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Board of Registered Nursing
It Has Failed to Use Sufficient Information When Considering Enrollment Decisions for
New and Existing Nursing Programs

Report Number: 2019-120


Audit Highlights . . .

Our audit of BRN’s oversight of nursing programs highlighted the following:

Results in Brief

In addition to its other duties as the state agency that regulates the practice of registered nurses (RNs), the Board of Registered Nursing (BRN) oversees California’s prelicensure nursing programs (nursing programs), which prepare students to practice as entry‑level RNs. BRN’s governing board (governing board) both approves new nursing programs in the State and makes decisions about the number of students that new and existing nursing programs are allowed to enroll (enrollment decisions). Two of the key factors that should influence BRN’s enrollment decisions are the forecasted supply of nurses that the State will need to fulfill demand and the available number of clinical placement slots—placements at a health care facility, such as a hospital, that nursing programs must secure for students to gain required clinical experience. In this audit, we found that BRN has failed to gather and use sufficient data related to both of these factors to appropriately inform its enrollment decisions.

Specifically, BRN’s 2017 forecast of the State’s future nursing workforce needs indicated that the statewide nursing supply would meet demand; however, it failed to identify the regional nursing shortages that California is currently experiencing and is expected to encounter in the years ahead. Although BRN’s methodology for determining the State’s overall nursing supply and demand was reasonable, it did not measure regional variations that would have identified regional nursing shortages. Given the size and diversity of California, regional forecasts would provide critical information to inform enrollment decisions and other actions by BRN’s governing board.

BRN’s governing board also lacks critical information about clinical placement slots when it considers enrollment decisions. When making these decisions, the governing board should consider the available number of clinical placement slots. If the governing board’s enrollment decisions allow for more enrolled students than the number of clinical placements available in the region, nursing programs end up having to compete for clinical space for their students. During the 2017–18 academic year, nursing programs reported that more than 2,300 students were affected by this clinical displacement—an insufficient supply of clinical placement slots. Nearly half of those programs reported that students from another program displaced their students, while many programs also reported losing clinical placements slots because facility staff workloads were too great to allow time for supervising nursing students. When displacement occurs, the nursing program losing placement slots must find new placement slots for its displaced students in order to provide the required clinical experience to its students.

BRN uses inconsistent and incomplete information to assess the availability of clinical placements because it has not provided guidance to its nursing education consultants (nursing education staff), who are employees of BRN, about the information they should provide to the governing board to aid it in considering enrollment decisions. Our review of 15 enrollment decisions found that BRN nursing education staff did not consistently provide to the governing board the information the staff had on the availability of clinical placements, such as how a proposed increase in enrollment would affect facilities that the requesting program planned to use for clinical placements. Some of BRN’s governing board members have also expressed concern that BRN’s existing process for assessing clinical displacement is not clear. Additionally, BRN does not gather and share with the governing board information concerning the total number of placement slots a clinical facility can accommodate annually and how many slots the programs that use the facility will need each year. Without this key information, BRN cannot properly gauge the risk of displacement when its governing board is making enrollment decisions.

To further enhance its information about clinical placement slots, BRN should require nursing programs to annually update information about the clinical facilities they use for student placements. With this information, BRN would be able to identify the types of facilities that programs most frequently use. Compiling this information and comparing it with other publicly available information about existing clinical facilities would also allow BRN to identify clinical facilities that programs do not currently use for placements, which could help nursing programs find additional facilities with capacity for their students.

Lastly, some of the nursing programs that BRN oversees are accredited by national nursing program accreditors (accreditors). Accreditors are private educational associations that verify whether programs meet and maintain acceptable levels of quality. We found that some of BRN’s requirements for nursing programs—specifically those related to approval of faculty, curriculum, and continuing compliance with state requirements—overlap with the standards imposed by accreditors. As part of the sunset review process, during which the Legislature evaluates the efficiency of certain state agencies, the Legislature should consider whether it would be appropriate to restructure any of BRN’s oversight to reduce duplication with accreditors while still achieving BRN’s mission to protect the public.

Selected Recommendations

The Legislature should amend state law to require BRN’s forecasts of the nursing workforce to incorporate regional analyses.

BRN should specify in policy the information its nursing education staff must present to the governing board for each enrollment decision it considers.

To better inform its enrollment decisions, BRN should gather information concerning the total number of placement slots a clinical facility can accommodate and how many slots the programs that use the facility will need.

As part of the sunset review process, the Legislature should consider whether it would be appropriate to restructure any of BRN’s oversight of nursing programs that might overlap with accreditation.

Agency Comments

BRN generally agreed with the recommendations we made to it. However, it raised concerns over the feasibility of some of the time frames for implementation.

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