BILL ANALYSIS �
AB 2183
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Date of Hearing: April 22, 2014
ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER
PROTECTION
Susan A. Bonilla, Chair
AB 2183 (Bocanegra) - As Amended: April 7, 2014
SUBJECT : Nursing.
SUMMARY : Requires the Board of Registered Nursing (BRN) to
adopt specific criteria, with a primary emphasis on applicants
who possess licensed clinical experience, for determining the
equivalency of course instruction when assessing the
qualifications of a registered nurse (RN) applicant who is
already licensed or registered as a nurse outside of this state
and who is filing for licensure by endorsement.
EXISTING LAW :
1)Establishes BRN to regulate the practice of nursing under the
Nursing Practice Act (Act). (Business and Professions Code
(BPC) Section 2700 et seq.)
2)Authorizes BRN to adopt, amend, or repeal such rules and
regulations as may be reasonably necessary to carry out the
Act. (BPC 2715)
3)Requires BRN to determine by regulation the required subjects
of instruction to be completed in an approved school of
nursing for licensure as a registered nurse and shall include
the minimum units of theory and clinical experience necessary
to achieve essential clinical competency at the entry level of
the RN. BRN's standards shall be designed to require all
schools to provide clinical instruction in all phases of the
educational process. (BPC 2786 (c))
4)Requires BRN to deny or revoke the application for approval
for any nursing school which does not give student applicants
credit in the field of nursing for previous education and the
opportunity to obtain credit for other acquired knowledge by
the use of challenge examinations or other methods of
evaluation. (BPC 2786.6)
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5)Requires BRN to prescribe, by regulation, the education for
which credit is to be given and the amount of credit which is
to be given for each type of education. The word "credit" is
limited to credit for licensure only, and BRN is not
authorized to prescribe the credit which an approved school of
nursing shall give toward an academic certificate or degree.
(BPC 2786.6)
6)States that an approved nursing program shall have a process
for a student to obtain credit for previous education or for
other acquired knowledge in the field of nursing through
equivalence, challenge examinations, or other methods of
evaluation. The program shall make the information available
in published documents, such as college catalog or student
handbook, and online. (16 California Code of Regulations (CCR)
Section 1430)
7)Requires BRN to establish criteria for evaluating the
education of applicants who have served on active duty in the
medical corps of any of the Armed Forces of the United States.
(BPC 2736.5)
8)Permits BRN to issue a license without examination to an
applicant who is licensed or registered as a nurse in a state,
district or territory of the United States or Canada having,
in the opinion of BRN, requirements for licensing or
registration equal to or higher than those in California at
the time the application is filed with BRN, and the applicant
has passed an examination for the license or registration that
is, in BRN's opinion, comparable to BRN's examination, as
specified. (BPC 2732.1 (b))
9)States that an RN applicant who has successfully completed
courses of instruction in a school or nursing program outside
of this state which, in the opinion of BRN at the time the
application is filed, are equivalent to the minimum
requirements of BRN for licensure established for an
accredited program in this state. (BPC 2736 (a)(2))
FISCAL EFFECT : Unknown
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COMMENTS :
1)Purpose of this bill . This bill requires BRN to clarify in
regulations what it considers equivalent course instruction
when determining whether to license an RN applicant who is
already licensed or registered as a nurse outside of
California. This bill also requires BRN to place a primary
emphasis on applicants who possess licensed clinical
experience, which would require BRN to give credit for
licensed professional experience towards licensure. This bill
is author sponsored.
2)Author's statement . According to the author's office,
"[Existing law] grants [BRN] the authority to grant a license
by 'endorsement'. [BRN] maintains the discretion to grant a
license to an applicant who completed a course of instruction
in a school of nursing outside of this state which is
equivalent to the minimum requirements of the board for
licensure. The statute gives discretion to [BRN] to make this
determination 'in the opinion of the board at the time the
application is filed'.
"The problem is that it is unclear to applicants who have not
received a response from the BRN about their application, what
the reason is for BRN to not respond to the application or to
not grant the application.
"This bill will provide individuals seeking RN licensure in
California with the necessary information as to how the BRN
determines whether to approve or deny an application for
licensure so that the individual may prepare accordingly and
ensure that they meet the necessary requirements to practice
in California."
3)Understanding current law for licensure by endorsement .
Current law permits BRN to issue licenses to individuals who
are licensed in Canada or in another US state, a process
called 'endorsement'. There are multiple statutes that affect
the endorsement process.
BPC 2732.1 permits BRN to issue a license to any applicant
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licensed or registered as a nurse in a state that has
requirements equal to or higher to those in California and
meets California's educational requirements:
BPC 2732.1 (b) "The board upon written application may
issue a license without examination to any applicant who is
licensed or registered as a nurse in a state, district or
territory of the United States or Canada having, in the
opinion of the board, requirements for licensing or
registration equal to or higher than those in California at
the time the application is filed with the Board of
Registered Nursing, if he or she has passed an examination
for the license or registration that is, in the board's
opinion, comparable to the board's examination, and if he
or she meets all the other requirements set forth in
Section 2736."
Section 2736 defines the general qualifications necessary for
licensure, including courses of instruction that are
equivalent to the minimum requirements for accredited
programs:
BPC 2736 (a) "An applicant for licensure as a registered
nurse shall comply with each of the following:
(1) Have completed such general preliminary education
requirements as shall be determined by the board.
(2) Have successfully completed the courses of instruction
prescribed by the board for licensure, in a program in this
state accredited by the board for training registered
nurses, or have successfully completed courses of
instruction in a school of nursing outside of this state
which, in the opinion of the board at the time the
application is filed with the Board of Registered Nursing,
are equivalent to the minimum requirements of the board for
licensure established for an accredited program in this
state.
(3) Not be subject to denial of licensure under Section
480."
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Thus, to be licensed by endorsement, an applicant must be
licensed in another state and meet the same minimum
educational requirements BRN requires of BRN-approved schools.
BRN reports that they had 11,321 applicants for licensure by
endorsement in 2013, of which 9,429 were licensed (and 1,892
were rejected). BRN states that each applicant who does not
pass muster receives a letter noting the applicant's specific
deficiency so that the applicant may seek out the remaining
required education to become licensed.
4)Excelsior College and competency-based learning . The primary
supporter of this bill, Excelsior College, is an accredited,
distance-learning, not-for-profit higher education institution
that offers an Associate Nursing Degree Program for
individuals with previous health care experience. Excelsior
uses a competency-based curriculum which builds upon a
student's prior experience - a model that is different from
the more traditional curriculum where classroom and clinical
education are provided "concurrently."
Excelsior College's nursing program was developed in 1973, and
BRN determined that it met sufficient minimum requirements for
approval in 1979. However, in 2004, BRN revoked its approval
because BRN reevaluated Excelsior's curriculum and found that
Excelsior must meet California's exact educational
requirements. According to a 2006 court case, this
reevaluation was sparked by concerns from a statewide
organization of Public Health Nursing Directors about the low
skill level of new graduates from some nursing schools.
BRN requires, among other educational directives, that an
applicant possess 810 supervised clinical practice hours and
an equal number of theoretical instruction hours in
geriatrics, medical-surgical, mental health/psychiatric
nursing, obstetrics, and pediatrics. BRN also requires that
all schools provide clinical instruction in all phases of the
educational process.
Excelsior operates a competency-based learning program and
allows its students to take and pass an exam to prove clinical
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skills and test out of certain requirements, in lieu of
traditional clinical and theoretical instruction. Its exam is
called the Clinical Performance Nursing Examination, a two and
a half day examination administered in a general hospital that
is designed to test the student's ability to administer
competent nursing care. In effect, Excelsior grants credit in
recognition of its students' previous experience if they pass
the clinical exam. BRN says that Excelsior's program does not
meet the concurrent clinical requirement of 810 supervised
clinical and theoretical hours of instruction, and therefore
cannot be accepted towards a license.
Unfortunately, existing law is neither completely clear nor
consistent in how this process should work. Current law
states that BRN shall require approved schools to "give
student applicants credit, in the field of nursing, for
previous education and the opportunity to obtain credit for
other acquired knowledge by the use of challenge examinations
or other methods of evaluation." This code section, BPC
2786.6, also directs BRN to develop regulations to determine
"the amount of credit which is to be given for each type of
education," presumably accommodating education beyond the
classroom.
However, BRN promulgated regulations that delegated the
responsibility to determine credit to approved schools, and
BRN states that they do not believe any schools grant credit
or allow testing to prove skills or knowledge based on prior
professional experience.
This bill would explicitly require BRN to develop criteria for
granting equivalent course credit for clinical experience
toward licensure, but BRN does not believe they are
statutorily mandated to do so. The language in this bill may
be insufficient to achieve the author's intent without further
clarifying existing law, as discussed further below.
5)Should professional experience be used to supplement education
in licensure by endorsement? Because BRN does not accept that
Excelsior may grant credit for their students' previous
clinical experience and because their theoretical and clinical
education does not occur concurrently, BRN believes that
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Excelsior students do not meet BRN's licensure standards.
Several other healing arts boards under the Department of
Consumer Affairs have licensure pathways for those individuals
who do not meet board-sanctioned initial educational
requirements, but who have demonstrated competency and safe
patient care through professional experience and licensure in
other states.
For example, the Medical Board of California (MBC) has a
licensure pathway for those applicants who received their
medical education at a foreign school or one previously
disapproved by MBC, and requires continuous practice and
specialty board certification, among other conditions.
Similarly, the Dental Board issues licenses by credential,
similar to endorsement, in which a dentist practicing in
another state may show continuous practice, passes the
California state or national clinical exam, and completes
continuing education, as specified.
BRN argues that there is no way for it to assess competency
based on experience, and that requiring identical education is
the only way to ensure patient safety. However, as the
Medical Board and Dental Board have shown, it is possible for
an individual practicing for years with an unblemished record
and subsequent specialized certification from a state with
unequal, but otherwise adequate, educational preparation and
national testing to practice safely in California.
6)Committee comments . As noted above, current law does not
explicitly require BRN to give credit for professional
experience when evaluating applicants for licensure for
endorsement. However, current law does require BRN-approved
schools to give students the opportunity to obtain credit for
"other acquired knowledge," by testing, which could be
construed as allowing credit for professional experience, if a
student proves his or her abilities.
Applicants for licensure by endorsement are required to prove
that they have completed education equivalent to that of
approved schools. Therefore, if approved schools can give
credit for experience, then licensed nurses who were given
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credit during their nursing education for experience should be
able to apply that credit towards California licensure.
However, BRN does not interpret the existing law as requiring
schools to give credit for experience, and instead explicitly
requires clinical instruction in all phases of the educational
process.
This bill would require BRN to adopt specific criteria for
determining the equivalency of course instruction that
incorporates evaluation of professional experience.
If it is the author's intent to require that BRN recognize
experienced-based education and develop regulations
accordingly, it may be helpful to further clarify existing
statutes and overtly require BRN to revise their regulations
to delineate exactly how much credit may be substituted by
professional experience, and under what conditions.
Accordingly, the author and Committee may wish to consider the
following amendment to that effect:
Amend 2786.6 to read:
"The board shall deny the application for approval made by,
and shall revoke the approval given to, any school of
nursing which:
(a) Does not give to student applicants credit, in the
field of nursing, for previous education and the
opportunity to obtain credit for other acquired clinical
and theoretical knowledge acquired through prior
professional experience by the use of challenge
examinations or other methods of evaluation; or,
(b) Is operated by a community college and discriminates
against an applicant for admission to a school solely on
the grounds that the applicant is seeking to fulfill the
units of nursing required by Section 2736.6.
(c) The board shall prescribe, by regulation, the education
for which credit is to be given and the amount of credit
which is to be given for each type of education, including
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clinical and theoretical knowledge acquired through prior
professional experience. The board may not delegate this
authority to approved schools. The word "credit," as used
in the preceding sentence, is limited to credit for
licensure only. The board is not authorized to prescribe
the credit which an approved school of nursing shall give
toward an academic certificate or degree. The board shall
consider relevant military education and experience, as
well as education and experience obtained while licensed in
other healthcare fields, in developing regulations. "
7)Arguments in support . The Association of California
Healthcare Districts writes, "There is a growing demand to
provide increased nursing services in California; with the
implementation of the Affordable Care Act, the need for
Californians to access health care services has and will
continue to increase. As many of our Healthcare Districts are
located in rural areas, a majority of our facilities have
limited access to a surplus of qualified individuals that
provide vital health care services. By expanding the scope of
educational qualifications, AB 2183 will ease barriers to
attract qualified nurses to California's health care
workforce.
"AB 2183 would ease concerns with current law, making it
possible for out-of-state licensees to consider employment in
California. Additionally, this measure is vital to increasing
the number of nursing professionals available in California.
"A growing health care workforce will continue to be an active
discussion in California. The sooner we can create clear
pathways for out-of-state nursing professionals to consider
employment in California, the sooner California can create
increased access to health care services for all
Californians."
8)Arguments in opposition . The California Nurses Association
writes, "[this] bill would undermine current licensure
requirements by establishing some form of standard
equivalency. We believe that our current licensure standards
are sufficient to ensure competent nursing practice, and see
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no reason to create exceptions to our standards. If an
individual would like to practice in California, we need to
ensure they meet our standards?
"Further, AB 2183 could have an impact that extends beyond
allowing RNs from other states to apply. The bill could open
the door for RNs from other countries who come from programs
which do not meet state standards. This would make it even
more difficult for the BRN to assess whether or not they are
issuing a license to an RN who will practice safely and
competently.
"Finally, we oppose AB 2183 because it creates disparity in RN
qualifications. California patients should have the
protections and comfort of knowing that all of the nurses
caring for them consistently meet state standards. Further,
we ought not to begin making exceptions to our standards for
some nurses, when hundreds of thousands of RNs work hard to
complete programs that meet our state's requirements so that
they can safely practice in our state."
9)Previous legislation . AB 705 (Blumenfield) of 2013 would have
required BRN to identify the military education, training, and
experience that is equivalent or transferable to coursework
required for licensure as a RN. This bill was held in
Assembly Appropriations Committee.
REGISTERED SUPPORT / OPPOSITION :
Support
Association of California Healthcare Districts
Excelsior College
Three individuals
Opposition
California Nurses Association
American Nurses Association/California
Analysis Prepared by : Sarah Huchel / B.,P. & C.P. / (916)
319-3301
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