Officials meddle in nursing market and exacerbate growing shortage

By Steven Greenhut
February 12, 2019

Sacramento — The California Board of Registered Nursing, the state agency that regulates nursing licenses and degrees, appears to be imposing caps on the number of nursing students that some private universities can enroll. Such caps go beyond the agency’s apparent statutory authority, but make little sense given California’s growing nursing shortage.

Federal data suggests that California will be short by nearly 45,000 nurses by 2030. Those numbers rely on estimates of current nursing demand and do not account for much higher likely demand as California lawmakers pursue various universal-healthcare proposals. Simply put, California needs more nurses, even though there may be temporary nursing surpluses in some regions, yet state officials are clogging up the nursing pipeline even as they pursue policies that will dramatically increase demand for healthcare services.

Whatever its intent, the nursing board’s behavior protects from private competition programs at community colleges and other public nursing schools. Those public schools tend to offer excellent programs. However, the reason that the private alternatives are luring students is simple: There are not nearly enough openings at California’s public institutions to serve the number of students who would like to become registered nurses.

This epitomizes the strange situation that has existed for more than a decade in California. There are well-documented nursing shortages and more than enough qualified students who want to fill them, but the education system cannot handle the number of applicants. That situation becomes infuriating when we consider that the source of the problem is state policy.

A potential nursing student can wait several years to secure a slot at most public nursing colleges. Policy makers nationwide are pushing for all nurses to receive four-year Bachelor of Science in Nursing (BSN) degrees, which makes the nursing board’s approach even more befuddling given that the community college programs offer only two-year Registered Nursing (RN) degrees. The private programs are not only filling a need, but they are providing the type of degrees that all licensed nurses in the state eventually will be required to have.

The board’s rationale for limiting private nursing programs centers on a bureaucratic term known as “clinical displacement.” Minutes from the March 2018 meeting of the Board of Registered Nursing’s education and licensing committee include widespread discussion from participants about this issue. It is a clear case of missing the forest for the trees.

The expressed concern is that if the state allows for the education of too many students, there won’t be enough clinical training opportunities for them at hospitals and other medical centers during their education process. Board members fear that adding new clinical rotations will displace other schools’ rotations. The policy presumably is about assuring that all nursing students get the field experience they need so that they gain the proper training they need to graduate. But it results in limiting the number of students and, ultimately, the number of registered nurses needed to fill growing demand as the workforce and population ages.

There already is an administrative process to prevent any clinical-displacement problem. Before the state allows a school to add a clinical rotation it must provide a document from its clinical partner attesting that it did not displace any other school’s rotation. By all measures, the process works fine. Furthermore, there are alternative ways for students to gain such training if rotations become scarce.

For instance, the state permits California nursing colleges to substitute 25 percent of their clinical training requirements with simulated lab training, including the use of mannequins and robotic mannequins. Other states allow colleges to substitute as much as 50 percent of such lab training. This innovative approach greatly reduces the pressure on the system.

In an April letter to the Board of Registered Nursing, leaders of several California trade organizations that represent nurses and nursing colleges argued that although colleges currently generally are producing enough nurses to meet demand for several years, “There remains, however, nursing shortages in underserved areas of the state ….” These groups encouraged “planned and approved enrollment growth in underserved geographic areas.” They also supported “expansion of clinical experiences” and “innovative modalities” which “can provide valuable alternatives to acute care clinical experiences for many nursing programs.”

The letter (signed by the Association of Nurse Leaders, the American Nurses Association of California, the California Association of Colleges of Nursing, the California Organization for Associate Degree Nursing Program Director – north and south chapters) expressed support for the BRN “prohibiting the growth of existing, new and out-of-state programs.” That is unfortunate, but unsurprising given that private programs provide competition. What’s surprising is that these groups seem to acknowledge BRN’s intention to cap enrollments.

Bottom line: Even groups that advocate for limits on nursing degrees recognize that there are some nursing shortages in California and that innovative lab approaches offer much promise in handling any concerns about clinical displacement. It is disappointing that these groups, and state regulatory officials, appear indifferent to the much bigger problem of nursing shortages. It also would be disappointing if bureaucratic inertia and efforts to protect existing programs – or artificially boost already high state nursing salaries – complicate a very real shortage.

To reiterate, federal studies suggest large shortages in California in the next 11 years. Even studies that point to some regional nursing surpluses show the emergence of shortages in some California metropolitan regions. The Healthforce Center points to “substantial shortages” in “the San Francisco Bay Area, Central Valley, and Central Coast regions” even though there are expected surpluses in the Los Angeles and Sacramento regions.

The answer is to let supply and demand sort out the solutions, not for the state to artificially constrict the number of degrees that it allows colleges to offer as a means to manage the supply of jobs. People move where they choose, and good-paying nursing jobs will lure people to the regions – or to other states or countries – that need them. Government bureaucrats do not determine the number of, say, lawyers, journalists or electricians. Why should nursing be any different?

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Steven Greenhut is a contributing editor for the California Policy Center. He is Western region director for the R Street Institute. Write to him at sgreenhut@rstreet.org.

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