BRN’s Forecasts of the Supply of Qualified Nurses Have Not Included Key Information
An adequate supply of nurses is critical to health care.BRN has an impact on the supply of nurses through its enrollment decisions, putting it in the unique position of being able to directly respond to and mitigate nursing shortages. BRN’s contractor explains in its 2017 forecast that nursing shortages generate significant challenges because the level of nurse staffing in hospitals and other care facilities can affect patient outcomes.BRN published its more recent 2019 forecast in May 2020, near the completion of our audit. Therefore we refer to conclusions cited in the 2017 forecast. The 2017 and 2019 forecasts are largely similar in their scope and methodology. The 2019 forecast projected that a small surplus of RNs statewide could emerge in the future. As described in the Introduction, state law requires BRN to analyze data and produce reports on the nursing workforce in California to help researchers and policymakers find solutions to nursing shortages.
However, the conclusion from BRN’s 2017 forecast that supply is adequate is inconsistent with other similar studies. This inconsistency has caused some confusion about whether the State will experience a nursing shortage. BRN’s forecast includes high and low estimates of supply and demand, but it indicates that the supply of and demand for RNs will be fairly well balanced across the State over the next 10 years, if current enrollment patterns and migration patterns of nurses into and out of the State remain stable. In contrast, various other studies and reports on the nursing workforce in California project a nursing shortage in the State or in areas within the State, although the studies differ as to the magnitude of the projected shortages. In particular, the projected statewide shortages range from none at all, according to BRN’s 2017 forecast, to a shortage of approximately 141,000 nurses by 2030, according to “United States Registered Nurse Workforce Report Card and Shortage Forecast: A Revisit” (RN Workforce Report Card), a study published in the May/June 2018 issue of the American Journal of Medical Quality. Table 2 shows five recent studies we identified and the key differences among them, such as their scope and how they measured supply and demand, that likely contributed to the different projections.
|Forecasts of the Registered Nurse Workforce in California*
|UCSF for BRN
|2017 to 2035
|Estimated the number of RNs entering, departing, and choosing to participate in the workforce
|Estimated future demand based on current hospital utilization and staffing patterns†
|Supply and demand are balanced
|Regional Forecasts of the Registered Nurse Workforce in California
|Healthforce Center at UCSF
|2018 to 2035
|Estimated the number of RNs entering, departing, and choosing to participate in the workforce
|Estimated future demand based on current hospital utilization and staffing patterns†
|Large differences across regions of the State.
|United States Registered Nurse Workforce Report Card and Shortage Forecast: A Revisit
|American Journal of Medical Quality
|2016 to 2030
|National study that provided statewide information
|Estimated the number of individuals in a region or state who are likely to work as a nurse based on estimated populations over a 10‑year period (2006 to 2015)
|Estimated number of jobs needed to meet population needs based on the 2015 national mean average of jobs per 100,000 people
|Shortage of 141,348 nurses
|Supply and Demand Projections of the Nursing Workforce
|U.S. Department of Health and Human Services
|2014 to 2030
|National study that provided statewide information
|Estimated the number of RNs entering, departing, and choosing to participate in the workforce and other factors, such as wage rates
|Estimated number of jobs needed to provide a level of care consistent with the baseline year—2014—based on hospital utilization and staffing patterns
|Shortage of 44,500 nurses
|Registered Nurse Shortage Areas Update
|California’s Office of Statewide Health Planning and Development (OSHPD)
|Actual number of registered nurses in a county
|Actual current hospital and long‑term care facility utilization
|28 counties are RN shortage areas
Source: Studies as listed in table.
* BRN published its 2019 forecast in May 2020, near the completion of our audit. The 2017 and 2019 forecasts are largely similar. In its 2019 version, BRN again reported a forecast of the nursing workforce on a statewide basis that did not include a regional analysis. It also generally used the same methodology as its 2017 forecast and projected that a small surplus of RNs statewide could emerge in the future.
† OSHPD data was used to create these demand models.
The methodology that BRN’s contractor used in its 2017 forecast is reasonable, but BRN could have asked for a more robust analysis. The contractor measured the supply of nurses statewide by reviewing the number of RNs entering, departing, and choosing to participate in the workforce. Specifically, the contractor considered factors such as the number of newly graduated nurses, the migration of nurses to and from other states, and the number of RNs with active licenses in the State. In fact, the model that BRN’s contractor used to measure supply is similar to those used in other health care studies that we identified.
Similarly, the contractor’s method for measuring demand is generally reasonable. Specifically, it identified the demand for nurses at hospitals and other health care facilities in California by reviewing the staffing patterns of RNs—in particular, the number of RN hours worked per day that a patient was in the hospital (patient day)—and data on hospital usage. BRN’s contractor also considered information that state law requires BRN to analyze, such as the number of RN hours worked, age‑specific demographics, and number of patient days. These factors are different from those used in the RN Workforce Report Card study, which defines RN demand as the estimated number of RN jobs needed to meet population needs. The section of law that requires BRN to analyze workforce data does not require BRN to collect and analyze information on the health care needs of California residents or the number of health care facilities that exist in California.
The 2017 forecast has a limitation that it acknowledged: it represents the State as a whole and does not reflect the fact that one region of California may experience a shortage while another faces a surplus of RNs. Because BRN’s forecast does not measure regional variations in supply and demand, it obscures regional shortages that currently exist and those projected to exist in the future. Thus, BRN’s forecast does not provide information that would help it respond to and mitigate regional nursing shortages.
BRN can influence the supply of nurses through its enrollment decisions. In fact, BRN’s contractor recommends in its 2017 forecast that policymakers continuously monitor factors that could influence regional shortages, such as the number of graduates from RN education programs and the interstate migration of nurses. According to BRN’s 2017 forecast, the solution to a nursing shortage in 2005 was in part to increase the number of graduates from California nursing programs, which led to a stable workforce. Additionally, the forecast indicates that if future numbers of student enrollments and graduates decline, a shortage could reemerge. Given the size and diversity of California, we believe a regional forecast would provide critical information to inform the governing board’s enrollment decisions and other actions to address identified shortages. BRN officials agreed that a regional analysis would provide valuable information.
Only two of the five studies we reviewed measured shortages on a more local level. Specifically, the 2018 Regional Forecasts of the Registered Nurse Workforce in California (2018 regional forecast) by the Healthforce Center at UCSF, and a 2019 report by OSHPD titled Registered Nurse Shortage Area Update (OSHPD report) employ a more localized analysis. In fact, the 2018 regional forecast, which was prepared by the same entity with which BRN contracts for its forecast and, using generally the same method for measuring supply and demand, identified and measured regional differences in the need for RNs within California. The 2018 regional forecast concludes that all regions except the Central Coast appear to have had nursing shortages that year and that by 2035 the Central Valley, Central Coast, and San Francisco Bay Area will experience or continue to experience nursing shortages. Figure 2 shows the counties that are included in each of the eight regions defined in the 2018 regional forecast and indicates whether the regional forecast projects a shortage, a surplus, or balanced supply and demand for each region in 2035. Similarly, the OSHPD report used patient day data and BRN’s active nurse licensee data from 2017 to classify 28 counties as having had a shortage of RNs in that year.
Some Regional Nursing Shortages Are Projected to Continue Within California
Source: Analysis of UCSF’s 2018 Regional Forecasts of the Registered Nurse Workforce in California.
Note: The supply and demand numbers for the regions include adjustments, to account for RNs commuting between regions, advanced‑practice RNs not working in RN jobs, and the number of RN hours worked by contract staff at hospitals.
If BRN’s forecast identified regional shortages and surpluses, it would be able to provide the governing board better information to consider the reasons that nursing programs assert for expanding their programs. We reviewed governing board meeting minutes and corresponding materials between 2017 and 2019 and found that 18 of the 35 requests from nursing programs to increase enrollment or open a new nursing program cited nursing shortages as a reason for requesting an enrollment increase. For example, in a June 2019 letter to BRN, Unitek College provided additional information to BRN about its proposal to start a registered nursing program at its Bakersfield campus. Unitek College cited community nursing workforce shortages and data from the 2018 regional forecast on the migration of RNs out of the Central Valley region as causes for concern. However, BRN’s forecast did not include relevant regional information that would allow its nursing education staff to verify those assertions. BRN officials stated that if BRN’s forecast identified more specific and concrete data on regional shortages, it would give the governing board better information to consider the assertions that nursing programs make for expanding their programs, such as nursing shortages that exist in their areas.
Regularly collecting information on California’s regional nursing workforce would also give BRN the information it needs to identify shortage areas and take action to mitigate those shortages. The Nursing Practice Act does not require BRN to address any identified shortages. However, BRN’s mission, in part, is to advocate for the health and safety of the public. As part of this advocacy, BRN should develop a plan to support increases in enrollment at existing nursing programs or new programs in areas with shortages, such as providing programs with information that they could use to identify additional clinical placements, as we discuss later.
BRN’s Process for Assessing the Availability of Clinical Placements Is Inadequate
The number of available clinical placement slots affects the number of student enrollments the governing board should approve and the eventual supply of nurses in the State. This information is also crucial to understanding the risk of clinical displacement. However, BRN does not track or consistently report this information to its governing board. In fact, it has not established what information its nursing education staff must provide to the governing board when it is considering enrollment decisions. We found that nursing education staff provided inconsistent information to the governing board, hampering its ability to properly gauge the risk that its decisions might displace students from their clinical placement slots. If BRN augmented information it collects about the number of clinical placement slots at facilities and stored that information in a database, it could better analyze the data and present to the governing board more robust and objective information to consider in making its enrollment decisions. Additionally, BRN could compare the facility information in its database with OSHPD’s health care facility data to identify additional facilities with potential clinical placement slots.
BRN Uses Inconsistent and Incomplete Information to Assess Whether an Adequate Number of Clinical Placement Slots Is Available
Another key factor that should influence the governing board’s enrollment decisions is the availability of clinical placement slots. Because the availability of clinical placement slots has an impact on the number of student enrollments the governing board should approve for a nursing program and the eventual supply of nurses in the State, having this key information is crucial for the board. However, BRN has not established a policy for its nursing education staff members that specifies the information they must provide to the governing board for each enrollment decision, such as the number of available clinical placement slots in a facility where a program plans to place students. We found that, for the 15 enrollment decisions made between January 2015 and September 2019 we reviewed (five requests for new nursing programs and 10 requests for enrollment increases at existing programs), nursing education staff did not consistently present to the governing board the information that nursing programs must submit regarding clinical placements, as Figure 3 shows. Specifically, for eight of the 15 decisions, nursing education staff did not present all the clinical placement information that nursing programs must provide. For example, for the five requests for new programs, nursing education staff did not present information about the number of students the programs intended to have in classroom nursing courses or the facilities they planned to use for the associated clinical experiences. Consequently, the governing board could not properly assess the risk of clinical displacement for these programs. Nevertheless, the governing board approved all but one of the requests. To help ensure that the governing board bases enrollment decisions on complete and consistent information in the future, BRN should establish a uniform format and structure for information that nursing education staff must provide to the governing board for each enrollment decision.
BRN’s Lack of Guidance Results in Staff Presenting Inconsistent Information to the Governing Board
Source: Analysis of state law, governing board meeting minutes, materials, and BRN’s director’s handbook
One possible unintended consequence of BRN’s enrollment decisions is the clinical displacement of students. Since at least 2009, BRN has been performing an annual survey of schools with nursing programs, a portion of which relates to clinical displacement. It asks responding nursing programs whether in the past year they lost clinical placement slots, how many students were affected, and the perceived reason that clinical placement slots were not available. BRN publishes the annual survey report on its website. As Figure 4 demonstrates, nursing programs reported in the most recent survey that more than 2,300 students were affected by a loss of clinical placement slots in academic year 2017–18—an amount generally similar to previous years. Most notably, nearly half of the nursing programs that lost a clinical placement reported that it occurred because other nursing programs took their clinical spots.
Summary of Survey Responses Related to Clinical Displacement
Source: BRN’s 2017–18 Annual School Report.
* Nursing programs can report more than one reason for clinical displacement.
To identify potential clinical displacement, BRN asks programs that are seeking initial approval or enrollment increases to contact nearby nursing programs and obtain statements indicating their support or opposition to the proposed change. BRN does this despite the fact that it requires the clinical facilities to assert, on the facility approval form that programs are required to submit to BRN, that a program’s use of a facility will not displace the students of other programs. The nursing education staff members then generally provide a summary of the statements to the governing board. According to BRN’s assistant executive officer, this practice first occurred in October 2016, when the education committee requested that Azusa Pacific University obtain statements from nursing programs potentially affected by its proposed enrollment increase. Since 2016 programs have continued to provide these statements to BRN. However, BRN has never established a process for handling these statements, such as promulgating a regulation to govern this process. For instance, the governing board approved requests for new programs and increased enrollment for several nursing programs despite existing statements of opposition.
BRN does not require its nursing education staff to independently verify the nearby nursing programs’ assertions in these statements. For example, when the statements present significant disagreement, such as the seven statements of opposition and five statements of support provided to BRN regarding a proposed enrollment increase, BRN policy does not require nursing education staff to contact the programs and investigate the discrepancy. Nearby nursing programs might compete with the new nursing programs for clinical placement slots, and thus they have no clear incentive to support increasing enrollment for another nursing program. Further, the nearby nursing programs do not always provide responses to the requesting program. For example, according to the governing board meeting materials, 25 of 38 programs did not respond to Concordia University Irvine’s June 2017 enrollment increase request. All of these factors call into question the validity and usefulness of the practice of soliciting the statements, and thus BRN should immediately discontinue its practice of asking nursing programs to seek statements of support or opposition from neighboring nursing programs.
Some governing board members and stakeholders agree that the existing process for assessing clinical displacement lacks clear direction and robust information. During the September 2019 board meeting, some governing board members echoed this sentiment as they made decisions involving enrollment increases. During this meeting, two governing board members acknowledged that the governing board had not provided its staff with clear direction on what information it needs when assessing clinical displacement. Stakeholders also voiced their displeasure with BRN’s current method of assessing clinical displacement during the stakeholder summit meetings in the fall of 2018. For example, the resulting summit report describes an interest in replacing BRN’s existing approval process with “reliable processes that provide sufficient evidence of clinical capacity/clinical placement.” BRN’s executive officer stated that gathering more information about clinical placement slots would help the governing board and BRN education staff better understand clinical capacity. Without accurate clinical placement information, BRN cannot consistently and confidently prevent current nursing students from being displaced.
BRN Is Not Collecting and Analyzing Useful Information Regarding Clinical Placement Slots and Capacity
Although BRN has a database with some information about the clinical facilities that nursing programs use (nursing program database), it does not track the number of available clinical placement slots or the total number of students placed at a clinical facility. Consequently, BRN cannot effectively analyze and report the risk of displacement to its governing board when it is considering enrollment decisions. As we mention in the Introduction, nursing programs must get BRN approval before using a clinical facility. BRN documents its approval on a facility approval form, on which the facility and program attest that the program’s clinical placements at the facility will not displace students from other nursing programs. The form also includes the program location and the content area for which the program is using the facility. Therefore, BRN should have a record of all facilities that nursing programs are using for clinical placement slots. BRN compiles some of the information captured in the facility approval form in its nursing program database. According to BRN, the database is intended as a tool for nursing education staff to hold information on nursing programs.
Yet, BRN does not gather certain critical information about available clinical placement slots in its nursing program database. In particular, BRN does not collect on its facility approval form or track the total number of students—or clinical placement slots—a clinical facility can accommodate annually or how many slots the programs that use the facility will need each year, as Figure 5 shows. As a result, BRN’s governing board lacks key information it needs to make enrollment decisions. For example, knowing the number of placement slots that a facility can accommodate would allow the governing board to determine whether a program’s request to increase enrollment by using that facility would exceed that capacity and risk displacing students.
BRN Is Not Taking Full Advantage of Its Nursing Program Database
Source: Analysis of state law and BRN’s data and documents.
As it is, the database is incomplete and unreliable because BRN has not added information for all the facilities where nursing programs have clinical placements. Some of the facility approval forms on file, as well as entries in the database, are over a decade old and include outdated and incomplete information because BRN does not require nursing programs to submit updated facility approval forms once a facility is approved. Consequently, if a nursing program does not submit an updated facility approval form, BRN may be unaware of changes to facility use, and therefore the governing board may not have current and complete information to assess how any changes could affect its enrollment decisions concerning that facility. To ensure that it maintains up‑to‑date information on the number of available clinical placement slots at facilities, BRN should revise its regulations to require nursing programs to report to it, using a facility approval form, anytime they make changes to their use of clinical facilities, as well as to report annually if they have made no changes. BRN should use these forms to update the information contained in its database.
If BRN’s database were complete and up to date, it could have used the data to analyze the risk of displacement related to a program’s request for an enrollment decision and informed the governing board of the results of its analysis. In fact, we tested this idea for the 16 nursing programs located in five Bay Area counties (Alameda, Contra Costa, Marin, San Francisco, and San Mateo). For these programs, we compiled the data from hundreds of facility approval forms BRN had in its files into a list, and we analyzed the data by program, facility, and content area. We found that, according to BRN’s records, the 16 programs reported using certain facilities for clinical placement slots far more frequently than others. For example, 11 of the 16 nursing programs we reviewed reported using UCSF Children’s Hospital in Oakland for their students to get their pediatric clinical experience.
According to the executive officer, BRN agrees that it should compile and analyze data related to clinical placement slots, and she indicated that BRN would be able to assign administrative staff or a data expert to do so. The executive officer also asserted that although BRN does not track clinical capacity and displacement on a statewide systematic basis, it has been gathering information related to clinical displacements through its annual school survey for several years. Although the survey gathers valuable information, such as the number of students that nursing programs reported had lost clinical placement slots and the nursing program’s perceived reason that clinical placement slots were not available, it does not capture statewide or regional information on clinical capacity.
Capturing in its database the total number of placement slots a clinical facility can accommodate and how many slots the programs that use the facility utilize and then publishing this information on its website, would allow BRN and other key stakeholders to begin to understand the capacity for clinical placement slots on a regional and statewide basis. We acknowledge that the number of available clinical placement slots changes over time, and multiple factors can affect a facility’s ability to predict the exact number of its annual placements. However, even if there are changes throughout the year, collecting annual estimates of clinical slots from facilities across the State will allow BRN to make better informed enrollment decisions that affect the State’s nursing supply. BRN should revise its facility approval form to collect the total number of students that a clinical facility can accommodate annually as well as the number of students the program needs to place annually.
BRN Is Forgoing Opportunities to Help Nursing Programs Identify Facilities With Potential Clinical Placement Slots
BRN could also analyze and share information that could foster additional clinical placement opportunities, which in turn could enable some nursing programs to increase enrollment and educate new nurses. Specifically, OSHPD has a downloadable list on its website of state health care facilities.According OSHPD’s website, this is a listing of facilities that are licensed by California Department of Public Health. If BRN had a complete and up‑to‑date database with information related to the facilities each nursing program is using, it could compare this information to OSHPD’s list of health care facilities and publish its comparison on its website. This comparison could assist nursing programs in identifying clinical facilities that other nursing programs are not using at all for clinical placement slots or that only a few are using.
In fact, using OSHPD’s information, we identified many facilities that, according to BRN’s records, are not currently placing students, and some of these facilities potentially could be sources for clinical placement slots. Using the information we compiled from BRN’s facility approval forms for the 16 nursing programs in five Bay Area counties we described earlier, we compared the facilities these programs used with OSHPD’s list of health care facilities in those same counties.The counties are Alameda, Contra Costa, Marin, San Francisco, and San Mateo. We found that the 16 nursing programs were using 121 of the 708 facilities on OSHPD’s list, or 17 percent. This means that there are hundreds of clinical facilities in those five counties that nursing programs are not currently using for clinical placement slots, representing a possible untapped source of additional clinical placement slots.
We also found from this analysis that nursing programs have clinical placements at most acute‑care hospitals but are not currently using nonacute facilities, such as home health agencies, hospice facilities, and clinics nearly as much. Specifically, the programs in the Bay Area we reviewed are using 82 percent of the acute‑care hospitals in OSHPD’s list, but are using only 10 percent of the clinics. In fact, this analysis helps identify possible additional nonacute facilities for placements, which was a priority for action from the stakeholder summits. Figure 6 illustrates the number of used and unused facilities in the five counties by facility type. In addition, we determined the content areas for which nursing programs were using each type of facility, as Figure 6 also shows. For example, skilled nursing facilities can accommodate several content areas and, while 34 of those facilities are currently being used, 107 are currently unused.
Facilities Not Used by Nursing Programs for Clinical Placements Could Be a Source of Additional Placements
Source: Analysis of BRN’s documents and OSHPD’s data for programs in the Bay Area.
* Because no programs currently use other clinical facilities, we could not determine the content areas that would apply.
It is important to note that just because a nursing program is not using a facility does not necessarily mean the facility is available for use or willing to provide clinical placement slots for nursing students. For example, a facility might not have enough staff to support student learning or might have other concerns. BRN and nursing programs would need to do additional work to contact currently unused facilities to gauge their interest in providing clinical placement slots. However, we believe such a comparison and the necessary follow‑up would provide valuable information to help identify additional clinical placement slots and alleviate some of the possible constraints on enrollment for nursing programs in areas experiencing a nursing shortage. BRN agreed that comparing its data from the facility approval forms with OSHPD data could be helpful in identifying facilities that might provide additional clinical placement slots.
BRN’s Process for Approving Nursing Programs Partially Overlaps With the Work of Accreditors
Some of BRN’s requirements for approving nursing programs are similar to accreditation standards. National Nursing Program Accreditors (accreditors) are private educational associations that assess whether nursing programs meet and maintain acceptable levels of quality. As part of their evaluation of nursing programs, accreditors verify that course content is consistent with contemporary nursing practices, instructors are using teaching methods that support expected student outcomes, and schools are meeting the needs of nursing students by providing adequate resources and support services. Although BRN approval is required for nursing programs in California, accreditation is optional. BRN reported that roughly half of the nursing programs in the State were accredited as of fiscal year 2017–18. Of those that are accredited, nearly all are accredited by the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission for Education in Nursing (ACEN). Both of these accreditors are recognized by the U.S. Department of Education as reliable authorities on the quality of nursing education.
BRN’s approval of nursing programs has similarities to accreditation in both its approval process and the standards it requires nursing programs to meet. For instance, both review processes involve an initial approval in which accreditors and BRN verify that nursing programs meet their standards; a cycle of periodic continuing approvals; and the requirement that nursing programs report substantive changes, such as enrollment increases or curriculum changes. For continuing approval, both processes require a program to conduct a self‑evaluation that provides similar information, such as licensure exam pass rates and faculty qualifications. BRN requirements for nursing program approval are found in state law. These requirements are similar to accreditation standards in many categories. For example, as shown in Table 3, the accreditors’ standards overlap with BRN’s requirements in each of the following areas: administrator and faculty qualifications and responsibilities, program resources, curriculum requirements, and testing standards. For certain areas, one accreditor verifies that nursing programs are meeting the same state requirements that BRN verifies. In fact, eight ACEN accreditation standards specifically require accreditors to verify that nursing programs are in compliance with state requirements or policies for the applicable area under review.
|SELECTION OF BRN’S REQUIREMENTS FOR
NURSING PROGRAM APPROVAL
|Nursing program faculty and administrators are qualified and have relevant experience.
|Nursing program has sufficient resources for students and faculty.
|Curriculum is comprehensive and includes concurrent clinical experience.
|Nursing program maintains a minimum pass rate for the licensure exam.
|The majority of clinical hours are completed in direct patient care.
|Nursing program considers clinical displacement when selecting a new clinical facility to use.
Source: Analysis of state law and accreditors’ documents.
✔ = The requirement is present in the accreditor’s standard.
X = The requirement is not present in the accreditor’s standard.
However, there are some important differences between BRN oversight and accreditation. According to the National Council of State Boards of Nursing (National Council), a state board’s mission is protecting the public and ensuring that nursing programs meet state requirements, whereas accreditors focus on quality and program effectiveness.The National Council is a nonprofit organization whose members consist of the nursing regulatory bodies in the 50 states, the District of Columbia, and four U.S. territories. Its mission is to empower and support nursing regulators in their mandate to protect the public. The National Council points out that boards of nursing also understand nursing education issues in their specific jurisdictions. Accreditors do not have statutory authority to close nursing programs that do not meet standards, while boards of nursing do have that authority. The National Council also states that boards of nursing can act right away when they identify problems with nursing programs; accreditors cannot act as quickly. Additionally, continuing approval visits by ACEN and CCNE may occur less frequently than BRN’s—up to every eight to 10 years for the accreditors compared to every five years for BRN. Also, BRN approves nursing program faculty prior to employment, whereas accreditors do not.
BRN’s executive officer strongly opposes the prospect of reducing BRN’s involvement in reviewing and approving nursing programs. She stated that accreditation reviews are too infrequent and are not focused on ensuring that nursing programs comply with BRN regulations. She added that BRN has identified noncompliance even at accredited programs, such as unapproved curriculum changes and insufficient resources. She also echoed the point made by the National Council that accreditors do not have statutory authority over nursing programs. She believes that maintaining BRN’s oversight and implementation of the review process is the only way to ensure consistent program review for all prelicensure nursing programs and that relying on accreditation does not enable BRN to achieve its mission of protecting the public and nursing students. Finally, she stated that reducing BRN oversight could result in registered nursing students and graduates not having sufficient educational preparation and opportunities to obtain the requisite knowledge, skills, and abilities needed to safely and competently perform required nursing functions.
Nevertheless, aligning state review with accreditation is not uncommon. We identified several California healing arts boards that rely on accreditation in place of or in conjunction with state review: the Medical Board of California, the Osteopathic Medical Board of California, the Physician Assistant Board, and the Dental Hygiene Board of California. This is not the case for California nursing programs: the State does not require accreditation for these nursing programs, and only half of them have chosen to become accredited. However, the State does require accreditation for nurse practitioner programs located in California, which are advanced‑practice programs. The National Council recommended in 2012 that all state boards of nursing require nursing programs to be accredited by 2020. As of March 2020, a total of 26 U.S. states and territories require accreditation, according to the National Council.
Additionally, collaboration between states and accreditors is encouraged. Although BRN specifically states that it will not accept reports prepared for accrediting bodies, ACEN indicated that it welcomes the opportunity to cooperate with state regulatory agencies for nursing with the goal of increasing efficiency and decreasing workload while maximizing outcomes. In addition, the National Council recommends that boards of nursing work toward harmonizing their approval process with accreditors.
Given the differences in the purposes of BRN’s approval and national accreditation, we are not suggesting that accreditation is an exact replacement for BRN’s oversight. Rather, we believe policymakers should consider, as part of their sunset review, whether it would be appropriate to restructure any of BRN’s oversight to reduce duplication with accreditation agencies while still achieving its mission to protect the public. Sunset review is a process intended to identify and eliminate waste, duplication, and inefficiency in government agencies. The purpose of sunset review is for a legislative committee to conduct a comprehensive analysis on a periodic basis to determine whether the subject agency is still necessary and cost‑effective. As a part of this process, the committee considers recommendations for changes and reorganization to help the agency better fulfill its purpose. Given that some of BRN’s oversight of nursing programs might be duplicated by accreditors, we believe the upcoming sunset review in 2021 would be an appropriate setting to consider whether the State would be better served by having BRN revise its regulations to leverage portions of the accreditors’ reviews in order to reduce duplication and more efficiently use state resources. For example, it could consider restructuring continuing approval requirements for nursing programs that are accredited and maintain certain high performance standards for consecutive years (for example, licensure exam pass rates, program completion rates, and job placement rates).
Other Areas We Reviewed
BRN’s Conflict‑of‑Interest Code Is Adequate, and Members of the Governing Board Recused Themselves Appropriately
BRN’s conflict‑of‑interest code (code) incorporates the terms of the Fair Political Practices Commission’s standard code and appropriately identifies positions within BRN that must report economic interests. State law requires that every agency adopt and promulgate a code. It also requires that, in their codes, agencies must specifically designate positions that involve the making of or participation in the making of decisions that may have a foreseeable effect on any financial interest for individuals in those positions, and the types of financial interests that those individuals must report. Additionally, agencies’ codes must contain provisions that outline circumstances under which designated employees must recuse themselves from participation in decision making. To report their economic interests, designated BRN employees file a Statement of Economic Interests—known as a Form 700—that the Fair Political Practices Commission publishes. Based on our review, every individual at BRN who is significantly involved in the approval process for nursing programs filed a Form 700 for each year from 2017 to 2019. However, two people filed two of their forms late after we found that they were missing and discussed it with a filing officer at Consumer Affairs. We found that governing board members appropriately recused themselves from decisions regarding nursing programs in which they had reported an economic interest during the audit period.
Nursing Education Staff Members Responsible for Reviewing Nursing Programs Are Adequately Qualified
BRN’s nursing education staff members are appropriately qualified to perform their oversight responsibilities. To assess their expertise, we reviewed the minimum qualifications of nursing education staff members as defined by their job classifications and compared each staff member’s most recent application file to those minimum qualifications. We also determined that the minimum qualifications appeared appropriate for the type of oversight work that nursing education staff perform. Nursing education staff members must have an active, valid California license as an RN and at least five years of nursing experience, which must include three years as a teaching nurse faculty member; or three years as a clinical specialist, nurse practitioner, or in‑service educator in a hospital, clinic, or private‑practice setting, and a master’s degree in nursing or a related field. Supervising nursing education staff members must have two years of experience performing the duties of staff‑level nursing education staff or five years of nursing experience, including three years as a teaching nurse faculty member and two years of experience in nursing administration. All of the 11 currently employed nursing education staff members meet or exceed the minimum education qualifications; in fact, six of the staff have a doctoral degree.
To better inform stakeholders and the governing board’s decision making, the Legislature should amend state law to do the following:
- Require BRN to incorporate regional forecasts into its biennial analyses of the nursing workforce.
- Require BRN to develop a plan to address regional areas of shortage identified by its nursing workforce forecast. BRN’s plan should include identifying additional facilities that might offer clinical placement slots.
As part of BRN’s sunset review in 2021, the Legislature should consider whether the State would be better served by having BRN revise its regulations to leverage portions of the accreditors’ reviews to reduce duplication and more efficiently use state resources. For example, it could consider restructuring continuing approval requirements for nursing programs that are accredited and maintain certain high performance standards for consecutive years (for example, licensure exam pass rates, program completion rates, and job placement rates). Additionally, the Legislature should consider whether and how BRN could coordinate its reviews with accreditors to increase efficiency.
To ensure that BRN and stakeholders have an understanding of clinical placement capacity in California, the Legislature should amend state law to require BRN to annually collect, analyze, and report information related to the number of clinical placement slots that are available and the location of those clinical placement slots within the State.
To better ensure that California has an appropriate number of nurses in the future, BRN should do the following by January 1, 2021:
- Revise the scope of work of its contract for workforce forecasting services to direct the contractor to incorporate regional analyses.
- Ensure that the governing board’s enrollment decisions and other actions adequately take into consideration the regional analyses in BRN’s future workforce forecasts. Specifically, it should amend its policies to require that when its staff present information to the education committee and the governing board to inform them on pending enrollment decisions, staff should include relevant information related to BRN’s most recent forecast of the nursing workforce.
To ensure that nursing education staff members provide complete information to the governing board when it is considering enrollment decisions, by January 1, 2021, BRN should establish in policy the specific information that its staff should present to the education committee and governing board, including data about clinical facilities that nursing programs use for placements, the content areas for which the programs use those facilities, and the total number of available placement slots and the risk of clinical displacements at the facilities.
To ensure that BRN is using up‑to‑date, accurate, and objective information to inform the governing board’s enrollment decisions and to assess clinical capacity for student placements, by April 1, 2021, BRN should do the following:
- Update its clinical facility approval form to capture annual capacity estimates from clinical facilities, as well as annual clinical placement needs of programs.
- Revise its regulations to require nursing programs to report any changes they make to their use of clinical facilities within 90 days of making a change and report annually if the program has made no changes.
- Compile and aggregate the information from the facility approval forms into a database and take reasonable steps to ensure that the information is accurate and current.
- Annually publish clinical capacity information on its website for public use.
- Immediately discontinue its practice of having nursing programs seek statements of support or opposition from neighboring nursing programs when considering requests for new programs or increased enrollment at existing programs.
To identify additional facilities that might offer clinical placement slots, by October 1, 2021, and annually thereafter, BRN should compare its nursing program database with OSHPD’s list of health care facilities. BRN should share the results of its comparison with nursing programs by publishing this information on its website.
We conducted this performance audit under the authority vested in the California State Auditor by Government Code 8543 et seq. and in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.
ELAINE M. HOWLE, CPA
California State Auditor
July 7, 2020