Streamlining Nursing Education Pathways: a Progress Report On Assembly Bill 1295 (Fuller)

March 15, 2011 Streamlining Nursing Education Pathways: A Progress Report On Assembly Bill 1295 (Fuller) L E G I S L A T I V E A N A L Y S T ’ S O F F I C E S N E P : A P R TREAMLINING URSING DUCATION ATHWAYS ROGRESS EPORT O A B 1295 (F ) N SSEMBLY ILL ULLER Chapter 283, Statutes of 2009 (AB 1295, Fuller), requires our offi ce to report by March 15, 2011 on the progress of the California Community Colleges (CCC) and California State University (CSU) in developing nursing education pathways between the two systems. This report fulfi lls that statutory requirement. B S N R P ACKGROUND ON TATE URSING EQUIREMENTS AND ROGRAMS State Requirements to Become a Registered Nurse All registered nurses in the state must have a license issued by the California Board of Registered Nursing (BRN). To obtain a license, students must complete a number of steps, including graduating from an approved nursing program. In California, there are two primary types of pre-licensure educational programs available to persons seeking to become a registered nurse: (1) an associate’s degree in nursing (ADN) program at a two-year college, and (2) a bachelor’s degree in nursing (BSN) program at a four-year university. (Students who already hold a bachelor’s or higher degree in a non-nursing fi eld are also eligible to apply for an entry-level master’s degree in a nursing program at a university.) Students that complete nursing program requirements are eligible to take the National Council Licensure Examination (NCLEX). Applicants that pass the examination and a criminal background check are licensed by BRN to practice as a registered nurse in California. Nursing Programs in California Currently, public and private colleges in California offer a total of 129 ADN and BSN programs. The CCC and CSU systems are two of the major educators and providers of registered nurses, with community colleges offering 77 of the state’s 90 ADN programs and CSU offering 19 of the state’s 39 BSN programs. As we discussed in Ensuring an Adequate Health Workforce: Improving State Nursing Programs (May 2007), for years the number of applicants to nursing schools in California has far exceeded the number of available slots. Although nursing schools have developed different strategies to decide which applicants to accept into a program, students are generally required to take certain prerequisite courses (such as anatomy and microbiology) before applying to a program. (Students at CSU must take eight common prerequisite courses; the number and type of prerequisite courses at CCC vary by campus.) Nursing programs take into account grades in these courses, among other factors, for purposes of selecting which students to admit. Community College Nursing Degree Requirements. Once admitted into a nursing program, CCC students must complete their community college’s requirements for an ADN. The ADN program consists of lower-division instruction (freshman and sophomore level) in both nursing and general-education coursework. The content LEGISLATIVE ANALYST’S OFFICE 1 covered in nursing courses is driven largely by the BRN, which sets educational standards for nursing schools. The general-education course requirements can vary by community college. However, in place of campus-specifi c general-education require- ments, colleges typically permit ADN students to complete a series of courses that also satisfy the lower-division general-education requirements for all campuses at both CSU and the University of California (UC) (called the Intersegmental General Education Transfer Curriculum [IGETC]), or CSU only (called CSU GE-Breadth). When nursing and general-education requirements are combined with prerequisite courses, the number of credits a student must earn to complete an ADN program typically totals about 70 units (just over two full years of academic study). This is about 10 units more than what is generally required for other associate’s degrees at the community colleges. CSU Degree Requirements. First-time students that are admitted to CSU’s BSN program must complete at least 120 units, which is equivalent to four full years of academic study. The BSN consists of both lower-division and upper-division coursework (freshman through senior level) in nursing and general-education instruction. As mentioned earlier, students must also complete prerequisite courses to be considered for admission to the nursing major. ADN-to-BSN Pathways. While individuals with an ADN can practice as registered nurses, some nurses seek to continue their undergraduate nursing education at a CSU campus or other four-year institution. They may transfer into a BSN program immedi- ately after obtaining their ADN and registered-nurse license, or choose to enroll in a BSN program after practicing as a registered nurse for a period of time. In pursuing a BSN, these nurses have an opportunity to expand their knowledge of the nursing fi eld (such as in community health), as well as to engage in a broader liberal arts education, through upper-division coursework. One of the main reasons nurses with an ADN seek a BSN is to open opportunities to pursue a graduate degree in nursing. Nurses with a master’s degree or higher often serve as educators, researchers, and administrators, as well as nurse practitioners, nurse anesthetists, and other advanced-practice nurses. Objectives of AB 1295 The purpose of AB 1295 is to ensure that registered nurses who wish to advance their nursing expertise and career by enrolling in a BSN program can do so without having to repeat the same courses and content they have already mastered. Specifi cally, by the beginning of the 2012-13 academic year, CSU is prohibited from requiring a student who already holds a nursing license and ADN from a community college to complete coursework whose content was already included as part of the community college curriculum. This includes instructional content in CCC nursing and general-education courses, as well as prerequisites. In creating streamlined educational pathways, the intent of AB 1295 is to speed ADN-to-BSN students’ time to graduation, resulting in cost savings to both students and the state. The statute authorizes the Chancellors of CSU and CCC to appoint representatives to “work collaboratively” in carrying out these require- ments, and directs our offi ce to report by March 15, 2011 on the segments’ progress. LEGISLATIVE ANALYST’S OFFICE 2 Related Initiatives. Several complementary developments have coincided with the efforts of CSU and CCC to implement AB 1295. • In 2008, the California Institute for Nursing and Health Care (CINHC), with support from foundations, provided funding for collaborative models of nursing education between ADN and BSN education programs at community colleges and universities. Several regional collaborations involving CCC and CSU campuses were developed through this initiative. Some of these have already awarded BSN degrees to students from ADN programs who received early advising and followed well-defi ned pathways. • The Legislature enacted Chapter 428, Statutes of 2010 (SB 1440, Padilla), the Student Transfer Achievement Reform Act. This act requires community college districts to develop associate degrees for transfer that meet specifi ed criteria, including a limit on course requirements. The act requires CSU campuses to grant priority consideration to students with these transfer degrees, and to grant them junior status upon admission. The act prohibits CSU from requiring these students to complete coursework whose content was included as part of their associate’s degree program or take more than 60 additional units to earn their baccalaureates. To aid in the implementation of this law, CCC and CSU faculty are developing transfer model curricula by discipline that will be accepted at all CSU campuses. (The ADN does not fall under SB 1440 because it requires more than 60 units.) • In October 2010, the Institute of Medicine of the National Academy of Sciences released a report titled The Future of Nursing: Leading Change, Advancing Health. Among the report’s recommendations was a suggestion that accreditors should require all nursing schools to offer defi ned academic pathways that promote seamless access for nurses to higher levels of education. Along with AB 1295, these initiatives are impelling the CCC and CSU to streamline progression from ADN-to-BSN programs. A A CTIVITIES AND CCOMPLISHMENTS The CCC and CSU Chancellors designated representatives to lead implementation efforts within their respective offi ces. Beginning in spring 2010, these individuals convened a series of meetings with nursing faculty and administrators from across the state. Early progress in identifying challenges and proposed solutions was followed by a hiatus of several months due to the departure of one of the lead staff members. Activities resumed in late February 2011 with a statewide conference on implementation of AB 1295 and related initiatives. At the time this report was prepared, plans were underway for a statewide workgroup meeting in April or May. This section provides a summary of key activities to date. LEGISLATIVE ANALYST’S OFFICE 3 Foundational Meeting. In April 2010, CCC and CSU faculty members and adminis- trators and representatives of the BRN and California Institute for Nursing and Health Care gathered for an initial implementation meeting. They identifi ed challenges and proposed solutions, and subsequently developed a detailed checklist of tasks for imple- menting AB 1295, summarized in Figure 1. Figure 1 Major Implementation Tasks Segment Target Date Date Requirement Responsible For Completion Completed Identify content required for RN CCC/CSU July 2010 7/18/2010 licensure Identify content required for ADN CCC/CSU July 2010 7/18/2010 Identify content unique to BSN CCC/CSU July 2010 6/3/2010 (no RN or ADN crossover) Identify pathway challenges CCC/CSU July 2010 8/6/2010 Determine solutions CCC/CSU October 2010 October 2010 Make CCC ADN general-education CCC March 2011 — requirements align with CSU General Education-Breadth requirements Identify mechanisms that validate CSU November 2010 — prior learning from RN licensure content and ADN content taken at CCC, translating to specifi ed number of university lower-division and/or upper-division BSN program credits Complete ADN-to-BSN Articulated CCC/CSU January 2011 — Nursing Pathways Roadmaps CCC = California Community College; CSU = California State University; RN = registered nurse; ADN = associate’s degree in nursing; BSN = bachelor’s degree in nursing. Curriculum Planning Meeting. In June 2010, the Gordon and Betty Moore Foundation hosted a two-day meeting with CCC and CSU nursing directors, chairs, faculty, and system administrators. To begin mapping curriculum requirements across programs, the attendees identifi ed characteristics and requirements of ADN and BSN degree programs, including BRN pre-licensure requirements, courses and content for each type of degree, and CSU nursing prerequisites. They also developed a comparison of underlying principles of ADN and BSN education. These activities provided a framework for dividing responsibility for specifi c content between community college and CSU programs to eliminate duplication. Curriculum Analysis. The CSU analyzed BSN degree requirements (including general education, nursing prerequisites, BRN-required curriculum, and BSN-required content areas for accreditation) to identify all applicable requirements and areas of overlap for which individual courses (whether taken at the community college or CSU) could serve multiple purposes, such as meeting general education and major require- ments and fulfi lling prerequisites. LEGISLATIVE ANALYST’S OFFICE 4 Baseline Curriculum Survey. The implementation leaders administered a survey to CCC and CSU nursing programs, and received responses from 47 colleges and 18 university campuses. The survey documented wide variation in the number of core nursing units and general-education units required for ADN programs. It showed modest variation in the number of units that ADN transfer students must complete at CSU. The total number of units required for ADN transfer students (including credits transferred from the community college and those completed at CSU) was slightly lower than the total required for students who attend CSU for their entire BSN program. Signifi cant fi ndings from the survey include: • Of the community colleges that responded, the majority do not require the common general-education patterns for transfer (CSU GE-Breadth or IGETC) for their ADN programs. • Numerous community colleges have nursing course requirements that exceed content required for registered nurse licensure. • Most ADN programs do not require two of the eight systemwide CSU nursing prerequisites (integrated chemistry and critical thinking). • There are numerous differences in the number of credits required for nursing prerequisite courses within both systems. (For example, while about half of responding ADN programs require four units of microbiology, others require fi ve units, and CSU campus requirements range from three to six units for the same course.) Many of these factors contribute to the high numbers of excess units many students accumulate to meet ADN, transfer, and BSN requirements. Work Group Kick-Off. In October 2010, nearly 180 nursing faculty and adminis- trators from the CCC and CSU, along with UC and private institutions, convened for a professional meeting. They formed six work groups to develop solutions to problems identifi ed in the preceding months. The work group topics are as follows: • General education and nursing prerequisites. • Surveys of baseline and changing data. • Advising roadmaps. • ADN-to-BSN curricular requirements. • Pilot programs. • Communications. LEGISLATIVE ANALYST’S OFFICE 5 There does not appear to have been signifi cant work group activity since the initial meeting. At the time this report was prepared, the implementation leaders planned to convene the work groups in April or May 2011, and expected the work groups to complete their work in advance of the convening. Seamless ADN-to-BSN Education Conference. In February 2011, a smaller group of representatives from CCC and CSU nursing programs met at the Moore Foundation to review progress, share best practices, and develop strategies for institutionalizing these practices across campuses. One idea discussed at this meeting is for CSU to develop a systemwide approach to awarding credit for prior learning or demonstrated competency. Currently, each campus has adopted its own approach, as guided by a Chancellor’s Executive Order governing awarding of credit. Another idea is to apply the framework being used for implementation of the Transfer Reform Act (SB 1440) to develop a transfer model curriculum for nursing that will be accepted at all CSU campuses. A ’ A NALYST S SSESSMENT While CSU and CCC have taken some positive initial steps to create articulated nursing degree transfer pathways, further work is needed to implement them by the 2012-13 academic year as envisioned by AB 1295. Additionally, although the legislation places responsibility fi rmly on CSU to implement the pathways, some changes are needed in CCC programs to facilitate effi cient articulation and transfer. Problem Well-Defi ned. Through initial meetings and surveys, CCC and CSU repre- sentatives effectively defi ned the problem and identifi ed potential solutions. Survey results, curriculum maps, analyses of unique and common requirements, and imple- mentation strategy checklists provide a useful foundation for implementation work. In addition, CCC and CSU representatives participating in joint meetings report improved understanding and working relationships with counterparts in the other segment. Challenges and Proposed Solutions Yet to Be Addressed. Despite initial progress, most of the problems and potential solutions identifi ed in the early work have not been addressed systematically by either system. (Some individual campuses have collaborated to implement solutions locally or regionally.) Lack of Clarity on General-Education Requirements. In our conversations with CCC nursing program administrators, we observed some continued lack of under- standing among them of CSU general-education requirements for transfer students. They were aware that students often have diffi culty meeting general-education require- ments within the required number of units, but some were not aware of the two well- established systemwide general-education transfer patterns—CSU GE-Breadth and IGETC—that are accepted by all CSU campuses. Some Promising Pathway Models Developed. Through the grant-funded initiative led by CINHC, several groups of CCC and CSU campuses developed pathways for collaborative ADN-to-BSN programs among partner institutions. Some of these have already succeeded in transferring and graduating BSN nurses within specifi ed numbers of units and academic terms. Early identifi cation of transfer students and early, intensive LEGISLATIVE ANALYST’S OFFICE 6 advising have been key to the successful pilots. These grant-funded projects demonstrate the feasibility of effi cient, collaborative ADN-to-BSN programs. Their continuation and expansion is uncertain, however, once grant funding expires. Systemwide Solutions Would Aid Progress. Participants in implementation meetings believe the solutions below hold promise to achieve the goals of AB 1295. We agree, and recommend that CSU and CCC leadership seriously consider them as systemwide reforms. Although the bill does not require a single, common pathway for all nursing programs, we believe there is benefi t to establishing consistent guidelines and parameters, particularly in areas where individual CSU campuses have requirements that could duplicate some ADN content, or where variations among CCC programs would make it impractical for CSU to ensure seamless transfer and avoid duplication. As with the SB 1440 process currently underway, campuses could have the option to adopt a common solution or to modify it with justifi cation. 1. Develop common general-education requirements for CCC ADN programs that meet CSU transfer admission requirements. The CSU GE-Breadth and IGETC provide templates that can be adopted or further refi ned for nursing programs. 2. Develop a statewide transfer model curriculum for nursing similar to those being designed in several disciplines pursuant to SB 1440. This model curriculum should include specifi c requirements in the nursing major that will be accepted for full credit toward CSU BSN degrees. Presumably, it would include coursework required to meet licensure and accreditation requirements, and pare down other campus-specifi c requirements. Combined with a common general- education pattern, a model transfer curriculum in nursing could provide a clear, streamlined pathway that permits students to earn an ADN and BSN within a prescribed number of units. 3. Establish a common approach across CSU campuses for awarding credit to ADN-to-BSN students for content mastered in obtaining registered-nurse licensure. Policies adopted by CSU permit campuses to award credit to students for prior learning. For nursing, our review fi nds that many (but not all) campuses award upper-division credit to ADN transfer students who, in passing the NCLEX, have demonstrated core nursing competencies. Even among those campuses that award credit, however, the amount of credit varies considerably (from 15 to 31 units). The basis for awarding credit also varies. For example, some programs award credit to students simply for passing the NCLEX; other programs require students to pass a separate challenge examination. Still others award credit for prior learning only after students complete specifi ed upper-division CSU coursework. We recommend that CSU establish a systemwide approach to awarding credit for ADN graduates who have passed the NCLEX by setting a standard or minimum credit level for this exam, as well as a standard basis for awarding the credit. LEGISLATIVE ANALYST’S OFFICE 7 C ONCLUSION Our review fi nds that CSU and CCC are generally on track to implement the require- ments of AB 1295. Together the segments have developed a constructive partnership, identifi ed the major issues that need to be addressed to create more-streamlined nursing pathways, and recommended potential solutions that we believe have merit. The next steps will necessarily involve academic and administrative leadership at the statewide level to create policies for common lower-division general education and nursing major requirements, as well as standardized approaches for awarding credit based on students’ mastery of core nursing competencies. The Legislative Analyst’s Offi ce (LAO) is a nonpartisan offi ce which provides fi scal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an E-mail subscription service, are available on the LAO’s Internet site at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, CA 95814. LEGISLATIVE ANALYST’S OFFICE 8