BILL ANALYSIS �
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|Hearing Date:January 9, 2012 |Bill No:SB |
| |122 |
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SENATE COMMITTEE ON BUSINESS, PROFESSIONS
AND ECONOMIC DEVELOPMENT
Senator Curren D. Price, Jr., Chair
Bill No: SB 122Author:Price
As Amended:January 4, 2012 Fiscal:Yes
SUBJECT: Nursing.
SUMMARY: Makes changes to the requirements for approval of a school
of nursing by the Board of Registered Nursing (BRN). They include:
(1) Granting the BRN authority to be the only agency responsible for
approving schools of nursing and to receive an appropriate fee from
applicants and for renewal of the school of nursing's authorization;
and, (2) Requiring that a school of nursing must be accredited by an
accrediting agency recognized by the U.S. Department of Education.
Existing law, the Business and Professions Code (BPC):
1) Provides for the regulation of various health professions by
regulatory boards within the Department of Consumer Affairs
(DCA).
2) Establishes the Nursing Practice Act which provides for the
certification and regulation of registered nurses, nurse
practitioners and advanced practice nurses by the BRN within
the DCA.
3) Specifies that the BRN consists of nine members and that as of
January 1, 2012, the BRN sunsets and its statutory authorization
becomes inoperative and is repealed. (BPC � 2701)
4) Specifies that the provision which provides for the appointment of
the Executive Officer for the BRN is also repealed as of January 1,
2012. (BPC � 2708)
5) Specifies that an approved school of nursing is one that has been
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approved by the BRN, gives the course of instruction approved by
the BRN, covering not less than two academic years, is affiliated
or conducted in connection with one or more hospitals, and is an
institution of higher education or is affiliated with an
institution of higher education. (BPC � 2786 (a))
6) Defines "institution of higher education" as community colleges
offering an associate of arts or associate of science degree and
private postsecondary institutions offering an associate of arts or
associate of science degree. (BPC � 2786 (a))
7) Requires that a school of nursing that is not an "institution of
higher education," as defined, shall make an agreement with an
institution of higher education in the same general location to
grant an associate of arts or associate of science degree to
individuals who graduate from the school of nursing or to grant a
baccalaureate degree with successful completion of an additional
course of study as approved by the BRN and the institution
involved.
(BPC � 2786 (a))
8) Provides that the BRN shall determine by regulation the required
subjects of instruction in an approved school of nursing and the
amount of clinical experience necessary.
(BPC � 2786 (b))
9) Specifies that it shall be the duty of the BRN, through its
executive officer, to inspect all schools of nursing in this state
at such times as the BRN shall deem necessary, and if it is found
that a school is not maintaining the standard(s) required by the
BRN, then the BRN may request the defects to be corrected and if
not corrected then the BRN may remove them from the approved list.
(BPC � 2788)
10)Provides that it is unlawful for anyone to conduct a school of
nursing unless the school has been approved as an accredited school
by the BRN, or is exempt as specified.
(BPC �� 2789, 2798)
Existing law, the Education Code (EC):
1)Establishes the Bureau of Private Postsecondary Education (BPPE)
within the Department of Consumer Affairs (DCA) and provides for
Bureau oversight and regulation of California private postsecondary
institutions pursuant to the Private Postsecondary Education Act of
2009 (PPE Act), including a school of nursing that is not accredited
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by accrediting agencies affiliated with the Western Association of
Schools and Colleges (WASC) or regional accrediting agencies
recognized by the United States Department of Education. (EC �
94820)
2)Establishes numerous unfair business practices for institutions
covered by the PPE Act, including prohibiting an institution from
promising employment or otherwise overstating the availability of
jobs or making untrue or misleading statements regarding student
completion, placement or expected salary rates. (EC � 94897)
3)Sets forth certain disclosure requirements pertaining to completion,
placement, licensure, and earning potential. (EC � 94910)
This bill:
1) Clarifies that an " institution of higher education " includes, but
is not limited to, community colleges and private postsecondary
institutions offering an associate of arts, associate of science,
or baccalaureate degree or an entry-level master's degree, and is
an institution that is not subject to the PPE Act.
2) Specifies that a school of nursing that is not an institution of
higher education , or affiliated with an institution of higher
education shall be subject to specified requirements set forth in
the PPE Act, and shall be approved by the BRN (not the BPPE).
3) Would subject a school of nursing or a new nursing program seeking
approval by the BRN to the following fee schedule:
a) A fee of $5,000 for approval of a nursing program.
b) A fee of $3,500 for continuing approval of a new
nursing program.
c) A fee of $500 for processing authorization of a
substantive change to an approval of a school of nursing.
4) Requires new nursing schools seeking BRN approval to be recognized
or approved by an accrediting agency recognized by the U.S.
Department of Education.
5) Requires the BRN to hold its meetings in the northern and southern
parts of the state.
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FISCAL EFFECT: Unknown. This bill is keyed "'fiscal" by Legislative
Counsel.
COMMENTS:
1. Purpose. This measure is sponsored by the Author. According to
the Author, in 2011, this Committee conducted oversight hearings to
review 7 boards: the Board of Registered Nursing, the Board of
Vocational Nursing and Psychiatric Technicians, the Dental Board of
California, the Board of Accountancy, the Contractors State License
Board, the Board for Professional Engineers, Land Surveyors and
Geologists, the California Architects Board (and the Landscape
Architects Committee). The Committee also reviewed the Athletic
Commission and the Professional Fiduciaries Bureau and conducted
oversight hearings of the Department of Real Estate and the Office
of Real Estate Appraisers. The Committee began its review of these
licensing agencies in March of 2011, and conducted three days of
hearings. Sunset bills were amended to implement legislative
changes as recommended in the Committee's Background/Issue Papers
for all of the agencies reviewed by the Committee last year.
SB 538 was one of the seven "sunset bills" authored by the Chair of
this Committee. The primary purpose of this measure was to extend
the sunset date of the BRN to January 1, 2016, and to also make
necessary statutory changes based on the review of the BRN by this
Committee on March 14, 2011. The changes related to the approval
of a school of nursing were intended to give the BRN complete
authority over the approval process for nursing schools and
eliminate any duplication for approval by the BPPE. It also
provided for the offset of those costs to the BRN in both approving
and providing for the ongoing oversight of nursing schools and
programs.
SB 538 was vetoed by the Governor for reasons other than the changes
proposed which are related to the approval by the BRN of nursing
schools and programs. One of the provisions provided in SB 538
allowed for more flexibility in the hiring of peace officer
investigators by the BRN. The Governor's veto measure argued that
this would be contrary to his efforts on pension reform due to the
higher benefits that would be accorded to those provided a peace
officer classification. For this reason the measure was vetoed.
SB 122 does not contain any of the provisions related to peace
officer investigators.
2.Background. The BRN is responsible for regulating the practice of
registered nurses (RNs) in California. Currently, there are almost
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380,000 licensed RNs in California, with over 23,000 new licenses
issued annually, and more than 170,000 licenses renewed annually.
The BRN also regulates interim permittees, i.e., applicants who are
pending licensure by examination, and temporary licensees, i.e.,
out-of-state applicants who are pending licensure by endorsement.
The interim permit allows the applicant to practice while under the
supervision of an RN while awaiting examination results. Similarly,
the temporary license enables the applicant to practice registered
nursing pending a final decision on the licensure application. The
BRN also issues certificates to Clinical Nurse Specialists, Nurse
Anesthetists, Nurse Practitioners, Nurse-Midwives and Public Health
Nurses. These titles are those most commonly used by the California
RNs and use of the titles is protected under the Business and
Professions Code.
The BRN also issues furnishing numbers to nurse practitioners and nurse
midwives to administer prescriptions and lists psychiatric/mental
health nurses. In addition to its licensing and certification
functions, the BRN also regulates and approves the following
entities:
California Pre-licensure Registered Nursing Programs.
Nurse-Midwifery Programs.
Nurse Practitioner Programs.
Registered Nursing Continuing Education Providers.
The BRN is responsible for implementation and enforcement of the
Nursing Practice Act; the laws and regulations related to nursing
education, licensure, practice and discipline. The BRN implements
regulatory programs and performs a variety of activities to protect
the public. These programs and activities include, setting
registered nurse educational standards for pre-licensure and
advanced practice nursing programs, issuing and renewing registered
nurse licenses, issuing certificates for advanced practice nurses
and public health nurses, taking disciplinary action for violation
of the Nursing Practice Act, and managing a Diversion Program for
registered nurses whose practice may be impaired due to chemical
dependency or mental illness.
The BRN also recognizes registered nursing is an integral component
of the health care delivery system. The BRN affects public policy
by collaborating and interacting with legislators, consumers,
health care providers, health care insurers, professional
organizations, and other state agencies. The BRN takes a proactive
role in structuring health care and evaluating nursing trends in
order to make sound policy decisions. According to the BRN, this
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enhances the Board's ability to interpret the Nursing Practice Act
and establish policies for its regulatory programs and activities,
which are then implemented by the BRN staff.
Due to the veto of SB 538, and the sunset of the BRN as of January
1, 2012, the 9 members of the BRN have been eliminated. The
Governor does intend, however, to immediately reconstitute the BRN
in January of 2012. In the meantime, the Governor, the former BRN
and the DCA have entered into an "Interagency Agreement" for the
DCA and its Director to assume the responsibilities, powers and
duties as permitted by law.
1. This Measure is Intended to Include the Following Statutory Changes
as Identified by This Committee During Its Oversight Hearings of
March, 2011 and Included in the Prior Version of SB 538:
a) Grants the BRN authority to be the only agency
responsible for approving schools of nursing. Approval of
pre-licensure nursing programs is an integral component of
the BRN's operation. The purpose of approval is to ensure
the program's compliance with statutory and regulatory
requirements. Approval of advanced practice nursing (i.e.,
nurse practitioner and nurse-midwifery) programs is
voluntary and at the request of the program. BRN approval
of advanced practice programs is advantageous to program
graduates because it facilitates their obtaining BRN
certification as a nurse practitioner or nurse-midwife.
Currently, there are 148 approved pre-licensure nursing
programs and 26 approved advanced practice nursing programs,
as follows:
Pre-licensure Programs
90 associate degree (ADN)
39 baccalaureate degree programs (BSN)
19 entry-level master's degree programs (ELM)
110 Public Programs
38 Private Programs
Advanced Practice Nursing Programs
22 nurse practitioner programs
4 nurse-midwifery programs
The approval process begins with a Letter of Intent from the
school or institution of higher education which is trying to
establish and offer a nursing program and must be submitted
at least one year in advance of the anticipated date for
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admission of students. After a Letter of Intent is
submitted, the applicant must then submit a Feasibility
Study to the BRN documenting the need for the program and
the program applicant's ability to develop, implement, and
sustain a viable pre-licensure RN program. The feasibility
study is rather extensive and usually requires the applicant
to seek the assistance of a consultant familiar with
providing the information needed by the BRN in determining
the feasibility of the program. Once the feasibility study
is accepted by the BRN, the program applicant must then
appoint a Program Director . The Program Director will have
responsibility for preparing a Self-Study for the proposed
program and coordinate any site visits by the BRN. The
Self-Study describes how the proposed program plans to
comply with all BRN nursing program related rules and
regulations. The BRN will assign a Nursing Education
Consultant (NEC) who verifies that the Self-Study
satisfactorily addresses the rules and regulations regarding
a nursing program, and will also make on-site visits where
the program will be maintained and the selected clinical
sites. Once the Self-Study is completed, the NEC will then
complete a report to be submitted to the BRN and recommend
that the BRN either grant or deny approval, or defer action
to grant the program additional time to resolve areas of
noncompliance. Once the program is approved by the BRN, it
receives a certificate of approval.
An applicant of a private postsecondary school or program
must then go through a secondary process that requires
approval from the Bureau of Private Postsecondary Education
(BPPE) if they are not accredited by the Western Association
of Schools and Colleges (WASC) or by a Regional accreditor.
This approval process can also take some time to complete
and it is not clear what advantage it provides in performing
similar requirements for feasibility and self-study which
are already required by the BRN. (It should be noted that
currently both the Medical Board of California and the
Dental Board are the only agencies that respectively approve
either medical schools or dental schools in California, as
well as other states and in foreign countries.)
The BRN indicated that the average length of time from
beginning to completing the initial BRN approval process is
about 18 months, but there have been instances in which this
approval process has taken almost four to five years for
particular programs, especially if they are private
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postsecondary schools. Data has shown that these schools
are a growing sector in the training of health care workers.
From 2001 to 2009, the percentage of nursing degrees
awarded by private postsecondary schools throughout the U.S.
grew from 4 % to 11 % of the national total, while nursing
awards from public colleges shrank from 78 to 70%. In
California, the share of public nursing programs has
decreased from its high of 85.6% to its current share of
76.1%. It is anticipated that this growth of private
nursing programs will continue, particularly in California.
Private programs in California grew from just 14 programs in
2001, to now over 38 in 2010. Also, student enrollment grew
from 951 students in 2001, to 4,607 in 2010.
It was indicated in this Committee's Report, that the
involvement of the BPPE in the approval of nursing school
programs seems unnecessary and therefore the BRN should
assume all responsibility regarding approval of these
programs. In doing so, the BRN should be given authority to
charge an appropriate fee to cover their costs for reviewing
documents, consulting with the program and conducting site
visits. This fee should be similar to fees currently
assessed by the BPPE for approval of school programs.
Current student protections provided under the Act will
continue to apply to those nursing programs which are
currently approved by BPPE and the BRN would now assume the
responsibility of responding to student complaints regarding
a nursing program.
a) It is intended that this measure will authorize the
BRN to issue a cease and desist order to a school of nursing
that has not been approved by the BRN and to inform the
Attorney General of a school which continues to operate
illegally. As indicated, the BRN has primary responsibility
for approval of pre-licensure nursing programs and when a
program is not approved it is not permitted to operate in
California and should not be able to open its doors to
potential nursing students. The BRN provides a notice on
its Website about the increasing number of "unaccredited"
nursing programs within California. The BRN's notice
indicates that they will not qualify an applicant to take
the National Council Licensing Examination (NCLEX), for
nursing students, or to be licensed, after completion of an
"unaccredited" nursing program. "If any portion of the
instruction is completed at or through an unapproved
program, it is considered unaccredited," as stated by the
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BRN. The BRN goes on to explain some of the indicators of a
program that may be unaccredited and to caution students to
verify whether such a program is accredited by seeing the
listing of the BRN's Website of approved nursing programs.
The BRN also specifically lists those programs which are
"approved." However, it does not appear as if it lists
those programs which may have not been approved by the BRN.
According to this Committee's Report, the efforts of the BRN
to only inform students of "unaccredited" programs may not
be sufficient. Recently, there was a nursing program that
continued to operate for over two years, even though the BRN
did not grant approval and in 2007 had ordered the school to
close. As many as 300 students paid $20,000 each to enroll
and attend classes at this school, some attending for over
two years. If potential students had checked the BRN
Website they would not have found this school listed as an
approved program, but sadly many potential students do not
know that the BRN provides this information and warning.
The AG was able to assure that the institution was finally
shut down and reached a settlement agreement with the owner
and operators of the school for $500,000 as restitution to
the former students. According to the then AG, Edmund G.
Brown, Jr., this sham nursing school created "the illusion
it was training future nurses by pretending to offer an
accredited nursing program and tricking graduates into
believing they had qualified to become nurses."
The Committee Report indicated that something must be done
to assure that once the BRN has decided that a program
should not operate in California, that school does not then
find a way to open its doors to students who ultimately
spend two to three years of their lives in a school they
think will qualify them to be a nurse, which sadly will not.
Better communication between the BRN and the AG's Office
and the BRN revisiting the school site may be an option. It
was recommended that the BRN must work more closely with the
AG's Office and perform site visits to assure that a nursing
program which is not approved does not somehow continue to
operate in California. There must be a requirement for it
to cease and desist operation and there must be an IMMEDIATE
shut down of this program if it continues to operate so that
students are not ultimately deceived and waste precious
years of their lives attending a bogus program.
Although the language to authorize the BRN to issue a cease
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and desist order to a school operating unlawfully without
BRN approval and to the notify the AG of the existence of
such a school, is not provided within this measure, the
Author indicates that it was an omission by Legislative
Counsel in the drafting of this bill. The Author proposes
including this language which was contained in the prior SB
538.
b) Requires Accreditation for Nursing Schools in
California. A recent report of the Center for American
Progress (CAP) indicates that there are about 19
institutional accrediting organizations in the United States
that accredit around 7,000 institutions, both for-profit and
nonprofit. These private organizations stress a voluntary
system of quality control. The idea that higher education
institutions should be primarily responsible for their own
quality is a core principle of institutional accreditation,
according to the Council for Higher Education Accreditation,
the leading voice for voluntary accreditation. The
accreditation process is built around the idea that an
institution's mission should be the touchstone for judging
academic quality. For instance, accreditors ask whether the
academic programs are of sufficient quality and integrity to
achieve the institution's mission and similarly whether the
institution maintains a faculty to fulfill the mission in
terms of qualification, numbers, and performance. However,
the fact that an institution is accredited does not
guarantee the quality of the individual programs, course, or
graduates. The CAP explains that program accreditation
differs from institutional accreditation in that it looks
more closely at the delivery of education within the
discipline. The U.S. Department of Education recognizes
more than 40 program accrediting agencies, including at
least 25 agencies that accredit health-related programs.
The Council for Higher Education Accreditation recognizes at
least 61 agencies. The Commission on Collegiate Nursing
Education and the National League for Nursing Accrediting
are two of the independent accreditors for nursing programs.
They both require programs to meet requirements related to
mission, administrative capacity, faculty and staff,
students, curriculum, clinical training, resources and
outcomes. The CAP states that institutional and program
accreditation certainly ensures some basic level of quality
in educational institutions. However, the relationship
between program accreditation and institutional
accreditation is complicated and it is not often clear to
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students. Nursing students can find themselves at a serious
disadvantage if they are enrolled in a program which is not
accredited or has accreditation which is not readily
recognized by other schools. The critical factor for
students attending accredited institutions is the ability to
transfer academic credits from one nursing program to
another to complete their pre-licensure education, and for
registered nurses who wish to pursue additional
education/degrees. In addition to impeding students'
academic progress, the inability to transfer academic
credits also creates a financial burden for students by
requiring that they pay twice for the same courses. The
Committee Report recommended that the BRN should carefully
consider a requirement for all nursing programs to be
accredited in light of recent legal decisions and actions
taken by other nursing boards, and by the Legislature, in
dealing with the issue of which accrediting organizations
would be recognized, and that it should also carefully
consider a timeline for implementing such a requirement so
as to not severely impact existing programs or those
programs which may be approved by the BRN in the near
future.
The BRN adopted a motion and has recommended requiring
accreditation for nursing programs provided in California
pursuant to discussions by its Education/Licensing Committee
and the full board. The reasons stated by the BRN are:
Accreditation is in the public interest.
Is a requirement for other types of heath care
professionals' education.
Assures the quality of the institution.
Provides consistent standards.
Increases the potential for transferability of
units.
Ensures that the institution provides an
environment that supports broad education and
intellectual stimulation.
Facilitates students' access to financial aid.
1. Related Legislation. SB 538 (Price, 2011) extended the inoperative
and repeal date (sunset date) of the BRN, and made several other
changes as were recommended in the Committee Report of the BRN.
The provisions provided in this measure, which are related to the
approval process of schools of nursing by the BRN, are identical to
those provisions which were contained in SB 538 of last year which
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was vetoed by the Governor. As indicated, the veto of this
measure was unrelated to these provisions.
2. Author's Amendment Due to Omission of Legislative Counsel. The
Author is proposing an amendment which would include language which
was inadvertently omitted by Legislative Counsel in the drafting of
this measure. A mock-up of this measure has been provided with
language that was included in SB 538 and which the Author would now
like to include as part of this measure. The additional language
would authorize the BRN to issue a cease and desist order to a
school of nursing that has not been approved by the BRN and to
inform the Attorney General of a school which continues to operate
illegally .
SUPPORT AND OPPOSITION:
Support:
None Received as of January 4, 2012.
Opposition:
None Received as of January 4, 2012.
Consultant:Bill Gage