Introduction
Background
The Board of Registered Nursing (BRN) is a state regulatory entity within the Department of Consumer Affairs (Consumer Affairs). State law establishes a nine‑member governing board (governing board) that serves as the governing body of BRN. It is composed of four members of the public and five registered nurses (RNs).The five registered nurses include two direct patient care nurses, an advanced practice nurse, a nurse administrator, and a nurse who is an educator or administrator of a nursing education program. The Senate Committee on Rules and the Speaker of the Assembly each appoint a public member, and the Governor appoints the remaining seven board members. State law provides that all appointments are for a four‑year term. Members can be reappointed, although no member can serve more than two consecutive terms. The governing board appoints an executive officer who has the overall responsibility for managing BRN’s resources and staff, overseeing BRN’s regulatory requirements, and interpreting and executing the intent of board policies for the public and other governmental agencies. In February 2020, BRN’s executive officer resigned, and the governing board appointed an acting executive officer who it subsequently appointed as executive officer in June 2020. BRN had about 240 total authorized staff positions and operated with a budget of about $55 million in fiscal year 2019–20.
BRN’s Mission and Functions
BRN’s stated mission is to protect and advocate for the health and safety of the public by ensuring the highest quality of RNs in the State of California. The Legislature created BRN in order to regulate and oversee the practice of nursing by implementing and enforcing the Nursing Practice Act, which specifies that protecting the public must be BRN’s highest priority in exercising its functions. Some of these functions relate to nursing education programs, and the licensure, practice, and discipline of RNs. BRN approves two types of nursing education programs: prelicensure programs and advanced practice programs. Prelicensure programs focus on preparing students to practice as entry‑level RNs, while advanced practice programs are for RNs who want to advance their education by earning further certifications, such as nurse practitioner, nurse anesthetist, or clinical nurse specialist. RNs practice nursing by providing direct and indirect patient care, including administering medication and therapeutic agents necessary to implement treatments ordered by licensed physicians. Our review focused specifically on BRN’s oversight of prelicensure nursing programs (nursing programs) located within the State.
State law requires BRN to adopt regulations that establish educational requirements for nursing programs. BRN ensures that nursing programs meet these educational requirements as part of its process for approving new nursing programs and inspecting existing programs, which includes verifying that programs provide required courses and hands‑on, clinical experience. Ultimately, BRN’s governing board approves nursing programs if they comply with these regulations.
Nursing Programs in California
Students graduating from a board‑approved nursing program must pass a national licensing examination in order to become licensed RNs in California. As of 2019, there were 145 board‑approved nursing programs in California. Of those programs, 105 are public schools—community colleges and public universities—and 40 are private schools. Admission to a nursing program can be competitive: in academic year 2017–18 the programs received more than 38,000 qualified applications, but only about 14,000 new students were able to enroll.An individual can apply to multiple nursing programs, so qualified applications could be greater than the number of individuals. All nursing programs must offer at least the minimum curriculum required by regulation, including specific numbers of coursework units in select areas, such as the science of nursing, related natural sciences, and behavioral and social sciences. Nursing programs can meet these curriculum requirements by offering a variety of degree programs: associate’s, bachelor’s, and entry‑level master’s degrees in nursing. Table 1 lists the types of nursing degrees offered by public and private schools in the State.
| TYPE OF PROGRAM | PUBLIC | PRIVATE | TOTAL |
|---|---|---|---|
| Associate’s–Typically takes two to three years to complete. Graduates earn an associate’s degree in nursing, and are prepared to provide nursing care. | 79 | 13 | 92 |
| Bachelor’s–Typically takes four years to complete. Graduates earn a bachelor’s degree in nursing and are prepared to provide nursing care and to move to administrative and leadership positions. | 21 | 20 | 41 |
| Entry‑level Master’s–Typically takes one to two years, depending on how many nursing course prerequisites the student has completed. Graduates earn a master’s degree in nursing. Designed for individuals who have a bachelor’s degree in another field and wish to become registered nurses. Graduates are prepared for advanced‑practice nursing careers in research, leadership, and patient care. | 5 | 7 | 12 |
Source: BRN’s website and director’s handbook and nursing program websites.
To graduate from a nursing program, students must complete units in both theoretical coursework and hands‑on, clinical experience in five content areas—medical/surgical, obstetrics, pediatrics, mental health/psychiatry, and geriatrics, as Figure 1 shows. To provide the required clinical experience, nursing programs must acquire placements (clinical placements) for students at clinical facilities, such as hospitals. Once a student completes the required coursework and clinical experience and graduates, she or he can apply to BRN to receive a nursing license and take the National Council Licensure Examination (licensure exam) and, upon passing, becomes an RN. Nursing programs in California must maintain a pass rate on the licensure exam of 75 percent for first‑time test takers, though they generally have higher pass rates. On average, 92 percent of first‑time test takers in California pass the exam.
Figure 1
Nursing Program Students in California Must Complete Both Classroom and Clinical Units to Become RNs
Source: State law and BRN’s website.
As of November 2019, BRN had 11 staff members who are responsible for overseeing nursing programs. Nine of these were nursing education consultants and two were supervising nursing education consultants (nursing education staff). These staff members visit proposed and existing nursing programs to help ensure that they are using approved curricula to prepare competent RNs, as well as to ensure compliance with regulations. BRN generally divides staff assignments geographically into Northern California and Southern California areas, with a supervisor over each area. Each nursing education staff member oversees a group of between six and 20 nursing programs.
BRN’s Approval of Nursing Programs and Enrollment Levels
Key Requirements for a Self‑Evaluation
A proposed nursing program must submit a self‑evaluation that includes the following items:
- Application for approval of a nursing program.
- Total curriculum plan that lists all courses of the program, including general education courses.
- Documentation of curriculum BRN requires for licensure, such as courses related to nutrition and cultural diversity.
- Narrative describing how the program will comply with rules and regulations related to the following:
– Faculty qualifications and changes to faculty.
– Required curriculum.
– Clinical facilities.
– Licensing exam pass rate standard.
Source: State law and BRN forms.
Nursing programs must receive approval from BRN in three circumstances: to establish a new nursing program (new program approval), to continue the nursing program following a review that takes place every five years after new program approval (continuing approval), and to make a substantive change. As a part of the new program approval process, a new nursing program must complete a feasibility study that demonstrates, among other things, a sustainable budget, evidence of availability of clinical placements for students, and information on the program’s applicant pool and sustainability of enrollment. If the governing board accepts the feasibility study, the proposed nursing program must appoint a nursing director and complete a self‑study—a self‑evaluation by the nursing program that demonstrates how it plans to comply with BRN rules and regulations and provides additional details about the program (self‑evaluation), as the text box shows. BRN’s nursing education staff members use the self‑evaluation to conduct an on‑site approval visit. During this visit, nursing education staff members do an in‑depth evaluation of the proposed nursing program to assess compliance with state law. When the governing board approves a new nursing program, it also approves how many students that program may enroll. New nursing programs must pay an approval fee to BRN of $40,000.
In addition, nursing programs must periodically demonstrate continued compliance with state law. BRN’s policy is to conduct site visits of nursing programs every five years to determine whether they are complying with state law. Ahead of such on‑site visits, a nursing program must provide another self‑evaluation, similar to that required for initial approval. Nursing programs established after January 1, 2013 must pay a continuing approval fee of $15,000 every five years to BRN.
If BRN finds that a nursing program did not comply with one or more of its rules and regulations, the program must respond to the findings at a meeting of the governing board’s Education and Licensing Committee (education committee), which consists of a subset of board members. According to BRN’s director’s handbook, in such instances, the education committee will recommend to the full governing board that it “defer action to continue approval” to give the program time to correct the violations. The program may remain in this deferred action status for no more than one year. If the school continues to be noncompliant, the governing board may place the program on “warning status, with intent to close the nursing program.”
Information Required When Submitting a
Request to Increase Enrollment
A letter of explanation on the nursing program’s letterhead, including descriptions of the following:
- The proposed change.
- The reason for the change.
- How the change will improve the education of students.
- How the proposed change will affect clinical facilities.
Source: BRN’s director’s handbook.
Furthermore, when a nursing program desires to make a major change to its curriculum, such as changes in the program philosophy and goals or objectives, it must first receive governing board approval. BRN also considers an enrollment increase to be a major curriculum change and, therefore, a nursing program must request governing board approval before increasing its enrollment. BRN charges a processing fee of $2,500 that must accompany a proposal for a major curriculum change. When a nursing program wants to make such a change, BRN policy requires the program to submit a letter of explanation that includes specific required information, which we list in the text box. Generally, for enrollment increases we reviewed, this information included the number of students by which the program requested to increase its enrollment.
Our audit focused on the governing board’s decisions to approve new nursing programs and enrollment increases. We refer to both new nursing program approval and the approval of an enrollment increase to an existing nursing program as enrollment decisions because both increase the number of enrolled nursing students. To inform these decisions, nursing education staff members review the information in the required self‑evaluation or letter of explanation from the nursing program that is making the request to determine whether the program has met the applicable requirements. The nursing education staff members then present their findings to the governing board’s education committee. The education committee advises and makes recommendations to the governing board regarding nursing program requests. Representatives from nursing programs requesting initial approval must appear at the education committee meeting to be available for questions. The governing board can approve, deny, or defer a nursing program’s request.
Factors Related to Enrollment Decisions
This report highlights two key factors related to the governing board’s enrollment decisions. The first factor is the number of RNs working in the State—the supply of nurses. In making decisions related to the number of students nursing programs can enroll, the governing board affects the flow of new nurses into the State’s nursing workforce, which can help alleviate or exacerbate shortages of nurses. In fact, state law enacted in 2002 requires BRN to collect and analyze nursing workforce data for future workforce planning. During an informational legislative hearing in 2001 on a nursing shortage—held before this law was introduced—various representatives from the nursing profession demonstrated to the Legislature that gathering more complete data on the nursing workforce would better enable researchers and policymakers to identify, and find solutions to, nursing shortages in California. The law requires BRN to produce reports on nursing workforce data at least every two years. To meet these requirements, BRN has contracted with the University of California, San Francisco (UCSF) (contractor) since at least 2005 to publish a biennial statewide nursing workforce forecast (forecast).
The second factor we highlight that influences the governing board’s enrollment decisions is the availability of clinical placement slots. When BRN evaluates a request to approve a new nursing program or increase enrollment in an existing nursing program, it considers whether the requesting program has secured sufficient clinical placement slots to accommodate the increase in students. Clinical placements are based on a written agreement with a clinical facility that has provided assurance of the facility’s availability to accommodate the program’s nursing students. Before a nursing program can use a facility for clinical placements—as a new program or for increased enrollment—the program must first obtain approval from BRN. The nursing program must complete and submit a clinical facility approval form (facility approval form) on which a facility representative attests that the program’s use of the facility will not displace students from other nursing programs currently using the facility to gain clinical experience. BRN nursing education staff members document their approval of the facility on the facility approval form, and BRN keeps records of these forms digitally in its network drive.
State law requires all students to complete 864 hours of clinical experience to ensure that they are competent to serve the public when they become licensed nurses. Given a two‑year nursing program with 16‑week semesters, students might spend on average 12 to 15 hours per week meeting the State’s clinical experience requirement. California is not alone in requiring clinical experience for a student’s nursing education. In fact, 42 state boards of nursing require nursing programs to include clinical experience for their students. However, only 12 states have a required number of clinical hours.
Clinical placement slots are a limited resource. Not all clinical facilities have the capacity or the desire to offer placement slots. The number of clinical placement slots available to a program can constrain the number of students the governing board will allow the nursing program to enroll. Clinical displacement occurs when a program loses placement slots that it is currently using to provide required clinical experience to students because a clinical facility decides to discontinue those placements for some reason. Although clinical displacement can happen for several reasons, including a change in facility staffing levels or emergency situations, such as the COVID‑19 pandemic in spring 2020, perhaps the reason of most interest to BRN occurs when students are displaced because other nursing programs took their clinical spots. When displacement occurs, the nursing program losing placement slots must find new placement slots for its displaced students, either on a different shift in the same facility or at another facility, in order to provide the required clinical experience to its students. This can be disruptive to nursing students and may hinder their ability to complete their required clinical experience.
As a possible approach to alleviating some of the enrollment constraint caused by limited clinical placement slots, nursing programs and other stakeholders in health care and government have sought to increase the portion of clinical experience hours that students can fulfill through simulation labs. Simulation is an activity or event replicating clinical practice using scenarios, high‑fidelity manikins, standardized patients, role playing, skills stations, and computer‑based critical thinking simulations. State law allows students to meet their clinical experience requirements with up to 25 percent indirect patient care, which includes simulation labs. However, in response to the COVID‑19 pandemic, Consumer Affairs issued a waiver on April 3, 2020, that allowed nursing students to complete their clinical experience with up to 50 percent indirect patient care, which could include simulation labs. Consumer Affairs set this waiver to expire after 60 days and then extended the expiration date to August 1, 2020. Although the scope of this audit did not include an evaluation of simulation labs as a reasonable substitute for in‑person clinical experience, we believe it is an area that could be considered as an approach to alleviating the constraint that the requirement for in‑person clinical placements might have on nursing programs’ ability to enroll more students.
Concerns Among Nursing Programs and Other Stakeholders
Stakeholders have called into question certain aspects of BRN’s authority to make enrollment decisions and whether portions of BRN’s director’s handbook constitute underground regulations. For example, in October 2018 the California Association of Private Postsecondary Schools petitioned the Office of Administrative Law (OAL) asserting that BRN had no legal authority to restrain the enrollment levels of approved nursing programs, that BRN’s exercise of this authority was based on certain guidelines in BRN’s director’s handbook that BRN had issued without complying with state law, and that these guidelines constituted an underground regulation. If a state agency issues, uses, enforces, or attempts to enforce a guideline or other rule without following the Administrative Procedure Act when it is required to do so, the rule is called an “underground regulation.” State law prohibits state agencies from enforcing guidelines or rules that constitute underground regulations. If a party believes a state agency has issued an underground regulation, that party may submit a petition to OAL seeking a determination of whether that guideline or rule is an underground regulation. Because BRN certified to OAL that it would no longer use or enforce the guidelines in question, OAL suspended the review it had initiated of the petition mentioned above.
In July 2019, West Coast University also filed a petition with OAL claiming that BRN was continuing to use and enforce some of the guidelines in question despite certifying to OAL that it would not. However, because BRN had already filed the certification stating it would not enforce the guidelines, and because a nursing program filed a lawsuit related to the guidelines in April 2019, OAL declined to take action on the matter in accordance with its regulations. OAL’s director stated that OAL is considering amending its regulations to allow for it to continue its inquiry and make a determination in cases in which an agency or department has filed such a certification, but parties assert that the department or agency is continuing to use and enforce underground regulations.
In addition, American Career College (ACC), a Los Angeles private college that offers nursing associate’s degrees, filed a lawsuit in April 2019 asking the court to find that BRN does not have the authority, power, or purview to determine the total number of nursing students that ACC may enroll. BRN has opposed the lawsuit because it believes it is authorized to regulate the number of students a nursing program is permitted to enroll. As the question of whether BRN has authority to make enrollment decisions regarding the number of permitted enrollments had been brought before the court, we made no such determination in this report regarding this issue because audit standards prohibit us from doing so. Instead, our report focuses on the actions BRN has taken in the recent past.
Additionally, in September and October 2018, multiple stakeholders from academia, health care providers, labor groups, and government participated in seven regional summit meetings (stakeholder summits) at different locations across California to discuss issues surrounding clinical education capacity, particularly the availability of clinical placements for nursing students. The resulting report identified six priorities for action that all seven regions agreed upon. Five of these priorities are related to clinical experience or placements:
- Seek to standardize requirements for nursing curricula, credits, and clinical hours.
- Encourage nursing programs and clinical facilities to participate in groups, consortiums, and scheduling systems related to clinical placements.
- Seek to standardize the requirements for licensing and accreditation of clinical facilities, as well as the onboarding and orientation process for students and faculty.
- Facilitate increased use of nonacute, community‑based, and ambulatory clinical sites statewide.
- Seek to enable students to use simulation for up to 50 percent of their clinical practice requirements.
The sixth priority involved establishing structures to encourage communication, collaboration, cooperation, and decision making among senior‑level nursing program and clinical facility staff.
Recent Developments
Prior to the completion of this audit, the California State Auditor (State Auditor) received a whistleblower complaint alleging that BRN executives in the enforcement division intentionally manipulated data and delivered a falsified report to the State Auditor to satisfy a recommendation the State Auditor had made during a 2016 audit of the enforcement division. In response to the complaint, the State Auditor launched an investigation and substantiated that BRN executives violated state law when they carried out a plan to artificially decrease caseloads for BRN investigators before delivering a falsified report to the State Auditor. The plan involved temporarily reassigning some of the BRN investigators’ cases to other employees who should not have had cases assigned to them. The investigation found that within 10 days of the State Auditor reviewing the falsified report and concluding that BRN had fully implemented the recommendation, BRN managers reversed the reassignments, increasing caseloads to their original level. A copy of investigative report I2020‑0027, Board of Registered Nursing: Executives Violated State Law When They Falsified Data to Deceive the State Auditor’s Office, can be found on our website at www.auditor.ca.gov. The audit team became aware of the investigation during this audit and re‑evaluated the risk assessment it conducted for the audit to ensure it could rely upon the documentation provided by BRN for this audit report. We determined that the documentation we obtained was reliable.