessee, and Virginia). Only APRN applications were obtained from three states (Alabama, New Jersey, and Rhode Island). Application types varied substantially, with zero states providing all application types for both RNs and APRNs. However, all types of RN applications were obtained from Kansas.

TABLE 1. States and application type obtained.

State	RN application		APRN application
	Obtained	Not obtained	Obtained	Not obtained
Alabama		+	Δ	*
		*		Ω
		Ω
		Σ
Alaska	+	Σ	Δ
	*			*
	Ω			Ω
Arizona	+	Ω	Δ	*
	*	Σ		Ω
Arkansas	+	*	Δ	*
		Ω		Ω
		Σ
California	+	Ω	Δ	*
Provided full application for RN by examination and informed that screening questions were the same in the APRN initial app	*	Σ		Ω
Colorado	*	+	Δ	*
		Ω		Ω
		Σ
Connecticut	+	*	Δ	*
		Ω		Ω
		Σ
Delaware	+	*	Δ	*
		Ω		Ω
		Σ
Florida	*	+	Δ	*
		Ω		Ω
		Σ
Georgia	+	Ω		Δ
	*	Σ		*
				Ω
Hawaii	+	Ω	Δ	*
	*			Ω
	Σ
Idaho	+	Ω	Δ	Ω
	*	Σ	*
Illinois	+	Σ	Δ	*
	*		Ω
	Ω
Indiana	+	Ω	Φ	Δ
	*	Σ		*
				Ω
Iowa	Σ	+	Δ	*
Provided a complete copy of APRN application, but only provided screening questions for RN		*		Ω
		Ω
Kansas	+		Δ	*
	*			Ω
	Σ
	Ω
Kentucky	+	*	Δ	*
	Ω	Σ	Ω
Louisiana	+	Ω	Δ	Ω
	*	Σ	*
Maine	Σ	+		Δ
		*		*
		Ω		Ω
Maryland	Σ	+	Δ	*
		*		Ω
		Ω
Massachusetts	+	Ω	Δ	*
	*	Σ		Ω
Michigan	+	*	Δ	*
		Ω		Ω
		Σ
Minnesota	+	Ω	Δ	*
	*	Σ		Ω
Mississippi	+	*	Δ	*
		Ω		Ω
		Σ
Missouri	+	Σ	Δ	*
	*			Ω
	Ω
Montana	+	Ω	Δ	Ω
	*	Σ	*
			Σ
Nebraska	+	Σ	Δ	*
	*		Ω
	Ω
Nevada	*	+	Δ	*
		Ω		Ω
		Σ
New Hampshire	+	*	Δ	*
		Ω		Ω
		Σ
New Jersey		+	Ω	Δ
		*		*
		Ω
		Σ
New Mexico	+	*	Δ	*
		Ω		Ω
		Σ
New York	+	*	Δ	+
		Ω		*
		Σ		Ω
North Carolina	+	Ω	Δ	*
	*	Σ		Ω
North Dakota	*	+		Δ
		Ω		*
		Σ		Ω
Ohio	+	Ω	Δ
	*		*
	Σ		Ω
Oklahoma	+		Δ	*
	*		*
	Ω
	Σ
Oregon	+	*	Δ	*
		Ω		Ω
		Σ
Pennsylvania	+	*	Δ	*
		Ω		Ω
		Σ
Rhoda Island		+	Δ	Ω
		*	*
		Ω
		Σ
South Carolina	*	+	*	Δ
		Ω		Ω
		Σ
South Dakota	+	*	Δ	*
		Ω		Ω
		Σ
Tennessee	+	*	∇	Δ
		Ω		*
		Σ		Ω
Texas	+	*	Δ	*
		Ω		Ω
		Σ
Utah	+	Ω	Δ	Ω
	*	Σ	*
Vermont	+	*	Δ	*
		Ω		Ω
		Σ
Virginia	+	*		Δ
		Ω		*
		Σ		Ω
Washington	+	Ω	Δ	Ω
	*	Σ	*
West Virginia	+	*	Δ	*
		Ω		Ω
		Σ
Wisconsin	+	Ω	Δ	*
	*			Ω
	Σ
Wyoming	+	*	Δ	*
		Ω		Ω
		Σ

• Note: RN application types: ⁺License by examination; *License by endorsement, reciprocity, multi-state, or compact; ^ΩLicense reinstatement (restoration or reactivation), ^ΣLicense renewal. APRN application types: ^ΔInitial APRN license (this includes CNP, CNRA, CNM, CNS; some states call “board authorization or “certification”); *License by endorsement (reciprocity, multi-state, or compact); ^ΩLicense reinstatement (restoration or reactivation); ^ΦPrescriptive Authority (Applies to Indiana—only APRNs who require prescriptive authority apply. It is not a license to practice, and APRNs not requiring prescriptive authority practice under their Indiana registered nurse license or out-of-state compact license); ^∇Mandatory Practitioner Profile Questionnaire (Applies to Tennessee—designated licensed health professionals are required to fill out an additional questionnaire in addition to their application). States in bold provided copy and pasted questions, verbal descriptions, or screen shots from the relevant application questions via an email. We were unable to ascertain if the was by examination, initial, endorsement, reinstatement, or renewal. They were defaulted to initial and by examination as table place holders. States bold and italicized provided a full application for the requested documents, unless otherwise noted.
• Abbreviations: APRN, advanced practice nurse; RN, registered nurse.

Few applications were available for download on the BON websites, and most required some form of communication with BON staff or Deans of Nursing to ask for their assistance in obtaining the applications. Occasionally, this resulted in a full copy of an RN or APRN application. More frequently, screen shots, copy and pasted questions, or verbal descriptions were provided concerning the relevant mental health or substance use questions.

Thirteen states (26%; Figure 1) fully adhered to Took-Kit criteria. However, this adherence mostly resulted from applications not including any mental health or substance use questions. The review of applications that violated the Took-Kit items revealed variation in questions across states, highlighting the need for standardization. Examples of non-compliant questions include:

• Alaska, “Within the past 5 years, have you been or are you currently being treated, or on medication for, any mental or emotional illness which may impair or interfere with your ability to practice safely and in a competent and professional manner? This question goes beyond current impairment.
• Arkansas, “Do you have any condition or impairment (including, but not limited to, substance abuse, alcohol abuse, or a mental disorder or condition) which in any way currently affects or limits your ability to practice safely and in a competent and professional manner?” This question separates physical from mental health.
• Missouri, “Are you currently participating in a substance abuse and/or alcohol or drug treatment program or been diagnosed with a substance abuse disorder which in any way currently affects or limits your ability to practice safely and in a competent and professional manner? If yes, explain fully in a separate notarized statement and provide any documentation that shows your diagnosis, prognosis, and treatment plan.” This question contains invasive language by requesting a notarized statement concerning diagnosis, prognosis, and treatment plans.

FIGURE 1

Nurse licensure application audit outcomes using Breen Foundation Tool-Kit adherence checklist.

DISCUSSION

Urgent action is needed as this audit revealed most states' applications violated the Tool-Kit items. Overall, the language used by many states when enquiring about mental health and substance use was extraneous, discriminatory, unnecessary, or stigmatizing. For example, Missouri's requirement to submit a notarized statement could be considered extraneous.

The simplest solution to becoming Tool-Kit compliant is question elimination or rephrasing questions using the Tool-Kit suggestion, “Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgment or that would otherwise adversely affect your ability to practice…in a competent, ethical, and professional manner?” (Dr. Lorna Breen Heroes' Foundation, 2022). However, obtaining state BON buy-in for changing nurse licensure questions could be further facilitated by endorsement and guidance from the NCSBN regarding the removal or revision of probing mental health and substance use questions from applications. Guidance would encourage uniformity and standardization of state-level applications, which could reduce applicants fear of punitive measures for disclosing or seeking mental health care.

Concerning the issue of application revisions, American BONs are trailing behind other professional accreditation and oversight bodies. The FSMB, which oversees state medical and osteopathic boards in the U.S., released license guidance in 2018. The Joint Commission (2022) released a statement clarifying that their accreditation standards do not require organizational inquiries pertaining to past mental health treatments or conditions. At an international level, the United Kingdom's Nursing & Midwifery Council uses a transparent approach by providing a downloadable Guidance on Health and Character (2019) document on their registrar's website. The document outlines the types of health and character questions that will be asked, why they are being asked, and what will be done with the information. Registration questions also do not inquire about specific mental health or substance issues, rather, the questions are about current general health issues, for example, “Do you have a health condition and/or disability that currently affects or could affect your ability to practice safely and effectively?” This type of transparency was missing from many American BON websites and applications.

State governments can also act through legislation by mandating regulatory boards to amend licensure applications by removing inappropriate questions related to mental health impairment across all healthcare professions. Despite being non-compliant in this audit, Virginia is moving the in right direction by taking a legislative approach for ameliorating invasive licensure questions with the 2023 passage of House Bill 1573 and Senate Bill 970 (Mental Health Conditions & Impairment, 2023; Robeznieks, 2023). This legislation requires Virginia health regulatory boards to replace questions pertaining to mental health conditions and impairment with (1) “Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients or clients?” and (2) “Are you able to perform the essential functions of a practitioner in your area of practice with or without reasonable accommodation?” States that eliminate intrusive mental health questions from applications can retrieve national recognition from the Breen Heroes' Foundation (2022). Lastly, for transparency, applications should be easily accessible to the public on BON websites. These approaches can assist in reducing stigma and barriers to care while fostering meaningful support for prospective RNs and APRNs.

Limitations

The main limitation of this audit was incomplete data due to difficulty obtaining all application types. Attempts were made to obtain the missing data through use of several follow-ups; however, these attempts were ultimately unsuccessful with some states. Because some application questions were sent as screenshots, copy and pasted questions, or verbal descriptions, the study team was unable to verify if there were any other questions in the full application that may violate the Tool-Kit checklist. Thus, states assessed as compliant should be interpreted with caution.

Another limitation was the heterogeneous nature of the application types by state. Required types of applications can vary by state, and even names of the application types can vary. For example, the Nurse Licensure Compact application can also be called a multistate license, and not all states participate in the compact. Some states may refer to their APRN applications as initial applications, while others may call them board authorization or certification application. In Indiana, APRNs practice under their RN license and apply for prescriptive authority if needed. All these variations made between state comparisons challenging as it was often unclear if same type of applications were available in each state. BONs need to work across state lines to standardize the names and types of applications.

Lastly, because applications were obtained between September 2022 and May 2023, certain states may have updated their application questions since the end of data collection. Shortcomings of this study will be addressed via a Phase 2 review by The Lorna Breen Heroes' Foundation. Specifically, Phase 2 will verify Phase 1 findings, include licensed practical/vocational nurse applications, and obtain missing data.

Linking evidence to action

• Invasive mental health questions on nurse licensure applications discourage people from obtaining help for mental health issues, place people at risk for suicide, and may violate the ADA.
• Most state BONs do not fully adhere to Took-Kit recommendations, indicating that nurses are commonly asked extraneous, discriminatory, stigmatizing, or unnecessary questions concerning their mental health and substance use.
• Guidance from national organizations and legislation from state governments concerning the removal or revision of invasive mental health questions could cultivate a supportive and stigma-reducing environment for nurses to ultimately feel supported in seeking help for mental health issues.

ACKNOWLEDGMENTS

We would like to acknowledge Jessica LaVrar, BA, The Ohio State University, for her assistance in contacting Boards and Colleges of Nursing, Troy Huffman, BA, The Ohio State University, for creating the US map figure, and all Boards of Nursing and Deans of Nursing who assisted with our application retrieval. We would also like to thank and acknowledge the Dr. Lorna Breen Heroes' Foundation for granting us use of their Tool-Kit and providing us with consultation and guidance.

CONFLICT OF INTEREST STATEMENT

J. Corey Feist, JD, is the President and Co-Founder of the Dr. Lorna Breen Heroes' Foundation. The Breen Heroes' Foundation Remove Intrusive Mental Health Questions from Licensure and Credentialing Applications: A Toolkit to Audit, Change, and Communicate was utilized for this study's audit. The remaining authors have no conflicts to disclose.

Open Research

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.