A performance audit of the Board of Nursing

              STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
A PERFORMANCE AUDIT
OF THE
BOARD OF NURSING
DECEMBER 1981
A REPORT TO THE
ARIZONA STATE LEGISLATURE
REPORT 81 - 1 7
DOUGLAS R. NORTON. CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
December 15, 1981
Members of the Arizona Legislature
The Honorable Bruce Babbitt, Governor
Ms. Shirley Rennicke, Executive Secretary
Board of Nursing
Transmitted herewith is a report of the Auditor General, A Performance
Audit of the Board of Nursing. This report is i n response to a
January 30, 1980, resolution of t h e J o i n t Legislative Oversight
Committee. The performance audit was conducted as a part of the Sunset
review s e t f o r t h i n A. R. S. § § 41- 2351 through 41- 2379.
The blue pages present a summary of the report; a response from the
President of the Board, M s . Sally Ann Lewis, is found on the yellow pages
preceding the appendices.
My s t a f f and I w i l l be pleased t o discuss or c l a r i f y items i n the report.
Respectfully submitted,
Staff: Gerald A. Silva
Coni Rae Good
Peter N. Francis
Sue Ann Wadell
Enclosure
V
Douglas R. Norton
Auditor General
LEGISLATIVE SERVICES WING SUITE 200 STATE CAPITOL PHOENIX, ARIZONA 85007 255- 4385
OFFICE OF THE AUDITOR GENERAL
A PERFORMANCE AUDIT OF THE
ARIZONA BOARD OF NURSING
A REPORT TO THE
ARIZONA STATE LEGISLATURE
REPORT 81- 17
TABLE OF CONTENTS
Page
SUMMARY
INTRODUCTION AND BACKGROUND
SUNSET FACTORS
FINDINGS
FINDING I
The S t a t e Board Test Pool Examination f o r Registered
Nurses and Licensed Practical Nurses is not scored in
accordance with statutory requirements.
CONCLUSION
RECOMMENDATIONS
FINDING I1
Statutory changes are needed i n the composition
of the Board of Nursing.
CONCLUSION
RECOMMENDATIONS
FINDING 111
The Board of Nursing generally imposes s t r i c t
penalties against nurses named i n complaints.
However, the Board needs to b e t t e r inform the
nursing community as to what constitutes
incompetency on the part of nurses.
CONCLUSION
RECOMMENDATIONS
FINDING I V
The Board of Nursing needs to reassess a nursing
program to which it granted f u l l accreditation
i n 1978.
CONCLUSION
RECOMMENDATION
OTHER PERTINENT INFORMATION
Page
45
Nurse P r a c t i t i o n e r s
The Kanpowar Study
Foreign Nurses
WRITTEN RESPONSE TO THE AUDITOR GENERAL REPORT
APPENDICES
APPENDIX I - Legislative Council Opinion: 0- 81- 56, July 1, 1981
APPENDIX I1 - Legislative Council Opinion: 0- 81- 67, July 23, 1981
APPENDIX I11 - Legislative Council Opinion: 0- 81- 68, July 27, 1981
APPENDIX I V - Preliminary Recommendations: 1981 Nursing Manpower
Study
LIST OF TABLES
TABLE 1 -
TABLE 2 -
TABLE 3 -
TABLE 4 -
TABLE 5 -
TABLE 6 -
TABLE 7 -
TABLE 8 -
TABLE 9 -
TABLE 10 -
TABLE 11 -
TABLE 12 -
TABLE 13 -
Summary of the Board of Nursing workload from
f i s c a l year 1977- 78 through 1980- 81.
Summary of the Number and Type of Board
Investigations and Disciplinary Actions from
Fiscal Year 1977- 78 through 1980- 81.
Summary of Board Revenues, Expenditures and
Full- time Equivalent Positions from Fiscal
Year 1977- 78 through 1980- 81.
Comparison of Scores Required to Pass the SBTPE
f o r Registered Nurses and Licensed P r a c t i c a l
Nurses during 1979 and 1980 to the 70 Percent
Score Required i n A. R. S. $ 32- 1633.
Page
2
Summary of the Number and Percent of Applicants 12
who passed the SBTPE i n 1980 who did not score
70 percent or more.
Comparison of the Registered Nurse and the
Licensed P r a c t i c a l Nurse.
Summary of Nursing Board Compositions i n the 50 19
S t a t e s and the D i s t r i c t of Columbia.
Summary of the growth of LPNs r e l a t i v e to RNs i n 20
Arizona: 1952 to 1980.
Summary of Disciplinary Actions taken by the Board 28
f o r Investigations Conducted during Calendar Years
1979 and 1980.
Comparison of the Nursing Board's Revocation o r 2 9
Suspension Percentage with f i v e other Arizona
Health Regulatory Boards t h a t have been reviewed
by the Office of the Auditor General as of
October 31, 1981.
Summsry of the Nature of Complaints Iieceived 5y 70
the Board during 1979 and 1980.
Comparison of the Nursing Board's Diciplinary 3 5
Options with other Arizona Health Regulatory Boards.
Summary of the Number, Type and Geographic Location 4 5
of the Nurse P r a c t i t i o n e r s C e r t i f i e d by the Board
as of July 1981.
SUMMARY
The Office of the Auditor General has conducted a performance audit of the
S t a t e of Arizona, Board of Nursing i n response to a January 30, 1980,
resolution of the Joint Legislative Oversight Committee. This performance
audit was conducted as a part of the Sunset review process s e t f o r t h i n
Arizona Revised S t a t u t e s ( A. R. s.) $ 941- 2351 through 41- 2379.
The s t a t e d goal of the Board, established i n 1921, is to ensure safe and
effective nursing services t o the public. To accomplish t h i s goal, a
vp. rlp t:~ o f fl: r: cti? r?: rve n e r f a - 3 ~ 3 i z : c l ? ~ d i ~ ~ I;) exan' r ~ t i c ?~ 3f ? Y: C<~?
applicants, 2) i n i t i a l issuance and annual renewal of l i c e n s e s ,
3) a c c r e d i t a t i o n of nursing schools, 4 ) c e r t i f i c a t i o n of nurse
p r a c t i t i o n e r s ( nurses s k i l l e d and trained i n s p e c i a l t y areas),
5 ) receiving and investigating complaints, 6) holding hearings, and
7) d i s c i p l i n i n g nurses f o r violations of practice standards.
Our review indicated t h a t Arizona law r e q u i r e s a p p l i c a n t s f o r licensure to
pass a written examination. The Board uses a national examination,
however, our review of the manner i n which the examination is graded
revealed that: 1) it is not scored i n accordance with Arizona s t a t u t o r y
requirements, and 2) 36 percent and 11 percent of the Registered Nurse
and Licensed P r a c t i c a l Nurse a p p l i c a n t s r e s p e c t i v e l y , would not have
passed if the passing score had been equivalent to that required by
Arizona l a w . ( page 9)
Our review of the composition of the Board of Nursing revealed t h a t unlike
most s t a t e s , Arizona does not allow f u l l LPN representation on the board
responsible f o r regulating nursing. It appears t h a t the Board's
effectiveness would be enhanced i f LPNs were added to the ~ o a r d ' s
membership. ( page 15)
Arizona s t a t u t e s require the Board of Nursing t o investigate complaints
against nurses, and revoke o r suspend licenses f o r proper cause. We found
that the Board has generally been s t r i c t when imposing penalties against
nurses. However, r. e e l s o foxnc! ? Cat: 1) there i z on a p p ~ r e n t lack of
knowledge within the nursing community as to what c o n s t i t u t e s incompetency
on the part of nurses, and 2 ) t h e Board has limited d i s c i p l i n a r y options
when contrasted with other Arizona health regulatory boards. ( page 25)
Finelly, o reyiev of schcols ayprcved by the Boerd revealed t h a t the Scar2
should reassess one nursing program t o which it granted f u l l accreditation
i n 1978. ( page 39)
Consideration should be given to the following recommendations:
- A. R. S. § $ 32- 1633 and 32- 1638 be amended to g r a n t t h e Board
authority t o s e t the passing score on its written examination
through its rules and regulations, and the v a l i d i t y of licenses
issued prior t o such a revision be recognized. ( page 14)
- The p r a c t i c a l nurse committee be eliminated; ( A. R. s. $ 32- 1607),
and A. R. S. $ 32- 1602 be amended to add two a c t i v e l y practicing
LPNs to the Board. ( page 24)
- The Board r?? tl'. f: r l.'. cc- csn hrjlders of the Board's r e s p o n s i b i l i t i e s
to investigate and resolve issues involving competency. ( page 36)
- The Board amend its rules and regulations to include f a i l u r e of a
licensee t c report ~ ~ i o l a t i o nosf the nursing Prectice Act as
unprofessional conduct. ( page 36)
- A. R. S. $$ 32- 1606, subsection B, and 32- 1663, subsection D, be
amended t o provide the Board with additional d i s c i p l i n a r y options
such as: probation, decree of censure and fines. ( page 37)
- The Board of Nursing should reassess t h e a c c r e d i t a t i o n s t a t u s of
a nursing program to which it granted f u l l a c c r e d i t a t i o n i n
1978. ( page 43)
INTRODUCTION AND BACKGROUND
In response t o a January 30, 1980, resolution of the Joint Legislative
Oversight Committee, the Office of the Auditor General has conducted a
performance audit of the S t a t e of Arizona, Board of Nursing. This
performance audit was conducted as a part of the Sunset review process s e t
f o r t h i n A. R. S. 5541- 2351 through 41- 2379.
I n 1921, f i v e years a f t e r Arizona's first nurses graduated from St. Mary's
School of Nursing i n Tucson, the Legislature established the State Board
of Nurse Examiners, ( l a t e r changed to the S t a t e Board of ~ u r s i n g ) .
The Board c u r r e n t l y c o n s i s t s of seven members: f i v e Registered Nurse ( RN)
members and two public members who were added to the Board i n 1979. In
1952, a five member p r a c t i c a l nurse committee was established to a s s i s t
and vote with the Board on matters p e r t a i n i n g s p e c i f i c a l l y to Licensed
P r a c t i c a l Nurses ( LPNS) .
The s t a t e d goal of - tihe Board is: i; o ensure safe and e f f e c t i v e nursing
services to the public. To accomplish t h i s goal, a v a r i e t y of functions
are performed including: 1) examination of nursing applicants,
2) i n i t i a l issuance and annual renewal of licenses, 3) a c c r e d i t a t i o n of
nursing schools, 4) c e r t i f i c a t i o n of nurse p r a c t i t i o n e r s ( nurses s k i l l e d
and trained i n s p e c i a l t y a r e a s ) , 5) receiving and investigating
complaints, 6) holding hearings, and 7) d i s c i p l i n i n g nurses f o r
violations of practice standards.
The Board has a s u b s t a n t i a l workload a s shown i n Table 1. I n f i s c a l year
1980- 81, 28,500 licenses were renewed, 3,000 temporary licenses were
issued, 1,700 examinations were administered and 52 nurse p r a c t i t i o n e r
c e r t i f i c a t e s were issued.
TABLE 1
SUENARY OF THE BOARD OF NURSING WORKLOAD
FROX FISCAL YEAR 1977- 78 THROUGH 1980- 81
Fiscal Year
I n i t i a l licenses issued 1,296 1,298 1,723 1,531
Annual renewal licenses issued 22,835 24,585 26,599 28,445
Examinations administered 1,597 1,524 1,695 1,731
Licenses granted by endorsement 2,408 2,469 2,503 2,209
Requests f o r licensing information
from other s t a t e s processed* 953 985 1,057 1,129
Temporary permits issued 2,241 2,840 2,935 2,856
Nurse p r a c t i t i o n e r c e r t i f i c a t i o n s
issued 2 2 3 6 78 5 2
Table 2 summarizes the nunrber and type of Board investigations and
d i s c i p l i n a r y a c t i o n s from f i s c a l year 1977- 78 through 1980- 81.
* Nurses licensed i n Arizona and moving to another s t a t e , then applying
for a license-
TABLE 2
SUMMARY OF THE NUMBER AND TYPE OF
BOARD INVESTIGATIONS AND DISCIPLINARY ACTIONS
FROM FISCAL YEAR 1977- 78 THROUGH 1980- 81
Fiscal Year
1977- 78 1978- 79 1979- 80 1980- 81
Investigations:
Relsted t o statements on applications 34 29 2 2 4 7
Related to complaints about licensees 30 35 6 2 8 2
Impostors 6 4 4 4
Number of hearings 7 6 11 12
Disciplinary actions taken against
licensees:
Following hearing:
Revocation 5 4 9 6
Summary revocation 0 0 0 1
Suspension 2 0 1 3
No action 0 0 0 2
Without hearing:
Denial 5 1 3
7
3
S - w a r y s u s p n s i o z C - 0 3
Summary revocation 0 0 0 4
Suspension ( by consent agreement) 0 1 3 8
Revocation ( by consent agreement) 0 1 7 19
Reinstatement of license 0 7 1 2
The Board and its a c t i v i t i e s are funded through fees charged f o r
examinations and licenses issued. Ten percent of the fees received is
deposited i n the S t a t e General Fund; the remaining 90 percent is used f o r
Board operations within the l i m i t s of an annual budget approved by the
Legislature. Table 3 summarizes the Board's revenues, expenditures and
full- time equivalent positions from 1977- 78 through 1980- 81.
* A csnsen* agreemerit is signed by a nurse name2 i n a corrplaint who
wishes to waive the r i g h t to a hearing and accept immediate suspension
or revocation of his/ her license.
SUMMARY OF BOARD REVENUES, EXPENDITURES AND FULL- TIME EQUIVALENT POSITIONS
FROM FISCAL YEAR 1977- 78 THROUGH 1980- 81"
Fiscal Year
1977- 78 1978- 79 1979- 80 1980- 81
Revenues :
I n i t i a l application f o r
licensure $ 159,200 *" $ 186,300 $ 189,900 $ 193,700
Renewal of licensure 242,600 262,400 276,300 290,300
Temporary permits 22,400 27,600 29,400 " 3,400
Miscellaneous income 8,400 20,900 25,200 25,500
$ 432.600 $= $ 520.800 $ 540.900
Expenditures:
Personal services $ 136,500
Enplayee- related services 22,700
Professional and Outside
services 46,700
' J" fyil- L=- 5 5t~ e 7,7Cc?
Travel- Out- of- S t a t e 3,300
Other operating expenditures 44,000
Capltal outiay 2,800
Refunds 0
Total
Full- time equivalent positions 10.5 10.5 11.5 11.5
The Office of the Auditor General expresses appreciation t o the members of
the Board of Nursing and its s t a f f f o r t h e i r cooperation and assistance
during the course of our audit.
* Source: Schedule four of the Budget Request from the Board f o r
f i s c a l years 1977- 78 through 1980- 81.
** Rounded to nearest $ 100.
SUNSET FACTORS
In accordance with A. R. S. $$ 41- 2351 through 41- 2379, nine f a c t o r s are
considered to determine, i n p a r t , whether the Board of Nursing should be
continued or terminated.
SUNSET FACTOR: THE OBJECTIVE ABD
PURPOSE I N ESTABLISHING THE BOARD
Arizona law does not s p e c i f i c a l l y s t a t e the purpose of the Board; however,
its s t a t u t o r y authority and duties include:
I. Examining and l i c e n s i n g a p p l i c a n t s , ( A. R. S. $$ 32- 1644 through
32- 1645) ;
2. Investigating complaints and denying, suspending or revoking
licenses f o r violations of the nursing law, ( A. R. s. § $ 32- 1663
through 32- 1664);
3. Accrediting schools and colleges of nursing, ( A. R. s. $$ 32- 1644
through 32- 1645) ; and
4. Promulgating rules and regulations governing the practice of
nursing, ( A. R. s. $ 32- 1606).
I n addition, i n its f i s c a l year 1980- 81 budget request, the Board of
Nursing s t a t e d the following as its goal:
"( TO) emure t h a t t h e public gets e quality czr, d.
quan- ci~ y of nursing services, t h a t are s a f e , e f f e c t i v e
and meet the parameters of s o c i e t y ' s needs i n terms of
honesty, i n t e g r i t y and morality."
SUNSET FACTOR: THE DEGREE TO WHICH THE BOARD
HAS BEEN ABLE TO RESPOND TO THE NEEDS OF THE PUBLIC
AND THE EFFICIENCY WITH \ i? IICH I T HAS OPERATED
Based upon our review, the Board appears t o have responded to a l l
complaints received, increased its i n v e s t i g a t i v e resources, and improved
the c e r t i f i c a t i o n of nurse p r a c t i t i o n e r s by hiring a Nurse P r a c t i t i o n e r
Consultant i n January of 1980.
The Board also appears t o have operated e f f i c i e n t l y . The number of
i n v e s t i g a t i o n s conducted by the Board has increased 90 percent from f i s c a l
year 1977- 78 t o f i s c a l year 1980- 81, compared t o a 47 percent increase i n a
expenditures and a s t a f f increase of one full- time position during the
same period.
SUNSET FACTOR: THE EXTENT TO WHICH THE AGENCY
HAS OPERATED WITHIN THE PUBLIC INTEREST
- - --
The Board has operated within the public i n t e r e s t i n its complaint
i n v e s t i g a t i o n and licensure processes; however, the Board should reassess
the a c c r e d i t a t i o n s t a t u s of a nursing program to which it granted f u l l 4
a c c r e d i t a t i o n i n 1978. ( page 39)
SUNSET FACTOR: THE EXTENT TO kV5ICB
- -- -- - - -- -- - -
RULES AND REGULATIONS PROMULGATED BY
THE BOARD ARE: CONSISTENT WITH LEGISLATIVE MANDATE
- - -
The Attorney General has found t h a t Board promulgated rules and
regulations are consistent with s t a t u t o r y mandate.
SUNSET FACTOR: THE EXTENT TO WHICH THE BOARD
HAS ENCOURAGED INPUT FROM THE PUBLIC BEFORE
PROMULGATING ITS RULES AND REGULATIONS AND THE
EXTENT TO WHICH IT HAS INFORMED THE PUBLIC AS TO
ITS ACTIONS AND THEIR EXPECTED IMPACT ON THE PUBLIC
A statewide public opinior, survey, commissioned by the Office of the
Auditor General, found t h a t over half of the public is aware of the Board
cf Nursing. Public awareness of the Nursing Board is greater than
awareness of most o t h e r h e a l t h regulatory boards included i n the survey.
The Board is attempting to become more v i s i b l e through its involvement i n
a Manpower Study of nursing and the scheduling of several meetings to
b e t t e r inform the nursing community of Board functions. ( page 25)
SUNSET FACTOR: THE EXTENT TO WHICH THE
AGENCY HAS BEEN ABLE TO INVESTIGATE AND
RESOLVE COMPLAINTS T! AT ARE VITHIR TTS JURISDICTION
Our review found that the Board of Nursing complaint investigations are
thorough, timely and well- documented; however, it appears t h a t the Board
has not been receiving a l l complaints that are within its jurisdiction.
In addition, expanding the Board's d i s c i p l i n a r y options, now limited by
law to suspension, revocation or denial of a l i c e n s e , would allow the
Board more f l e x i b i l i t y i n responding t o violations. ( page 25)
SUNSET FACTOR: THE EXTENT TO WHICH THE
ATTORNEY GENERAL OR ANY OTIIER APPLICABLE AGENCY
OF STATE GOVERNMENT HAS THE AUTHORITY TO
PROSECUTE ACTIONS UNDER ENABLING LEGISLATION
The Attorney General has the authority t o prosecute violations of Board
s t a t u t e s ; however, options appear t o Be too r e s t r i c t e d . ( page 25)
SUNSET FACTOR: THE EXTENT TO WHICH THE --,--- .----- .----- -- ---
BOARD HAS ADDRESSED DEFICIENCIES I N ITS
ENABLING STATUTES WHICH PREVENT IT FROM
FULFILLING ITS STATUTORY NARDATE
Although the Board has expressed d i s s a t i s f a c t i o n with some of the
provisions of A. R. S. $$ 32- 1633 and 32- 1638 pertaining t o examinations, it
has not o f f i c i a l l y ? ronosed s t z t u t o q - changes.
SUNSET FACTOR: THE EXTENT TO WICK
CHANGES ARE: NECESSARY I N THE LAWS OF THE BOARD
TO ADEQUATELY COMPLY WITH THE FACTORS LISTED
For a discussion of t h i s issue see pages 14, 24 and 36.
FINDING I
THE STATE BOARD TEST POOL EXAMINATION FOR REGISTERED I! URSES A! iD LICENSED
PRACTICAL NURSES IS NOT SCORED I N ACCORDANCE WITH STATUTORY REQUIREMENTS.
Arizona law r e q u i r e s a p p l i c a n t s f o r l i c e n s u r e a s a Registered Nurse or ti
Licensed P r a c t i c a l Nurse t o pass a w r i t t e n examination with a score of 70
percent or more. Arizona, l i k e most s t a t e s , uses a w r i t t e n examination
t h a t is prepared and graded by the National League f o r Nurses. Our review
of the manner i n which the n a t i o n a l examination is graded revealed t h a t :
1) it is not scored i n accordance with the Arizona requirements, and
2 ) 76 percent and 11 percent of the Registered Nurse and Licensed
P r a c t i c a l Nurse a p p l i c a n t s , r e s p e c t i v e l y , who passed the n a t i o n a l
examination i n 1980, would not have passed i f the passing score had been
equivalent t o t h a t required by Arizona law.
Arizona Examination Reauirements
Arizona Revised Statu-; es $$ 32- 16' 33 and 32- 1678 r e q u i r e s Registered Nurse
and Licensed P r a c t i c a l Nurse a p p l i c a n t s t o pass a w r i t t e n examination with
a score of 70 percent o r more i n order t o be licensed by the Board as
s t a t e d i n p a r t by A. R. S. $ 32- 1633:
" An a ~ ~ l i c a ns ht a l l be reauired t o Dass with a arade of
seventy percent o r more a w r i t t e n examination i n such
s u b j e c t s r e l a t i n g t o the d u t i e s and s e r v i c e s of a
r e g i s t e r e d nurse taught i n an accredited school of
p r o f e s s i o n a l nursing as the board determines and, i n
the d i s c r e t i o n of the board, a supplexnental o r a l o r
p r a c t i c a l examination covering such s u b j e c t s ...."
( ~ m p h a s i sa dded)
A. R. S. $ 32- 1638 s t a t e s :
" An applicant s h a l l be required t o pass, with a grade
of seventy percent or more a w r i t t e n examination i n
such s u h j e c t s r e l a t i n g to the d u t i e s and s e r v i c e s of a
p r a c t i c e 1 nurse taught i n an accredited school of
p r a c t i c a l nursing.. .. " ( ~ m ~ h a saidsd ed)
Examination and Grading Procedures Used
In 1945, the Board of Nursing adopted the S t a t e Board Test Pool
Examination ( SBTPE), prepared by the National League f o r Nurses Testing
Service ( NLN,) as the ~ o a r ds' written examination required f o r licensing
of RNs and LPNs. Every s t a t e , except California,** uses the SBTPE as t h e i r
written examination.
Our review of the manner i n which the SBTPE is graded revealed that it is
not scored i n accordance with Arizona s t a t u t o r y requirements. In grading
the SBTPE, the NLN has a r ' o i t r e r i l y adopted 350 points on its examination
as the minimum passing score. The 350 point c r i t e r i a reportedly
approximates one and one half standard deviations below the mean ( average)
score. I n addition, through a r a t h e r complicated process the NLN converts
the a p p l i c a n t ' s raw score f i r s t t o a corrected raw score which is
eventually compared to the 350 point passing c r i t e r i a to determine i f the
applicant passed the examination.
Wher, audit s t a f f analyzed the above grading procedures it was deternined
that the 350 point passing c r i t e r i a recommended by NLN was lower than the
70 percent score specified i n Arizona law. For example, the 350 point
c r i t e r i a for the F~ t'~' u, r;- 1": EST22 Hegistered Nurse examination was
equivalent to a score of only 60 percent as opposed t o the 70 percent
score specified i n A. R. S. $ 32- 1633.
Table 4 compares the scores required t o pass the SBTPE f o r Registered
Nurses and Licensed P r a c t i c a l Nurses during 1979 and 1980 to the 70
percent score required i n A. R. S. $ 532- 1637 and 32- 1638.
* California designs its own examination f o r LPNs.
TABLE 4
COMPARISON OF SCORES REQUIRED TO PASS THE SBTPE FOR
REGISTERED NURSES AND LICENSED PRACTICAL NURSES EURING
1979 AED 1980 TO THE 70 PERCENT SCORE REQUIRED I N A. R. S. $$ 32- 1633 A1: E 32- 1638
Score Hequired
Test to Pass the Required Score
- Date
RN Examination
February 1979
July 1979
February 1980
a July 1980
LPN Examtnstiox
April 1979
October 1979
April 1980
October 1980
National Nursing ExamiLLyilons Per A. R. S. $$ 32- 1633 and 32- 1638
A s shown above, the SBTPE administered i n 1979 and 1980 required a
passing score ranging from 60 to 63 percent f o r the four RN
examinations and 61 t o 65 percent f o r the four LPN examinations.
Compliance
According t o t h e L e g i s l a t i v e Council i n an opinion dated July 1,
1981," use of a passing score on the examination which is below 70
percent is not i n compliance with law:
" One of the fundamental rules of statutory
construction is that plain, c l e a r and
unambiguous language is t o be given that
meaning. . . it is obvious t h a t correc t l v answerina
65 percent of the questions t o obtain a point
score of 350 is not the equivalent of the
s t a t u t o r v reauirement of a 70 ~ e r c e n t grade."
( Emphasis added)
Furthemore, according t o the Council, licenses defectively or
i l l e g a l l y granted by the Board could be revoked.
* See Appendix I f o r f u l l text.
" A license issued by the Board... authorizes the nurse
to practice u n t i l notified of a defect or i l l e g a l i t y i n
the issuance of the license... the board may revoke a
license f o r any reason t h a t would have j u s t i f i e d a
r e f u s a l t o issue the license i n i t i a l l y , including the
f a i l u r e t o achieve a passing examination grade."
( Emphasis added)
We estimate t h a t 36 percent and 11 percent of the Registered Nurse and
Licensed P r a c t i c a l Nurse applicants, respectively, who passed the SBTPE i n
1980 would not have passed i f Arizona law had been followed." Table 5
summarizes the number and percentage of applicants who passed the SBTPE i n
1980 but who did not score 70 percent or more.
TABLE 5
SUMMARY OF THE NWEEB dY9 PEP. CEFJT OF AFPLICAKTS I+ IIIO PASSED THE SBTPE
I N 1980 BUT WHO DID NOT SCORE 70 PERCENT OR MORE
Number and Percent
Type of Number of Applicants of Passing Applicants Who Did
Applicant wno Passed the SnTPE Not Score 70
Registered Nurses
P r a c t i c a l Nurses
Total
Because of time constraints audit s t a f f r e s t r i c t e d its analysis of the
SBTPE to 1980. I f the r e s u l t s depicted i n Table 5 are representative of
o t h e r y e a r s as well, a s u b s t a n t i a l percentage of Registered Nurses, and to
a l e s s e r degree Licensed P r a c t i c a l Nurses, who have been licensed by the
Board did not pass t h e w r i t t e n examination as required i n Arizona s t a t u t e s .
* The actual numbers of licenses granted may be s l i g h t l y l e s s since some
applicants who took the e x a ~ i n s t i o x may have withdrawn t h e i r
application or chosen to be licensed i n another s t a t e .
Other S t a t e Score Requirements
It should be noted that most s t a t e s accept the 350 point passing c r i t e r i a
recommended by the NLN as meeting examination requirements. In f a c t , only
one* and five** s t a t e s , r e q u i r e s c o r e s of more than 350 points to pass the
Registered Nurse and Licensed P r a c t i c a l Nurse examinations, respectively.
Further, most s t a t e s have adopted a general s t a t u t o r y provision which
allows t h e i r Board of Nursing to e s t a b l i s h a passing score on the
licensing examination through Administrative Rules and Regulations. Model
l e g i s l a t i o n developed by the American Nurses' Association ( ANA) also
recommends t h a t the passing score be established by Boards of Nursing
through t h e i r rules.
" The applicant s h a l l be required t o pass a written
examination i n such subjects as the board may
determine. Each written examination may be
supplemented by an o r a l or a p r a c t i c a l examination.
The board may use any part or a l l of the S t a t e Board
Test Pool Examination for registered/ practical nurse
licensure, its successor examination, or any other
nationsil;. s2; tndardized examination i d e n t i f i e d by the
board i n its rules. The passing score s h a l l be
established by the board i n its rules." ( Emphasis
added)
According to the ANA, t h i s language allows f o r f l e x i b i l i t y i n determining
examination content and authorizes the use of a national standardized
examination t o f a c i l i t a t e i n t e r s t a t e licensure.
CONCLUSION
~ h~ - L\ -- L- l t ~ , e i ~ 22 rdUii~ htL-- i 1 o r g c iburses ~ n cit ~ ccfise; -:' ra~ u i e a ~
Nurses is not scored i n accordance with statutory requirements. A s a
r e s u l t , 36 percent and 11 percent of the Registered Nurse and Licensed
P r a c t i c a l Nurse a p p l i c a n t s , r e s p e c t i v e l y , who passed the written
examination i n 1980, would not have i f Arizona law had been followed.
* Hawaii
** Hawaii, Minnesota, New Jersey, Washington and Wisconsin.
RECOMMEKDATIOBS
Consideration should be given t o the following recommendations:
1. A. R. S. $$ 32- 1633 and 32- 1638 be amended to grant the Board
a u t h o r i t y t o s e t the p a s s i n g s c o r e on its w r i t t e n examination
through its r u l e s and regulations.
?' . "-- I l. r- * \. . . LL., . ., '.' ,- '- r , -.., 7.-: .. L.. . ,-. C . .',.. -< . . a,- .-.'.. A ;::$ cy $ c. z?~,:!: z2 :- Li-:: L. c- >:',. ;- ' t
a
recognized.
FINDING I1
STATUTORY CHANGES ARE NEEDED REGARDING THE COMPOSITION OF THE BOARD OF
NURSING.
The Board of Nursing is composed of f i v e Registered Nurses ( RNS) and two
public members.* In 1952, a f i v e member p r a c t i c a l nurse committee was
created t o a s s i s t the Board and vote on matters p e r t a i n i n g only t o
Licensed P r a c t i c a l Nurses ( LPNS) .
Our review of the composition of the Board of Nursing revealed that unlike
most s t a t e s , Arizona does not allow f u l l LPN representation on the board
responsible f o r regulating nursing. A s a r e s u l t :
- A s u b s t a n t i a l segment of the nursing profession i n Arizona is not
f u l l y represented on the Board.
- The dual ~ o a r d / L Pc~ o mmittee s t r u c t u r e causes confusion as to
r e s p o n s i b i l i t i e s and authority, and impairs the Board's
efficiency.
- The subordinate r o l e currently afforded LPNs has caused strained
r e l a t i o n s h i p s between Board and p r a c t i c a l nursing committee
members.
It appears t h a t the ~ o a r d ' s effectiveness would be enhanced i f LPNs were
added t o the Board's membership.
Current Structure
A. R. S. $ 32- 1602 establishes the Board of Nursing consisting of f i v e
registered nurses and two public members:
* Public members were added t o El, e Z C ~ P Tfn~ l?' i'S,
" There s h a l l be a s t a t e board of nursing which s h a l l
ccnsist of seven members appointed by the governor.
Five members s h a l l be registered nurses. Two members
s h a l l represent the public and s h a l l not be persons who
a r e licensees of any health occupation board, employees
of any health care f a c i l i t y , agency or of a corporation
authorized to underwrite h e a l t h c a r e insurance or who
have f i n a n c i a l i n t e r e s t s i n o r are engaged i n the
governance or administration of a health care f a c i l i t y ,
agency or corporation. Members s h a l l be appointed f o r
a term of f i v e years, t o begin and end on June 30."
I n a d d i t l ~ a , a practica; nurse committee was established i n 1952 t o advise
the Board and vote on matters pertaining to p r a c t i c a l nursing. A. R. S.
$ 32- 1607 s t a t e s :
" There s h a l l be a p r a c t i c a l nurse committee which s h a l l
consist of f i v e members appointed by the Governor. A l l
the members s h a l l be licensed p r a c t i c a l nurses under
the provisions of t h i s chapter. One member s h a l l be
appointed each year f o r a term of f i v e years, to begin
and end dune 36.
" The committee s h a l l a s s i s t , consult and advise the
board with respect to p r a c t i c a l nursing matters and
with respect to examination and licensing of persons
applying f o r a license t o practice and assume the t i t l e
of p r a c t i c a l nurse. Action as to such matters s h a l l be
taken only upon a majority vote of the combined
members hi^ of the ~ r a c t i c a l nurse committee and the
board." ( Emphasis added)
Interviews with individuals formerly involved with the Board revealed that
a separate p r a c t i c a l nurse committee was established i n 1952 as a
coapromise between the position of the Registered Nurses ( RNs) who opposed
including Licensed P r a c t i c a l Nurses ( LPNS) on the Board and the LPNs who
wanted Board representation.
The primary differences between an RN and an LPN are: education,
supervision requirements, r e s p o n s i b i l i t i e s and practice functions.
Table 6 compares RNs t o LPNs.
1. Degree earned
2. Objectives of training
3. Education received
4. Requirement for
licensure
5. Examination
6. Supervision requirements
7. Functions
COMPARISOIT OF THE LICENSED PRACTICAL NURSE AND THE REGISTERED NUBSE
Licensed P r a c t i c a l Nurse Registered Nurse
Diploma o r c e r t i f i c a t e from a n a c c r e d i t e d school of
p r a c t i c a l nursing or the equivalent as determined
by the Board
Diploma o r c e r t i f i c a t e from an accredited school
of professional nursing
Basic bedside care Advanced bedside care, Leadership Adninistration
Basic nursing s k i l l s i n Medicai, S u r g i c a l , O b s t e t r i c and a. Basic nursing s k i l l s i n Medical, Surgical,
P e d i a t r i c areas, with i n t e g r a t i o n of Psychiatric Obstetric, P e d i a t r i c and Psychiatric
Nursing and Pharmacology concepts areas
b. Advanced nursing s k i l l s
c. Leadership management s k i l l s
d. Liberal Arts background
a. Good moral character
b. Good health
c. Completion of two years of high school. or equivalent
or equivalent
d. Completion of an accredited p r a c t i c a l nurse
program
Successfully pass SBTPE* f o r p r a c t i c a l nurses
May p r a c t i c e nursing only under the supervision of an
RN or physician
R4- 19- 42. Functions of the Licensed P r a c t i c a l Nurse.
A . A licensed p r a c t i c a l nurse nay provide n u r s i ~ gc are
only under the supervision of a r e g i s t e r e d nurse
or licensed physician.
B. The licensed p r a c t i c a l nurse performs the following
functions:
1. P a r t i c i p a t e with registered nurses i n the planning,
implementation and evaluation of nursing care by:
a . Providing for the emotional and physical comfort
of p a t i e n t s ;
b. Observing, recording and reporting the condition
of the p a t i e n t , signs and symptoms which may be
i n d i c a t i v e of change i n the p a t i e n t ' s condition
to the appropriate person;
Sane as LPN; however, must complete professional
nurse prograa a t a n a c c r e d i t e d school and
four years of high school or its equivalent
Successfully pass SBTPE f o r professional nurses
None
R4- 19- 47. Functions of the Registered Nurse.
A. The registered nurse s h a l l be responsible
and accountable f o r making decisions t h a t are
based upon educstionel preparation and
experience i n nurslfig.
B. The registered nurse s h a l l be held accountable
for the q u a l i t y afid quantity of nursine core
given to p a t i e n t s . This includes:
1. Providing the nursing leadership i n the
planning f o r and provision of nursing care
t o p a t i e n t s ;
2. Giving d i r e c t nursing care to each p a t i e n t
according to needs or assigning these functions
t o a s s i s t a n t s i n accordance with the
preparation and competency of the available s t a f f ;
* SSTPE is the S t a t e Board Test Pool Examination.
Table 6 ( Cont'd) '
7 . Functions ( ~ o n c l ' d ) Licensed P r a c t i c a l Nurse
c. Performine nursing procedures f o r which the
preparation of the licensed p r a c t i c a l nurse has
provided t h e n e c e s s i r y degree of s k i l l and judgment;
d. Assisting with the r e h a b i l i t a t i o n of p a t i e n t s
according to the p a t i e n t ' s care plan.
3. The d i r e c t i o n and continuous evaluation of
nursing practice; applying nursing knowledge,
administrative techniques and teaching
p r i n c i p l e s toward the u l t i m a t e g o a l of
excellence i n p a t i e n t care and promotion
of good health p r a c t i c e s ;
4. Continuous e f f o r t to recognize the a b i l i t i e s
and p o t e n t i a l i t i e s of a l l nursing personnel and
to a s s i s t each individual i n an attempt t o a t t a i n
optimum performance;
5. Assessing the p a t i e n t ' s needs, planning f o r
implementing and evaluating the nursing care
of each p a t i e n t ;
6. Organizing, administering, and supervising the
implementation of a written nursing c a r e p l a n
f o r each patient.
C. The r e g i s t e r e d nurse s h a l l be held accountable
f o r t h e q u a l i t y and quantity of nursing care
given to p a t i e n t s rendered by s e l f or others
who are under h i s or her supervision.
1. The registered nurse may:
a. Assign s p e c i f i c nursing d u t i e s to other
q u a l i f i e d personnel;
b. Assign the administration of medications to
other licsnsed nurses only;
c. Ascign t h e d u t i e s or rendering treatments to
licensed nurses or a u x i l i a r y workers based upon
t h e i r e d r c a t i o n a l p r e p a r a t i o n and experience.
2. The registered nurse s h a l l appraise the
care given by the licensed nursing s t a f f and
a u x i l i a r j workers under h i s or her d i r e c t i o n
and s h a l l give a s s i s t a n c e a s needed.
7. The registered nurse i s responsible f o r
the c l i n i c a l nursing record which r e f l e c t o the
p a t i e n t ' s nursing care and progress. The
registered nurse may delegate some portions
of the recording of t h e c a r e given and the
observations made t o t h e a s s i s t a n t s who have
rendered t h e s e r v i c e .
Most Other States Have LPN
Representation on the Regulatory Board
Arizona is one of only three s t a t e s t h a t do not have an LPN
representative on the board t h a t regulates nurses. Of the remaining
s t a t e s , 41 include LPNs on the board and seven have separate LPN
regulatory boards. Table 7 summarizes the nursing board
conpositions i n the 50 s t a t e s and the D i s t r i c t of Columbia.
TABLE 7
SUMMARY OF NURSING BOARD COMPOSITIONS I N THE 50 STATES AND THE DISTRICT OF COLUMBIA
Separate LPN
No LPN LPN Advisory
LPN Representation on Board Representation Board Council
b Alabama
Arkansas
Colorado
Connecticut
Delaware
Florida
D Hawaii
I l l i n o i s
Indiana
Iowa
Kansas
Kentucky
B Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
B Missouri
Nebraska
Nevada Alaska
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Wisconsin
Wyoming
California Arizona
Georgia Idaho
Louisiana
Montana
Washington
West Virginia
D i s t r i c t of Columbia
The average composition f o r those boards with f u l l representation is
five RNs, two LPNs and two public members. Audit s t a f f contacted
boards i n Indiana, Nebraska, New Mexico, Nevada, Oregon, Rhode
Island, Virginia and FIyoming regarding the workability of combined
boards. A l l respondents s t a t e d t h a t t h e r e p r e s e n t a t i v e s of the
various factions were active board p a r t i c i p a n t s a d worked well
together.
A Substantial Segment of the
Nursing Profession i n Arizona
Is Not Fully Represented on the Board
Tt? len pre; tLcal z; rc; ng comi",- tse xiis e s t 6 t i L ~ i ~ eidn IS52, LLcre % ere
106 LPNs i n Arizona, or only two percent of the nursing professionals.
However, by 1980, the number of LPNs had grown t o 7,763, or 25 percent of
the nursing professionals i n Arizona. Table 8 summarizes the growth of
LPNs r e l a t i v e to RNs i n Arizona from 1952 to 1980.
TABLE 8
SUMMARY OF THE GROWTH OF LPNs RELATIVE TO RNs I N ARIZONA
1952 TO 1980
Number
Year LPNs RNs
Percentage of Nursing Professionals
LPNs - RNs
A s shown above, a s u b s t a n t i a l segment of the nursing professionals i n
Arizona are not f u l l y represented on the Board.
Confusion as to Resoonsibilities
And Authority and Impaired Efficiency
The current ~ oard/ committee s t r u c t u r e has caused confusion i n voting,
unnecessary administrative work and i n e f f i c i e n t use of Board time.
During our review, s e v e r a l c a s e s were observed i n which LPN committee
members made and seconded motions as well as voted i n matters pertaining
t o RNs. The following are examples:
* Source: Registry of Nurses, Board Office.
** Figures f o r RNs and LPNs from 1962 through 1980 were obtained from
s t a t i s t i c a l records a t the Board office.
January 1978
A motion was made that the Board r a t i f y licenses f o r both RNs and LPNs
and c e r t i f y an expanded role f o r RNs. The motion was moved by an RN
member of the Board and seconded by an LPN member of the p r a c t i c a l
nurse committee.
March 1980
A motion was made t h a t the Board r a t i f y licenses f o r RNs. The motion
was made by an LPN member of the p r a c t i c a l nurse committee.
In a memorandum dated July 23, 1981," t h e L e g i s l a t i v e Council s t a t e d t h a t
LPN committee members do not have authority to make motions, second
motions, or vote on matters involving registered nurses:
" The authority of the committee members does not extend
to matters concerning registered nurses... it would be
improper f o r committee members to make motions, second
motions or vote on registered nursing matters or
matters involving registered nurses and ? ractic=
nurses." ( Emphasis added)
Furthermore, according t o the Council improper LPN voting could invalidate
Board actions :
" A motion or vote by a Committee member on a registered
nursing matter might invalidate the action of the board
because they are not members of the Board f o r t h a t
purpose. . . ."
* See Appendix I1 for f u l l memorandum t e x t .
2 1
Unnecessary Administrative Work
And I n e f f i c i e n t Use of ~ o a r d ' sT ime
The dual Board/ committee s t r u c t u r e requires additional administrative work
because two separate agendas must be s e t . During regular Board meetings,
one day is normally devoted to registered nursing matters handled by the
Board alone. A second day is scheduled as a combined ~ oard/ committee
meeting which concentrates on p r a c t i c a l nursing matters. Determining when
to schedule and how to handle general nursing matters affecting both
classes of nurses has caused d i f f i c u l t i e s i n s e t t i n g the two agendas.
In addition, the dual ~ oard/ committee s t r u c t u r e has resulted i n a
i n e f f i c i e n t use of Board time given the Board's heavy workload and busy
meeting schedule. We noted i n our review of Board agendas and minutes of
meetings, that general matters were often discussed twice; once during the
Board only meeting day, and again a t the combined meeting of the Board and a
committee. General matters usually include: 1) manpower study reports,"
2) nursing conventions, and 3) credentialing reports.""
Strained Relationships Be- t- w een Board
And P r a c t i c a l Nursing Committee Members
The current dual Board/ committee s t r u c t u r e has resulted i n poor
communication and s t r a i n e d r e l a t i o n s h i p s between Board and p r a c t i c a l nurse
committee members.
Board and committee members interviewed during our audit made numerous
references to the poor relationship between the Board and the committee.
The following are examples of comments made:
* See page 47 f o r a f u l l discussion.
** Credentialing reports deal with a current American Nurses' Association
study to c r i t i c a l l y examine, compare and evaluate a l l aspects of
credentialing mechanisms i n nursing service and education including
accreditation, c e r t i f i c a t i o n , licensing and academic degrees.
1 - " The current ~ ommittee/~ oard structure is not
c l e a r l y understood and has caused
misunderstandings.
- "(~ ommittee members) are not given enough of a say
i n what goes on.
- " As long as there are RNs on the Board, ' we are
peasants. ' We are seen as not having the
i n t e l l e c t u a l capacit , the educational a b i l i t y o r
t h e e x p e r e n t i a l background to make decisions. In
essence, LPNs do more work i n the hospital s e t t i n g
i n d i r e c t p a t i e n t contact than the RN-
- " I t seem( s) l i k e the LPN ( i s n ' t ) getting any
respect, yet sometimes, i f it weren't f o r the LPN
members there wouldn't be enough Board members for
a meeting.
- " I think t h a t the l i n e s of communication could be
opened... I think what we have to do is explain t o
the LPN what h e r r o l e is.
- " The LTN functions almost l i k e a second c l a s s
c i t i z e n . . . .
- " The LPN is i n jeopardy. Too much regulation is
exercised on them, yet no one is looking out f o r
them.
- " RNs are a s g u i l t y a s doctors i n regards t o
treatment of LPNs. RNs t r e a t LPNs as doctors
t r e a t RNs. I think LPNs have a great deal t o
o f f e r and should have equal represpntation on the .-
Board .' I
One of the major causes of t h i s poor r e l a t i o n s h i p appears t o be the
subordinate role of the committee members. The r e l a t i o n s h i p between Board
and committee members became especially strained following the termination
of the Board's executive secretary i n May 1981, because LPN committee
members were excluded by law from voting on the matter. In addition, LPN
committee members resent the f a c t t h a t members of the public who have no
formal training i n nursing are represented on the Board while they are not.
One Board member s t a t e d t h a t LPNs were properly represented given t h e i r
educational background. By c o n t r a s t , it was s t a t e d t h a t the public
members were qualified t o serve on the Board due t o t h e i r b e t t e r
educational background.
CONCLUSION
Because Arizona does not allow f u l l LPN representation on the Nursing
Board :
- Arizona is unlike the 41 s t a t e s t h a t do allow LPN representation.
- A s u b s t a n t i a l segment of the nursing professionals i n Arizona is
not f u l l y represented on the Board.
- There a r e confused r e s p o n s i b i l i t i e s and authority between the
Board and the p r a c t i c a l nurse committee and therefore the Board's
efficiency is impaired.
- Relationships between Board and LPN members are strained.
It appears t h a t the ~ o a r'd s effectiveness would be enhanced i f LPNs were
added t o the Board's membership.
RECOMMENDATION
consideration should be given to the following recommendations:
1. The p r a c t i c a l nurse committee be eliminated; ( A. R. s. $ 32- 1607),
and - ,.. .
2. A. R. S. $ 72- 1602 be menCed t o add two actively practicing LPNs to
the Board.
FINDING I11
THE BOARD OF NURSING GETTERALLY IMPOSES STRICT PENALTIES AGAINST NURSES
NAMED I N COMPLAINTS. HOWEVER, THE BOARD NEEDS TO BETTER INFORM THE
NURSING COMMUNITY AS TO WHAT COIJSTITUTES INCOMPETEiJCY ON THE PART OF
NURSES.
Arizona s t a t u t e s require the Board of Nursing t o i n v e s t i g a t e complaints
a g a i n s t nurses, and suspend or revoke l i c e n s e s f o r proper cause. Our
review of the Board's handling of complaints revealed t h a t :
- The Board has g e n e r a l l y imposed s t r i c t p e n a l t i e s a g a i n s t nurses
named i n complaints.
- There is an apparent lack of knowledge within the nursing
community as t o what c o n s t i t u t e s incompetency on the p a r t of
nurses. A s a r e s u l t , some incompetent nurses may be allowed t o
continue t o p r a c t i c e nursing.
- m* l~ i eE card has limi$ ed d i s c i p l i n c i ~ o ptions when c c c t r a s t e d with
other Arizona h e a l t h regulatory boards.
Board Authority t o
Conduct I n v e s t i g a t i o n s
Arizona Revised S t a t u t e s provide the Board with t h e a u t h o r i t y t o
i n v e s t i g a t e and d i s c i p l i n e persons o r i n s t i t u t i o n s v i o l a t i n g t h e Nursing
P r a c t i c e Act. A. R. S. $ 32- 1606, subsection B, s t a t e s t h a t the Board s h a l l :
" 3. Examine, l i c e n s e and renew t h e l i c e n s e s of
duly q u a l i f i e d a p p l i c a n t s , and conduct hearings upon
charges c a l l i n g f o r suspension or revocation of a
l i c e n s e o r a c c r e d i t a t i o n of schools of nursing, as
provided i n t h i s chapter, and f o r proper cause may
deny, suspend o r revoke l i c e n s e s or a c c r e d i t a t i o n of
schools of nursing.
" 4. Cause the rose cut ion of Dersons v i o l a t i n e
t h i s cha2ter. l' (~ rnphasis added)
In a d d i t i o n , A. R. S. $ 32- 1654, subsection A, s t a t e s t h a t :
" Upon the f i l i n g with the board of a sworn
complaint charging a licensee with any conduct
specified i n 532- 1663, subsection D, the board s h a l l
conduct an i n v e s t i g a t i o n thereof. For purposes of the
investigation, the board may employ investigators.
Evidence may be taken by deposition or affidavit."
( ~ m ~ h a saidsd ed)
Grounds f o r Board actions are established by A. R. S. 532- 1663, subsection D:
" The Board may revoke or suspend any license to
practice nursing issued under t h i s chapter i f the
licensee is, a f t e r hearing found:
" 1. Guilty of fraud o r deceit i n procuring or
attempting to procure a license to practice nursing.
" 2. To have been convicted of a felony or any offense
i n v o l r i ~ gm o:* al t u q i t u d e .
" 3. Guilty of procuring, aiding, abetting or
attempting, agreeing cr offering t o procure or a s s i s t
a t a criminal abortion.
" 4. Guilty of unprofessional conduct or u n f i t or
incompetent by reason of negligent habits or other
causes.
" 5. Then ( s i c ) habitually intemperate or addicted to
the use of habit forming drugs, or mentally
incompetent, or physically unsafe f o r nursing duty.
" 6. To have had h i s license to practice nursing
denied, suspended or revoked i n another j u r i s d i c t i o n
and not reinstated.
" 7. Guilty of wilfully or repeatedly violating the
provisions of t h i s chapter." ( ~ m ~ h a saidsd ed)
" Unprofessional conduct" is defined by Board Rule R4- 19- 44:
" Pursuant t o A. R. S. 932- 1663, Subsection A,
Paragraph 4, and Subsection D, Paragraph 4 , t h e Board
may take d i s c i p l i n a r y a c t i o n against a licensed nurse
or an applicant f o r a nursing license f o r
unprofessional conduct, unfitness, or incompetence by
reasons of negligent habits o r other causes.
Unprofessional conduct, unfitness or incompetency by
reasons of negligent habits or other causes is defined
to mean and includes without l i m i t a t i o n the following:
" 1. Gross negligence i n t h e p r a c t i c e of nursing;
" 2. Failure to maintain minimum standards of
acceptable and prevailing nursing practice;
" 3. I n t e n t i o n a l l y or negligently causing physical
or emotional injury to a p a t i e n t ;
" 4. Unauthorized removal of narcotics, drugs,
supplies, or equipment from any health care f a c i l i t y ,
school, i n s t i t u t i o n or other work place location;
" 5. Failure to maintain a record f o r each patient
which accurately r e f l e c t s the evaluation and treatment
of t h e p a t i e n t ;
" 6. Falsifying or making materially i n c o r r e c t ,
inconsistent or u n i n t e l l i g i b l e e n t r i e s i n any patient
records or i n the records of any health care f a c i l i t y ,
school, i n s t i t u t i o n or other work place location
pertaining to the obtaining, possessing or
administration of any controlled substance a s defined
i n the Federal Controlled Substances Act;
" 7. Obtaining, possessing, administering or using
any narcotic or controlled substance i n violation of
any Federal or S t a t e criminal law, or i n violation of
any health care f a c i l i t y , school, i n s t i t u t i o n or other
work place location policy;
" 8. Leaving a patient care nursing assignment
without properly advising appropriate personnel;
" 9. The use of any intoxicating beverage or the
i l l e g a l use of & ny narcotic or aangerous dr; g uhile on
duty i n any h e a l t h c a r e f a c i l i t y , school, i n s t i t u t i o n
or other work place location;
" 10. Being under the influence of alcoholic
beverages, or under the influence of i l l e g a l drugs or
drugs which impair judgment while on duty i n any health
care f a c i l i t y , school, i n s t i t u t i o n or other work place
location; .*. ..
" 11. Engaging i n fraud, misrepresentation, or
deceit i n writing the licensing examination;
" 12. Impersonating another licensed p r a c t i t i o n e r ;
" 13. Permitting or allowing another person to use
his or her license f o r the purpose of nursing the sick
o r a f f l i c t e d f o r compensation;
" 14. Abandoning or neglecting a patient requiring
immediate nursing care without making reasonable
arrangement f o r continuation of such care, or
" 15. Unauthorized removal of a p a t i e n t ' s l i f e
support system without appropriate medical or legal
authorization."
S t r i c t Penalties Against
Nurses Named i n Com~ laints
The Board has generally imposed s t r i c t penalties against nurses named i n
complaints. Table 9 summarizes t h e d i s c i p l i n a r y a c t i o n taken by the Board
f o r complaints it received i n 1979 and 1980. It should be noted t h a t a l l
complaints received by the Board are investigated.
TABLE 9
SUMMARY OF DISCIPLINARY ACTIONS TAKEN BY THE BOARD
FOR INVESTIGATIONS CONDUCTED DURING CALENDAR YEARS 1979 AND 1980
Disciplinary Action
Following hearing:
Revocation
Suspension
No action
Without hearing:
?? e~ ocztiokn- 1 cc~ sents grneme? t
Suspension by consent agreement
Denial of f u l l licensure*
No action - not enough evidence
No action - no j u r i s d i c t i o n
Pending as of December 31, 1980
Granted license*"
Moved t o other state***
0 the r****
Number Percentage
A s shown above, i n 49 percent of the cases the Board revoked or suspended
the license of nurses named i n complaints received during 1979 and 1980.
According to the Board's executive secretary:
" S t r i c t penalties are imposed i n the i n t e r e s t of the
public. The Board considers its primary r e s p o n s i b i l i t y
to be t h a t of protecting the public. Serious
consideration is given t o complaints against nurses,
especially those which are drug- related, because these
complaints frequently involve s i t u a t i o n s which
jeopardize p a t i e n t s ' safety and well being."
* Complaints were against temporary permit holders. ** Complaints involved expired licenses.
**+ Board w i l l not allow renewal of license.
+* w* These were referred to other agencies.
When contrasted with other Arizona health regulatory boards, the
percentage of Nursing Board complaints resulting i n license
revocation or suspension is high. Table 10 compares the Nursing
Board's revocation or suspension percentage with five other Arizona
health regulatory boards that have been reviewed by the Office of
the Auditor General as of October 31, 1981.
TABLE 10
COMPARISON OF THE NURSING BOARD'S REVOCATION OR SUSPENSION PERCENTAGE
WITH FIVE OTHER ARIZONA HEALTH REGULATORY BOARDS THAT HAVE BEEN REVIEWED
BY THE OFFICE OF THE AUDITOR GENERAL AS OF OCTOBER 31, 1981
Arizona Health
t Regulatory Board
The Arizona State Board of
Dental Examiners
The Arizona Board of
D Optometry
The Board of Dispensing
Opticians
The Naturopathic Board of
Examiners
The Board of Medical
Examiners
Percentage of
Period During Complaints Resulting
Number of Which Complaints i n License Revocation
Complaints Received Were Received or Suspension
98 January 1, 1978 - 0%
December 31, 1978
78 January 1, 1975 - 25"
December 31, 1978
96 January 1, 1976 - 0
December 31, 1980
6 January 1, 1980 - 0
June 30, 1981
373 January 1, 1979 - 0 5
June 30, 1980
The State Board of Nursing 115 January 1, 1979 - 49
December 31, 1980
A s shown above, the Nursing Board has revoked or suspended the
license of a person named i n a complaint f a r more frequently than
the other health regulatory boards l i s t e d i n Table 10.
* Revocations ( 5) were f o r not practicing i n Arizona within 60
days of receiving a license by reciprocity. Suspensions ( 2)
were for misrepresentation, advertising and f a i l u r e t o r e g i s t e r
address with the county.
Lack of Knowledge as to What
Constitutes Incompetency
A surprisingly low percentage of the complaints received by the Board i n
1979 and 1980 were related to the competency of the licensee. Instead,
most of the complaints were drug- related. This condition is apparently
the r e s u l t of a lack of awareness on the part of the nursing community as
t o what constitutes incompetency on t h e p a r t of nurses and the Board's
r e s p o n s i b i l i t i e s regarding incompetent nurses.
Table 11 summarizes the nature of the complaints received by the Board
during 1979 and 1980.
TABLE 11
SUMMARY OF THE NATURE OF COMPLAINTS RECEIVED BY THE BOARD DURING
1979 AND 1980
Nature of Complaint Number Percentage
Drug- related
Unprofessional conduct
Competency
License expiration
Impostor
Other
A s shown above, a vast majority of the complaints against nurses are
drug- related, such as drug t h e f t o r drug abuse, whereas only six percent
are related to issues of competency. The reason f o r such a low percentage
of competency complaints appears to stem from a lack of knowledge on the
part of the nursing community regarding the Board end its rules and
regulations and a tendency on t h e p a r t of the nursing i n s t i t u t i o n s to
handle competency issues in- house.
During the course of our audit we interviewed eight d i r e c t o r s of nursing
for Arizona hospitals and nursirg homes regarding the Board and the
complaint process. A l l of the d i r e c t o r s said t h a t they report
drug- related complaints involving nurses t o the Board; however only one
s t a t e d t h a t she reports matters involving competency to the Board.
Of the e i ~ h td i r e c t o r s intemiewnd, four s t a t ~ dt h a t they ere une- uvorc of
the Board's j u r i s d i c t i o n i n the area of nursing competency. In addition,
one d i r e c t o r s t a t e d t h a t incompetency involved a general s k i l l level and
a s such did not pose a d i r e c t t h r e a t to the safety of t h e p a t i e n t .
Therefore, such matters were properly handled " in- house." According t o
these d i r e c t o r s , when a competency issue is handled in- house the
f a c i l i t y : 1) t r i e s to upgrade the nurse's s k i l l s ; 2) t r a n s f e r s the nurse
t o a d i f f e r e n t u n i t ; or 3) terminates the nurse with advice t o take extra
nursing courses. However, the f a c i l i t y does not usually contact the
Board. One d i r e c t o r of nursing offered the following explanation:
" There is a lack of education of what the Board does i n
t h i s area - people d o n ' t t h i n k of using the ~ o a r d . "
The nursing i n s t i t u t i o n s ' practice of handling competency issues in- house
and not f i l i n g complaints with the Board poses a threat to the public i n
t h a t an incompetent or even p o t e n t i a l l y dangerous nurse merely moves from
one i n s t i t u t i o n to another. Such movement from one i n s t i t u t i o n to another
is riot only possible f o r most nurses but very l i k e l y , given the shortage
of nurses i n Arizona. The following case i l l u s t r a t e s the point.
- Case
I n December 1980, a h o s p i t a l i n v e s t i g a t i n g committee found t h a t a nurse
had abused an adolescent patient i n November 1980. The nurse had pulled
the p a t i e n t ' s hair, squirted water i n h i s face and banged h i s head against
a counter, a brick wall, a door and a r e f r i g e r a t o r door. The committee
concluded t h a t while the abuse was i n t e n t i o n a l i n nature it was apparently
not done with the purpose of causing physical harm to the patient because
there was no r e s u l t a n t t i s s u e damage. According to the committee's f i n a l
r e p o r t , t h e nurse " exercised extremely poor judgment" and showed " a lack
of professionalism" on the evening of the incident. It was recommended
t h a t the nurse be terminated from employment a t t h e h o s p i t a l .
Comment
Although the nurse was terminated a t the h o s p i t a l , he subsequently found
employment a t another f a c i l i t y . Because the incident was not reported to
the Board of Nursing it was not able t o i n - ~ e s t i g a t e the incident and take
d i s c i p l i n a r y action.
Perhaps another reason why competency issues are frequently n o t reported
to the Board is a perception by nursing personnel t h a t competency is not
e s s e n t i a l f o r c e r t a i n types of nursing assignments and t h a t nurses
generally have a r e l a t i v e l y Low p r o f i l e as f a r as the public is
concerned. During our audit, a d i r e c t o r of nursing f o r a p r i v a t e h o s p i t a l
s t a t e d that:
" Competency cases are not sent t o the Board. The Board
of Nursing has never come out with a clear- cut policy
statement i n t h i s regard, so I don't send any, although
I have never had any ( nurses) so incompetent t h a t they
couldn't handle a nursing home." ( Emphasis added)
Further, when analyzing the complaints received by the Board during 1979
and 1980, we noted t h a t l e s s than f i v e percent were from the public. That
s t a t i s t i c , while not conclusive i n and of i t s e l f , c e r t a i n l y i n d i c a t e s t h a t
nurses have l e s s v i s i b i l i t y than other types of h e a l t h c a r e providers i n
an i n s t i t u t i o n a l s e t t i n g .
It should be noted t h a t the Board held two conferences, i n April 1980 and
September 1981, a t which d i s c i p l i n a r y procedures were discussed. Further,
the Board' s rules, which c l e a r l y define unprofessional conduct , are
available to licensees of the Board. However, it appears that the Board
needs t o take additional action, such as requiring reporting of Nursing
Practice Act violations i n its rules and regulations and mailing
n o t i f i c a t i o n s to licensees, t o increase nursing community awareness of the
Board's role i n competency issues.
Limited Disciplinary Options
A. R. S. $ 32- 1606, subsection B, paragraph 3, authorizes t h e Board t o
suspend, revoke or deny a license to a nurse. However, those are the only
options available t o the Board and a s such it has fewer d i s c i p l i n a r y
a l t e r n a t i v e s than most other Arizona health regulatory boards or nursing
boards i n other s t a t e s .
In an opinion dated July 27, 1981," t h e L e g i s l a t i v e Council described the
l i m i t s of the Board's d i s c i p l i n a r y options:
" The Board only has authority t o revoke or suspend the
license of an accused nurse who is found g u i l t y of any
of the actions s e t f o r t h i n A. R. S. $ 32- 1663,
subsection D. The Board does not have authority to
order a period of probation o r take o t h e r d i s c i p l i n a r y
action short of suspension or revocation of a
license...." . i .- . akrr
According t o the Council, the Board has more d i s c r e t i o n i n reissuing a
suspended o r revoked license under its Rule R4- 19- 45. Thus the Board can
order a period of supervised p r a c t i c e and/ or t h a t other conditions be met
before a reapplication f o r licensure is considered. Rule R4- 19- 45 s t a t e s
the following:
" A. A nurse whose license t o practice nursing has been
suspended f o r a period of time s h a l l automatically be
r e i n s t a t e d a t termination of the period of suspension
a s established by the Board i f t h e s t i p u l a t i o n s i n the
order have been met.
* See Appendix I11 f o r memorandum t e x t .
" B. A nurse whose license to practice nursing has been
denied or revoked, may make application t o the Board
a f t e r a period of two years f o r the issuance of a
denied license or reissuance of a revoked license under
the following terms and conditions:
" 1. An application s h a l l be submitted i n writing,
verified under oath, and s h a l l contain t h e r e i n o r have
attached thereto s u b s t a n t i a l evidence t h a t t h e b a s i s
f o r denial or revocation has been removed and that the
issuance of a license w i l l no longer c o n s t i t u t e a
t h r e a t to the public health or safety.
" 2. The Board s h a l l consider t h e a p p l i c a t i o n and may
designate a time f o r t h e a p p l i c a n t to appear a t a
regularly scheduled meeting of the Board so that
evidence of q u a l i f i c a t i o n and competency to practice
can be presented.
" 3. After reviewing the evidence and deliberating the
matter, the Board may grant the applicant a temporary
permit to practice f o r a time period specified, or the
Board may deny the application.
" 4. The Board may require that the applicant complete
a specified period of supervised practice. On
completion of the supervised practice period, the Board
w i l l consider the evaluation of the a p p l i c a n t ' s
performance. In narcotic cases, the Board may require
periodic psychological or psychiatric evaluations and
reports, u r i n a l y s i s and a f f i d a v i t s concerning narcotic
use. These conditions must be met before an
application is considered."
- .. .-
Thus, the Board can order a period of supervised practice ( probation), but
only a f t e r suspending or revoking a license."
The Board's d i s c i p l i n e r y o- - ions apgear t o be too r e s t r i c t i v e when
contrasted with other Arizona health regulatory boards. Table 12 compares
the Board's d i s c i p l i n a r y options with t h e o t h e r Arizona health regulatory
boards.
* It should be noted t h a t according to the Board's a s s i s t a n t Attorney
General, the Board can impose probation on a nurse named i n a
complaint, i f the nurse consents to such action.
TABLE 12
COMPARISON OF THE NURSING BOARD'S DISCIPLINARY OPTIONS
WITH THE OTHER ARIZONA HEALTH REGULATORY BOARDS
- Disciplinary Options
Deny Suspend Revoke Censure Reprimand Probation Fine Other
Nursing Board
Podiatry Examiners
Chiropractic Examiners
Dental Examiners
Medical Examiners
Naturopathic Examiners
Dispensing Opticians
Optometry
Osteopathic Examiners
Pharmacy
Physical Therapy Examiners
Psychologist Examiners
Veterinary Examiners
Medical Radiologic Technician Examiners
Homeopathic Examiners
Nursing Care I n s t i t u t i o n Examiners
Further, 25 o t h e r s t a t e s s t a t u t o r i l y provide t h e i r nursing boards with
e i t h e r a d d i t i o n a l options, such a s probation, reprimand and censure, o r
broad d i s c r e t i o n a r y a u t h o r i t y with regard t o d i s c i p l i n e .
F i n a l l y , Board members, s t a f f and o f f i c i a l s i n the nursing community
indicated a need f o r a broader range of Board d i s c i p l i n a r y options. For
example, the following comments were made:
" 1. I would l i k e t o see added: probation, reprimand,
censure.. . .
" 2. The Board should be given broader d i s c i p l i n a r y
options. .. but they should be spelled out.
" 3. There may be a need... for a probation option ....
" 4. The Board should be able t o place a nurse on
probation. "
CONCLUSION
While t h e Board has generally imposed s t r i c t d i s c i p l i n a r y p e n a l t i e s
a g a i n s t nurses named i n complaints, it appears t h a t the nursing community
is f r e q u e n t l y n o t f i l i n g complaints with the 2351' d vhen the i s s u e is one
of a n u r s e ' s competency. This absence of competency complaints apparently
stems from a lack of knowledge within the nursing community regarding the
Board and a tendency on the p a r t of nursing i n s t i t u t i o n s t o handle
competency i s s u e s in- house. F i n a l l y , the Board lacks d i s c i p l i n a r y options
when contrasted with other Arizona h e a l t h regulatory boards.
RECOMMENDATIONS
. - L C L b _ d s : ' c ~ b- v: i & L-, L,- " 5 L - -&- c - &.- AU L t C L ? L I ~ . ~ c ~ ~ ~ 6 ; ~ ~ i i S .
1. The Board n o t i f y l i c e n s e holders of the Board's r e s p o n s i b i l i t i e s
t o i n v e s t i g a t e and resolve i s s u e s involving competency.
2. The Board amend its r u l e s and r e g u l a t i o n s t o include f a i l u r e of a
l i c e n s e e t o report v i o l a t i o n s of the Nursing P r a c t i c e Act a s
unprofessional conduct.
3. A. R. S. $$ 32- 1606, subsection B, and 32- 1663, subsection D, be
amended t o provide the Board with a d d i t i o n a l d i s c i p l i n a r y options
such as probation, decree of censure and f i n e s .
FINDING I V
THE BOARD OF NURSING NEEDS TO REASSESS A NURSING PROGRAM TO WHICH I T
GRANTED FULL ACCREDITATION I N 1978.
The Board of Nursing is required by law to establish minimum standards for
schools of nursing, and to accredit and approve nursing programs which
meet the Board's requirements. A review of schools approved by the Board
revealed t h a t the Board should reassess a nursing program to which it
granted f u l l a c c r e d i t a t i o n i n 1978.
Board Authority To
A ~ ~ r o vNeur sing Schools
Arizona Revised S t a t u t e s $ 32- 1606 requires the Board to e s t a b l i s h minimum
standards for nursing schools and to accredit nursing programs:
" B. The Soard s h a l l :
" 1. Establish minimum curricula and standards for
schools of nursing and ccarsas praptiring persons
f o r licensing under t h i s chapter and provide f o r
surveys of schools and courses it deems necessary.
" 2. Accredit schools and approve coyxses meeting the -- requirements of t h i s chapter and of the board."
( ~ r n ~ h a saidsd ed)
When an i n s t i t u t i o n is considering a nursing program i t must apply to the
Board f o r i n i t i a l approval submitting a preliminary report of its plans.
Once i n i t i a l approval is granted a survey v i s i t is conducted by a s t a f f
member, and one or two consultants. Based on t h e i r report the Board w i l l
grant or deny provisional a c c r e d i t a t i o n .
A f t e r t h e program has graduated its f i r s t c l a s s , it becomes e l i g i b l e f o r
f u l l accreditation. Thereafter, the program is r e v i s i t e d a t l e a s t every
four years. If the report is s a t i s f a c t o r y , f u l l a c c r e d i t a t i o n is
continuous.
There are currently 11 p r a c t i c a l nurse programs, 14 Associate Degree
professional nurse programs and four Baccalaureate Degree professional
nurse programs."
One School Should
Be Reassessed
Our review of schools accredited by the Board of Nursing rerealed that the
Board accredited a nursing program i n 1978 t h a t may not meet a c c r e d i t a t i o n
standards established by the Board i n 1980. A s a r e s u l t , the Board should
reassess its a c c r e d i t a t i o n of the program. The following is a summary of
the program's h i s t o r y and a c c r e d i t a t i o n problems.
In June 1970, the Board of Nursing granted provisional a c c r e d i t a t i o n to
the school f o r an Associate Degree* nursing program. The school, located
on an Indian Reservation, planned to serve a majority of Native American
students and i n c r e a s e t h e number of trained nurses working i n the Indian
nation. The program graduated its f i r s t two students i n 1973.
* 2 .-
In 1975, the program was placed on conditional s t a t u s by the Board because
it lacked a d i r e c t o r and a s t a b l e faculty. The school suffered a high
turnover of f a c u l t y p a r t l y because of its remote location.
In 1976, additional concerns were raised about the school. These concerns
included: 1) poor c l i n i c a l f a c i l i t i e s ; 2) lack of ethnic culture content
i n the curriculum, with carryover t o c l i n i c a l experience; and 3) a high
f a i l u r e r a t e on the S t a t e Board Test Pool Examination ( sBTPE).
* The Associate Degree program is a two- year Registered Nurse ( RI?)
program.
In 1977, a survey v i s i t by the Board of Nursing revealed t h a t the
program's deficiencies had not been corrected, and i n 1978 a c c r e d i t a t i o n
was removed by the Board. However, a t a subsequent hearing requested by
the school, the Board changed its decision and suspended t h e s c h o o l ' s
a c c r e d i t a t i o n f o r seven months pending another survey v i s i t and the
r e s u l t s of the next s t a t e licensing examination.
A survey team r e v i s i t e d the school and found t h a t several improvements had
been made including a new basic curriculum, b e t t e r c l i n i c a l experience,
b e t t e r nursing program administration and b e t t e r faculty preparation. The
team recommended f u l l a c c r e d i t a t i o n , however, it found teaching
deficiencies, f a c u l t y i n s t a b i l i t y and a continuing high f a i l u r e r a t e on
the s t a t e examination. The team a l s o expressed concern regarding the
effectiveness of the new curriculum.
1978 Accreditation Standards
versus 1980 Accreditation Standards
The Board's a c c r e d i t a t i o n standards i n 1980, d i f f e r somewhat from its
standards i n 1978. A major difference between the two standards concerns
the passing requirement on the licensing examination. I n 1980, the Board
promulgated R4- 19- 14, subsection A, paragraph 9, which requires t h a t at
l e a s t 80 percent of the graduates of a nursing program, pass the s t a t e
licensing examination on t h e i r f i r s t writing i n order f o r the program to
obtain and maintain f u l l accreditation.
Rule R4- 19- 14, subsection A, paragraph 9 s t a t e s the following:
" State Board Test Pool Examination: The minimum
requirement is t h a t 80 percent of the f i r s t time
candidates writing i n t h i s S t a t e must achieve a passing
standard score determined by the board. The board may
consider additional documented s t a t i s t i c s concerning
the S t a t e Board Test Pool Examination scores received
i n other s t a t e s by Arizona graduates i n determining
compliance with t h i s requirement. A written warning
w i l l be sent to nursing program o f f i c i a l s when the
t o t a l number of f i r s t time candidates passing is a t or
below 80 percent. Subsequent to the warning and within
such time as it deems proper, the board w i l l require an
evaluation r e p o r t i d e n t i f y i n g f a c t o r s contributing to
the high f a i l u r e percentage and the corrective measures
t o be implemented. When information about any school
program indicates there has been a below 80 percent
passing r a t e of f i r s t time candidates on three
consecutive examinations, f u l l a c c r e d i t a t i o n s t a t u s
s h a l l be withdrawn and the program placed on
conditional a c c r e d i t a t i o n s t a t u s u n t i l the c r i t e r i o n is
met or f o r a maximum period of two years. I f the
c r i t e r i o n is not met within the designated time, the
program s h a l l be removed from the o f f i c i a l list of
accredited programs." ( Emphasis added)
By way of c o n t r a s t , i n 1978, the Board's rule governing t h e use of the
licensing examination as an a c c r e d i t a t i o n standard stated:
" R4- 19- 14. Evaluation
... the Board i n its evaluation of a program s h a l l use
a s one of its tools the r e s u l t s of S t a t e Board
Examination of candidates." ( ~ m ~ h a saidsd ed)
Further, the Board had a written policy, not a r u l e , which required the
following:
YA school who has a f a i l u r e r a t e of 20 percent or over
on i t h e ] S t a t e Board of Nursing Examination f o r three
consecutive examinations w i l l be placed on Conditional
Approval. The Board of Nursing w i l l request t h a t the
school evaluate the problem of f a i l u r e s and submit a
plan t o the Board as to how the problem might be
corrected." ( ~ m ~ h a saidsd ed)
Had the Board adhered s t r i c t l y t o the above policy, it would not have
accredited the subject nursing program because, from 1973 t o 1978, only
t h r e e of the s c h o o l ' s 19 graduates ( 16 percent) had passed the Registered
Nurse examination.
However, i n November 1978, the Board did grant f u l l a c c r e d i t a t i o n t o the
school because: 1 ) the ~ o a r d ' s a s s i s t a n t Attorney General advised them
t h a t t h e Board's d e n i a l of a c c r e d i t a t i o n based upon a w r i t t e n policy, not
a r u l e , would not withstand a l e g a l challenge;* and 2) the school
agreed: t o publish its s t a t e l i c e n s i n g examination passage r a t e i n the
school c a t a l o g , t o provide c e r t a i n a d d i t i o n a l information t o the Board,
and t o pledge continued cooperation t o improve its program.
CONCLUSION
The Board of Nursing is required by law t o e s t a b l i s h minimum standards f o r
schools of nursing. The Board should reassess one nursing program t o
which i t granted f u l l a c c r e d i t a t i o n i n 1978, because the school may not
s a t i s f y t h e a c c r e d i t a t i o n standards e s t a b l i s h e d by the Board i n 1980.
RECOMMENDATION
Consideration should be given t o the following recommendation:
- The Board of Nursing should reassess the a c c r e d i t a t i o n s t a t u s of
a nursing program t o which it granted f u l l a c c r e d i t a t i o n i n 1978.
* It should be noted t h a t p r i o r t o 1978 the Board had placed t h r e e
schools whose graduates had a f a i l u r e r a t e on the examination i n
e x c e s s o f 20 p e r c e n t on c o n d i t i o n a l a c c r e d i t a t i o n . One school
subsequently l o s t a c c r e d i t a t i o n f o r its r e g i s t e r e d nurse program i n
1977, because the f a i l u r e r a t e f o r its graduates remained i n excess of
2Q percent'
OTHER PERTINENT INFORMATION
During the course of our a u d i t , we reviewed the following additional
information pertaining t o the Board of Nursing.
Nurse P r a c t i t i o n e r s
I n 1980, the Board of Nursing c e r t i f i e d approximately 52 Nurse
Practitioners. Currently, there are 324 Certified Nurse
P r a c t i t i o n e r s i n Arizona with s i x types of c e r t i f i c a t i o n available
t o them and a seventh i n the r u l e adoption process. Nurse
P r a c t i t i o n e r s are Registered Nurses who, by v i r t u r e of additional
t r a i n i n g , have extended t h e i r r o l e i n t o s p e c i a l t y a r e a s a s
authorized by the Board of Nursing through its r u l e s and
regulations. Table 13 summarizes the number, type and geographic
location of the Nurse P r a c t i t i o n e r s c e r t i f i e d by the Board as of
July 1981.
TABLE 13
SUMMARY OF THE NUMBER, TYPE AND GEOGRAPHIC LOCATION OF
THE NURSE PRACTITIONERS CERTIFIED BY THE BOARD AS OF JULY 1981
Type of C e r t i f i c a t i o n .-
Nurse
Midwife P e d i a t r i c Family Adult 0b/ Gyn Neo Natal Total
Arizona:
Apache County 10
b Coconino County
Cochise County
Graham County
Greenlee County
Maricopa County 16
Mohave County
Gila County
Navajo County 1
Pima County 10
P i m l Ccuntg
Santa Cruz County
Yavapai County
B Y- aa County
Out- of- State - 1
Total 22
A study conducted by the American Nurses' Association suggests t h a t the
c e r t i f i c a t i o n of Nurse P r a c t i t i o n e r s may not be a proper area f o r s t a t e
regulation. The study distinguishes between s t a t e licensure and
c e r t i f i c a t i o n by nongovernmental agencies or associations:
" Licensure
" Licensure is a process by which an agency of s t a t e
government grants permission to individuals accountable
f o r t h e p r a c t i c e of a profession t o engage i n the
practice of t h a t profession and prohibits a l l others from
l e g a l l y doing so. It permits use of a p a r t i c u l a r t i t l e .
Its purpose is t o protect the public by ensuring a
minimum level of ~ r o f e s s i o n a l com~ etence. Established & A
standards and methods of evaluation are used to determine
e l i g i b i l i t y for i n i t i a l licensure and f o r periodic
renewal. Effective means are employed f o r taking action
against licensees f o r a c t s of professional misconduct,
incompetence, and/ or negligence.
" C e r t i f i c a t i o n
" C e r t i f i c a t i o n is a process by which a non- governmental
agency or association c e r t i f i e s that an individual
licensed t o practice a profession has met c e r t a i n
predetermined standards specified by t h a t profession for
specialty practice. Its purpose is t a assure various
publics t h a t an individual has mastered a body of
knowledge and acquired s k i l l s i n a p a r t i c u l a r
specialty." ( Emphasis added)
C e r t i f i c a t i o n of nurse p r a c t i t i o n e r s is authorized by A . R. S.
$ 32- 1601( 5) ( e) :
" The performance of such additional a c t s under
emergency o r other conditions requiring education and
training and which are recognized by the medical and
nursing professions as proper to be performed by a
professional nurse under such conditions and which are
authorized by the board of nursing i n collaboration
with t h e j o i n t board of medical examiners and
osteopathic examiners i n medicine and surgery through
its r u l e s and regulations ...."
A r t i c l e V of the Board's Rules and Regulations on extended nursing
p r a c t i c e define c r i t e r i a f o r e s t a b l i s h i n g nurse p r a c t i t i o n e r courses of
study, educational requirements f o r c e r t i f i c a t i o n , s p e c i a l t y a r e a s i n
which c e r t i f i c a t i o n may be granted, and circumstances under which drugs
may be dispensed.
The Manpower Study
I n June of 1981, four public meetings were held throughout Arizona,
sponsored by various Arizona h e a l t h agencies, t o d i s c u s s the findings and
recommendations of a study done by Eastwest Research Associates,
Incorporated, under the guidance of the Nursing Manpower Project Advisory
Council-
The s t u d y ' s g o a l s were:
" 1. To determine the current supply of and demand f o r
nurses i n Arizona, and
" 2. To suggest a s e r i e s of policy recommendations t o
meet f u t u r e requirements."
With regard t o the S t a t e ' s n u r s i n g s h o r t a g e , the s t u d y r e p o r t e d :
" The e x t e n t of Arizona's c u r r e n t pzofessional nurse
shortage is estimated t o be 1,272 f u l l - t i m e equivalent
p o s i t i o n s , or about 8.3 percent of the c u r r e n t supply
of nurses. About 60 percent of these p o s i t i o n s a r e
required by h o s p i t a l s , 14 percent by nursing homes, 13
percent by physicians, and the remainder by other types
of employers."
The following recommendations, some of which p e r t a i n t o the Board of
Nursing, were made by the Manpower P r o j e c t t o address the shortage of
nurses i n Arizona:
" 1. C r e a t i o n o f a s t a t e w i d e c o u n c i l o f n u r s i n g i n
Arizona.
" 2. Implement changes i n recruitment, r e t e n t i o n ,
u t i l i z a t i o n and work environment f o r nurses i n
Arizona:
a. That Arizona nurses' associations and
organizations including the Arizona S t a t e
Board of Nursing:
1) Collaborate i n developing and
implementing s t r a t e g i e s for the
recruitment and retention of students
and nurses i n both educational and
employment s e t t i n g s .
2) Continue t o include nurses on councils,
boards, committees, task forces, and
advisory bodies which are charged to
plan, organize, and implement health
care services.
" 3. Expand what the public knows of and expects from
professional nurses :
a. That Arizona nurses' associations and
organizations including the Arizona S t a t e
Board of Nursing collaborate i n a long- term
e f f o r t t o inform the public of nursing as a
profession and how t h e p r a c t i c e of nursing
impacts upon t h e d e l i v e r y of health care.
" 4. That the Arizona Board of Regents improve the
a r t i c u l a t i o n between LPN, diploma, ADM and BSN
nursing programs i n Arizona:
" 5. That the Arizona State Board of Nursing im~ rove
Arizona's a b i l i t y t o plan f o r meeting its health
care needs:
a. Improve the a v a i l a b i l i t y of data which
r e f l - e ~ t ;~~ y- rsi.+ r: c - r - ~ n*., l - -~ . - ? ~ - r r - ~ ~ f l j ? - mC.- ..- e
t h a t data is available inc a manner which .-
permits ongoing planning f o r nursing manpower.
b. Enhance the compatibility of Arizona RN and
LPN data to allow the exchange of information
( with emerging s t a t e and regional data
collection systems) as appropriate.
c- Compile annual data from Arizona schools of
nursing on the number of applicants,
admissions and graduates t o f a c i l i t a t e
planning f o r Arizona nursing manpower.""
* See Appendix I V f o r f u l l t e x t .
Foreign Nurses
Most foreign nurses applying f o r licenses t o practice i n the United S t a t e s
have experienced d i f f i c u l t y passing s t a t e examinations. In Arizona, only
24 percent of the 348 foreign nurses who applied f o r a registered nursing
license between 1978 and 1980 passed the s t a t e board examination a t t h e i r
f i r s t writing. Nursing Board s t a f f a t t r i b u t e the high f a i l u r e r a t e of
foreign nurses to: 1) an i n a b i l i t y t o read and comprehend English
adequately, 2) differences i n nursing terminology i n the U. S., and
3) use of a " multiple choice" t e s t i n g format unfamiliar to foreign nurses."
According to an o f f i c i a l of the American Nurses' Association, nurses who
f a i l registered nursing examinations i n the U. S. often s u f f e r personal
hardships and can be exploited by employers. For example, some
foreign- trained nurses unable to qualify f o r a U. S. license have t o work
as nurses aids, which are nonprofessional positions paying lower wages.
I n some cases, however, these nurses may still be required to perform
professional nursing functions. Other foreign nurses who f a i l the RN exam
reapply f o r LPN licenses and accept lower paying p r a c t i c a l nursing
positions. A few nurses who f a i l s t a t e licensing examinations face
deportation.
To address t h i s problem, the Commission on Graduates of Foreign Nursing
Schools ( CGFNS) has developed an examination, given i n English i- ious
countries around the world, which h e l p s f o r e i g n nurses prepare f o r
licensing examinations in the U. S, The examination t e s t s English
comprehension and nursing knowledge, and i d e n t i f i e s deficiencies needing
additional work. Nurses who pass the examination are issued a c e r t i f i c a t e
by the Commission.
* Foreign nursing examinations are i n essay form.
49
Currently, foreign nurses are required to hold the CGFNS c e r t i f i c a t e to be
e l i g i b l e for: 1) a Federal Immigration and Naturalization Service
nonimmigrant occupational preference visa, and 2) Federal Department of
Labor occupational preference visa and work permit available to immigrants
entering the U. S.
In addition, a survey by the Commission on Graduates of Foreign Nursing
Schools found t h a t 25 s t a t e s require foreign nurses to hold the CGFNS
c e r t i f i c a t e prior t o taking the s t a t e licensing examination. Most foreign
nurses ( about 78 percent) holding the c e r t i f i c a t e successfully pass
licensing examinations given i n the U. S.
1645 W. JEFFERSON, SUITE 254
PHOENIX, ARIZONA 85007
PHONE 255- 5092
December 10, 1981
Douglas R. Norton
Auditor General
S t a t e of Arizona
Phoenix, Arizona 85007
Dear M r . Norton:
The attached r e p o r t r e p r e s e n t s the response of the Arizona S t a t e Board
of Nursing to the performance a u d i t conducted by your Sunset Review
Team.
I f any questions should a r i s e , please f e e l f r e e t o contact me.
Sincerely,
Sally A. Lewis, MPH, RN
President
cc: Gerald S i l v a , Performance Audit Manager
-' - CFZ.
I n t r o d u c t i o n
The Arizona Board of Nursing wishes to thank the Auditor General's Sunset
Review Team for t h e i r cooperation i n reviewing and reporting of t h i s Board's
a c t i v i t i e s .
Since the Board considers its primary r e s p o n s i b i l i t y t o be t h a t of p r o t e c t i n g
the public, it is pleased t o read i n t h i s report t h a t the Board has " revoked
or suspended the l i c e n s e of a person named i n a complaint f a r more frequently
than the other h e a l t h regulatory boards l i s t e d . " In a d d i t i o n , the Board ap-p
r e c i a t e s t h e Auditor General's acknowledgement t h a t the Board has operated a
within t h e p u b l i c i n t e r e s t i n its complaint i n v e s t i g a t i o n and l i c e n s u r e process;
t h a t it has operated e f f i c i e n t l y ; and t h a t " public awareness of the Nursing Board
is g r e a t e r than awareness of most other h e a l t h regulatory boards . . . . I 1
Further, the Board is i n agreement with a l l of the recommendations of the Review
Team and has already made some procedural changes i n addition t o supporting the a
recommended l e g i s l a t i v e changes.
Recommended L e g i s l a t i o n
The Sunset Review r e p o r t recommends the L e g i s l a t u r e consider the following amend-ments
t o the Board of Nursing's s t a t u t e s : @
1. To grant the Board a u t h o r i t y t o s e t the p a s s i n g s c o r e on its w r i t t e n
examinations through its r u l e s and r e g u l a t i o n s .
Comment: The Board agrees with the recommendation. This change w i l l
give the Board the f l e x i b i l i t y t o e s t a b l i s h the passing score based
upon the rec~ mmendations of the National ~ % u n c i l of S t a t e ~ oa- f ( I
Nursing to allow f o r t h e f r e e movement of nurses between the s t a t e s .
For example, the s t a t e boards of nursing a r e adopting a comprehensive
n a t i o n a l l i c e n s i n g examination i n July 1982 which w i l l n e c e s s i t a t e the
establishment of a new passing score which is considered t o be necessary
f o r s a f e nursing p r a c t i c e . The Board plans t o adopt the score which is
c o n s i s t e n t w i t h the scores adopted by the majority of other s t a t e s so •
t h a t l i c e n s u r e of nurses i n Arizona who graduate from programs i n other
s t a t e s w i l l be f a c i l i t a t e d .
In addition s i n c e t h e r e has been no evidence t h a t public s a f e t y has been
jeopardized by accepting the standard score of 350, which was equated
t o the 70% passing score i n the Board's Rules and Regulations of 1964, ( I
the Board agrees t h a t t h e v a l i d i t y of l i c e n s e s issued p r i o r to a r e v i s i o n
i n the law be recognized.
2. To add two a c t i v e l y p r a c t i c i n g LPNs t o the Board and to eliminate the
p r a c t i c a l nurse committee.
Comment: The Board recognizes t h a t t h e e f f i c i e n c y of carrying out i t s
r e s p o n s i b i l i t i e s would be enhanced by eliminating the p r a c t i c a l nurse
committee and including two a c t i v e l y p r a c t i c i n g LPNs t o f u l l Board member-ship.
The Board and t h e P r a c t i c a l Nurse Committee a r e i n agreement with
5 2 0
Page 2
t h i s change i n t h e Board's composition. The Board has requested the
L e g i s l a t i v e Council t o d r a f t language t o implement the change.
3. To include f a i l u r e of a l i c e n s e e t o r e p o r t v i o l a t i o n s of the Nursing
P r a c t i c e Act as u n p r o f e s s i o n a l conduct i n its r u l e s and regulations.
- C-- o mment: The Board is concerned t h a t r e l a t i v e l y few complaints a r e
submitted r e l a t i n g t o incompetency i n c o n t r a s t t o thc number of com-p
l a i n t s o f drug and a l c o h o l a b u s e . I n September 1981, t h e Board
i n v i t e d the nursing a d m i n i s t r a t o r s of all h o s p i t a l s i n Arizona t o
d i s c u s s the r o l e and r e s p o n s i b i l i t i e s of the Board as w e l l a s the
employer's r e s p o n s i b i l i t y t o r e p o r t u n s a f e n u r s i n g p r a c t i c e . More
than s i x t y nursing a d m i n i s t r a t o r s were i n a t t e n d a n c e . Since t h a t
time, t h e Board has received and is i n v e s t i g a t i n g a t I e a s t four corn-p
l a i n t s r e l a t i n g s p e c i f i c a l l y t o incompetent n u r s i n g p r a c t i c e .
I n a d d i t i o n , the Board has i n c r e a s e d its e f f o r t s t o d i s s e m i n a t e i n f o r -
11iation t o its l i c e n s e e s a s w e l l a s employers of n u r s e s r e l a t i n g t o
i n competency and u n s a f e n u r s i n g p r a c t i c e by p r o v i d i n g c o p i e s of the
law and r u l e s and r e g u l a t i o n s t o anyone c a l l i n g the o f f i c e f o r i n f o r -
mation, by speaking t o and o f f e r i n g t o speak t o new employees during
o r i e n t a t i o n , RNs e n r o l l e d i n r e f r e s h e r courses, and o t h e r nursing
o r g a n i z a t i o n s . The Board is p l a n n i n g a s t a t e w i d e conference on t h e
Nurse P r a c t i c e Act w i t h i n the next year and p l a n s t o do t h i s on an
annual b a s i s .
4. To provide t h e Board w i t h a d d i t i o n a l d i s c i p l i n a r y o p t i o n s such as
p r o b a t i o n , d e c r e e of censure and f i n e s .
- Co- mm ent: The Board f e e l s t h z t t h e d i s c i p l i n a r y a c t i o n it has taken
has been a p p r o p r i a t e . A d d i t i o n a l d i s c i p l i n a r y o p t i o n s w i l l provide t h e
Board with more f l e x i b i l i t y i n c a r r y i n g out its r e s p o n s i b i l i t i e s .
* *--. -- Recommended- - P rocedural Improvement:
The Sunset Audit Review r e p o r t recommended t h a t t h e Board should r e a s s e s s t h e
a c c r e d i t a t i o n s t a t u s of a n u r s i n g program t o which it granted f u l l a c c r e d i t a t i o n
i n 1978.
Comment: The Board has continued t o assess t h i s s c h o o l ' s n u r s i n g
program a s it does a l l nursing programs t o determine whether they
continue t o meet t h e s t a n t i a r d s f o r a c c r e d i t a t i o n . The Board a s s e s s e d
t h e progress of t h e Associate Degree nursing program r e f e r r e d t o i n t h e
r e p o r t s i n c e 1978 at t h e following Board meetings:
1/ 12/ 79 The Board reviewed t h e p r o g r e s s r e p o r t submitted and
noted t h a t t h e f a c u l t y provided a review s e s s i o n t o
prepare its graduates f o r t h e February S t a t e Board
L i c e n s i n g e x a m i n a t i o n ; t h a t t h e s k i l l s l a b o r a t o r y
u t i l i z a t i o n had i n c r e a s e d ; t h a t a f a c u l t y workshop on
s t u d e n t e v a l u a t i o n and f a c u l t y dt~ velopment was planned;
and t h a t t h e l i c e n s i n g exam s c o r e s would bc p r i n t e d i n
t h e school c a t a l o g a s had been agreed upon.
3/ 1/ 79 The Board reviewed and accepted t h e p r o g r e s s r e p o r t submitted
i n compliance with the requirements e s t a b l i s h e d when the school
was granted f u l l a c c r e d i t a t i o n i n November 1978. The r e p o r t
included t h e s c h o o l ' s plans f o r t h e e s t a b l i s h m e n t of a Task
Force t o s t u d y r e a s o n s f o r the high f a i l u r e r a t e on the l i c e n s i n g a
exam and t h a t the f a c u l t y was making s p e c i a l e f f o r t s t o s e e t h a t
t h e o b j e c t i v e s of the curriculum were f u l l y met.
5/ 25/ 79 The Board received a s c h o o l c a t a l o g which included t h e requirement
t h a t t h e r e s u l t s of t h e number of graduates w r i t i n g and passing
the s t a t e l i c e n s i n g exam be p u b l i s h e d .
1/ 3/ 80 The Board requested t h e presence of r e p r e s e n t a t i v e s from t h e
program appear i n person t o p r e s e n t a p r o g r e s s r e p o r t . The
Hoard approved t h e r e q u e s t t o d e l e t e i n f o r m a t i o n r e g a r d i n g
state l i c e n s i n g exain r e s u l t s from c a t a l o g because of the
n e g a t i v e e f f e c t on r e c r u i t i n g new s t u d e n t s and on graduates
of t h e program.
( I
9/ 12/ 80 The Board was advised of t h e a d d i t i o n of another q u a l i f i e d f a c u l t y
member.
11/ 14/ 80 The Board approved t h e r e q u e s t t o extend t h e program from two
t o t h r e e y e a r s with m u l t i p l e e x i t c r e d e n t i a l i n g . Extension
a
of the program would give t h e s t u d e n t s more time f o r completion
of t h e g e n e r a l e d u c a t i o n c o u r s e s thus provide s t u d e n t s an optimum
environment f o r s u c c e s s f u l completion of o b j e c t i v e s , reduce the
high a t t r i t i o n r a t e , and i n c r e a s e t h e s t u d e n t ' s chance of success
on t h e s t a t e l i c e n s i n g examination. a
1/ 16/ 81 The Board accepted the annual r e p o r t submitted by the school.
9/ 2/ 81 The Board t a b l e d t h e r e q u e s t t o approve two new c l i n i c a l f a c i l i t i e s
u n t i l a f t e r t h e f u l l o n - s i t e survey v i s i t t o be conducted i n 1982.
F i n a l l y t h e Board has noted t h a t p r o g r e s s i n maintaining t h e c r i t e r i a f o r f u l l
10
z c r e d i t a t i o n has been enhanced by t h e l e a d e r s h i p of t h e c u r r e n t d i r e c t o r of t h e
n u r s i n g program who was h i r e d i n August 1978.
In summary, the Board a s s t a t e d e a r l i e r c o n s i d e r s its primary r e s p o n s i b i l i t y t o be
t h a t of p r o t e c t i n g t h e p u b l i c and t h u s has worked d i l i g e n t l y t o c a r r y out t h a t a
r e s p o n s i b i l i t y . The Board w i l l continue t o o b j e c t i v e l y c a r r y out its mandate.
The Board f e e l s t h a t the recommendations of the Sunset Audit Review Team c o n t r i b u t e
t o t h a t goal.
July 1, 1981
TO: Douglas R. Norton
Auditor General
FROM: Arizona Legislative Council
RE: Request for Research and Statutory Interpretation ( 0- 81- 56)
This is in response to a request submitted on your behalf by Gerald A.
Silva in a memo dated June 8, 1981. No input was received from the attorney
general concerning this request.
FACT SlTUATION:
Arizona Revised Statutes ( A. R. S.) sections 32- 1633 and 32- 1638, subsection
A s t a t e "/ a/ n applicant shall be required t o pass, with a grade of seventy per
cent or more, a written examination. . . ."
The state board of nursing ( board) administers a national examination and accepts
350 " points" on the examination as a passing score. Documents at the board s t a t e
that this point score can be obtained by correctly answering 54 t o 65 percent of
the questions on the registered nurse examination, and 61 t o 65 percent of the
questions on the practical nurse examination.
QUESTIONS PRESENTED:
1. Is the board in c~ mpliance with A. R. S. sections 32- 1633 and 32- 1638,
subsection A if i t accepts 350 points as a passing score?
2 If it is not, what are the ramifications t o the license holder and to
the board?
ANSWERS:
1. No.
2. See discussion,
1. One of the fundamental rules of statutory construction is that plain,
clear and unambiguous language is to be given t h a t meaning unless impossible or
absurd consequences may result. Balestrieri v. Hartford Accident and Indemnit
Insurance Co., 112 Ariz. 160 ( 1975). Assuming that each question on th:
examination is given equal weight, i t is obvious that correctly answering 65% of
the questions to obtain a point score of 350 is not the equivalent of the
statutory requirement of a 70% grade.
The powers and activities of an administrative agency are prescribed and
measured by law. Swift & Co. v. S t a t e Tax Commission, 105 Ariz. 226 ( 1969);
Kendall v. Malcolm, 98 Ariz. 329 ( 1965). Although a national examination may
provide convenience for the examinee, facilitate administration and promote
uniformity among the s t a t e s , these goals are irrelevant when in conflict with the
statutory requirement. The examination must be administered in such a way as to ( I
require a passing grade of 70% or more.
It should be noted t h a t t h e board may i n its discretion, administer an oral
or practical examination in addition t o the written test. A. R. S. sections
32- 1633 and 32- 1638, subsection A. Even in such a case, t h e s t a t u t e s still
require a grade of 70% on the written portion.
2 A license issued by the board under color of law authorizes the nurse
to practice until notified of a defect or illegality in the issuance of the
license or until the license is revoked. The board has the authority t o revoke a
license for any reason t h a t would have justified a refusal t o issue the license
initially. A. R. S. section 32- 1606; 53 C. J. S. Licenses section 44 ( 1948).
CONCLUSION:
1. The examination must be administered so as to require a passing grade
of 70% or more. Assuming each question is of equal weight, a point score of 350
does not meet the requirement of a 70% grade.
2. A licensee may continue t o practice nursing until the license i s
revoked or notice is given of a defect or illegality in issuing the license. The
board may revoke a license for any reason that would have justified a refusal to
issue the license initially, including the failure - t. o achieve a passing examination grade. *- il
cc: Gerald A. Siiva
Performance Audit Manager
APPENDIX I1
LEGISLATIVE COUNCIL OPINION
0- 81- 67
JULY 23, 1981
M E M O July 23, 1981
TO: Douglas R. Norton
Auditor General
FROM: Arizona Legislative Council
RE: Request for Research and Statutory Interpretation ( 0- 8 1- 67)
This is in response to a request submitted on your behalf by Gerald A. Silva in a
memo dated July 10, 198 1. No input was received from the Attorney General concerning
this request.
FACT SITUATION:
Arizona Revised Statutes ( A. R. S.) section 32- 1602, subsection A provides for a
State Board of Nursing ( Board) consisting of seven members. A majority of the Board
constitutes a quorum pursuant t o A. R. S. section 32- 1605, subsection B.
Arizona law also provides for a five member Practical Nurse Committee
( Committee) to advise the Board on matters pertaining t o practical nursing. A. R. S.
section 32- 1607, subsection D states that:
The committee shall assist, consult and advise the board with respect t o
practical nursing matters and- with respect t o examination and licensing of
persons applying for a license to practice and assume the title of practical
nurse. Action as to such matters shall be taken only upon a majority vote of
the combined membership of the practical nurse committee and the board.
The practical nurse committee shall meet with the board at least annually.
*-
On a few occasions, the Board has met with only three Board members z n t .
One such meeting was a combined meeting with five members of the Committee. At this
meeting, according t o Board minutes, a motion was made by a Committee member t o
approve registered nurse ( RN) licenses granted by endorsement. In addition, i t was noted
that, at other combined meetings, Committee members seconded motions and apparently
voted on matters which involved both registered nurses and licensed practical nurses.
QUESTIONS PRESENTED:
1. Does the presence of three Board members and five Committee members
p- ,-, < - ; + , T + 2~ . L I qrclrum fc- ccnd: rctjng ! x! siness at a combined meeting of the Board and the
Committee?
2. Is it proper for Committee members to make motions, second motions or vote
on matters which may involve registered nurses or both registered nurses and practical
nurses?
3. What are the ramifications for the Board, if a quorum is not present at a
combined Board- Committee meeting?
4
4. What are the ramifications if it is not proper for Committee members to make
motions, second motions or vote on matters which involved registered nurses?
ANSWERS:
I. " Board" means the state board of nursing, and when used in
connection with matters pertaining only to practical nurses or practical
nursing, means the combined membership of t h e s t a t e board of nursing and
the practical nurse committee provided for by this chapter. A. R. S. section
32- 1601, paragraph 2.
The combined Board- Committee has twelve members, seven members from the Board and ( I
five members from the Committee.
A. R. S. section 1- 216, subsection B provides that " m majority of a board or
commission shall constitute a quorum," A majority of the Tom bined Board- Committee
would be seven members. Eight members of the total of twelve members of the combined
Board- Committee were present at the meeting described in t h e f a c t situation. A
majority of the members was present. The three Board members and five Committee
members present at t h a t meeting constituted a quorum of the combined
Board- Committee. It should be emphasized that the presence of the above mentioned
members only constitutes a quorum for conducting business concerning practical nursing
matters.
It should also be noted that, even though a quorum may have been present at the
meeting, A. R. S. section 32- 1607, subsection D requires a majority vote of the combined
membership before any action may be taken. A majority vote of the total membership
rather than a majority vote of the quorum present is required for an action of the
combined Board- Committee to be val- i d. A. R. S. section 32- 1607, subsection D.
2. Administrative agencies have no common law or inherent powers. Their powers
a r e t o be measured by the statutes under which they operate. Kendall v. Malcolm, 98
Ariz. 329, 404 P. 2d 41 4 ( 1 965). A. R. S. section 32- 1607, subsection D provides in relevant
part as follows:
/ T h e committee shall assist, consult and advise the board with
respect? o practical nursing matters- and with respect t o examination and
licensing of persons applying for a license t o practice and assume the title
of practical nurse. ( Emphasis added.)
Committee members only have authority t o participate in actions concerning practical
nursing matters.
The a u t b r i t y of t h e committee members does not extend to matters concerning
registered nurses. The Board is responsible for registered nursing matters and the
combined Board- Committee is responsible for practical nursing matters. It would be
improper for Committee members to make motions, second motions or vote on registered
nursing matters or matters involving registered nurses and practical nurses.
3. As discussed in Answer 1, the three Board members and the five Committee
members constitute a quorum of the combined Board- Committee for conducting business
concerning practical nursing matters. If the voting requirements of A. R. S. section
32- 1607, subsection D are satisfied the actions on practical nursing matters taken by that
group are valid.
Actions taken on registered nursing matters with only three members of the Board
present are void. It does not matter whether the actions were taken at a meeting of the
combined Board- Committee or not. Registered nursing matters a r e t o be considered by
the Board. The presence of a quorum of the Board i s necessary to act on such matters.
There a r e seven members on the Board. A. R. S. section 32- 1602, subsection A.
A. R. S. section 32- 1605, subsection B provides t h a t "/;? 7 majority of the board, including
one officer, shall constitute a quorum." A majority o F t h e Board would be four members.
Three members do not constitute a quorum of the Board.
The requirement that a quorum be present is jurisdictional and may not be
waived and the action of less than a quorum is void. 73 C. J. S. Public
Administrative Bodies and Procedures section 21 ( 1951).
When an action is " void1 it is v/ Jull; ineffectual; nugatory; having no legal force or
binding effect; unable, in law, t o support the purpose for which i t was intended." Black's
Law Dictionary 141 I ( 5th ed. 1 979).
4. Committee members have no authority t o make motions, second motions or
vote on matters involving registered nurses. Only Board members can validly make
motions, second motions or vote on registered nursing matters. A motion or vote by a
Committee member on a registered nursing matter might invalidate the action of the
board because they are not members of the Board for that purpose. Determination of
whether or not the action taken is invalid should be on a case- by- case basis.
The more important consideration in the f a c t situation presented is that three
Board members do not constitute- a quorum. Since the quorum requirement is
jurisdictional any action of less than a quorum is void.
CONCLUSIONS:
1. The presence of three Board members and five Committee members constitutes
a quorum for conducting business concerning practical nursing matters at a combined
Board- Committee meeting.
2. Committee members do not have authority t o make motions, second motions or
vote on matters which may involve registered nurses or registered nurses and practical
nurses.
3. The presence of three members of the Board does not constitute a quorum and
any actions taken by less than a quorum a r e void.
4. A motion or vote by a Committee rnember on a registered nursing matter might
invalidate the action of the Board. Determination of whether o r not the action taken i s
invalid should be on a case- by- case basis.
cc GeraldA. Silva
Performance Audit Manager
APPENDIX 111
LEGISLATIVE COUNCIL OPINION
0- 81- 68
JULY 27, 1981
M E M O July 27, 1981
TO: Douglas R. Norton
Auditor General
FROM: Arizona Legislative Council
RE: Request for Research and Statutory Interpretation ( 0- 81 - 68)
This is in response to a request submitted on your behalf by Gerald A. Silva in a
memo dated July 10, 1981. No input was received from the Attorney General concerning
this request.
FACT SITUATION:
Arizona Revised Statutes ( A. R. S.) section 32- 1664 requests the Board of Nursing
( Board) t o investigate sworn complaints filed with the Board:
A. Upon the filing with the board of a sworn complaint charging a
licensee with any conduct specified in section 32- 1663, subsection D, the
board shall conduct an investigation thereof . . . .
If the compIaint appears to be substantiated, the Board is required to hold a
hearing and issue t o the accused a notice which includes a copy of the sworn complaint.
A. R. S. section 32- 1664, subsection B states:
B. If the investigation in the opinion of the board reveals reasonable
grounds to support the charge the board shall appoint a time and place for
hearing t h e m a t t e r and shall cause notice thereof, together with a copy of
the sworn complaint, to be served on the accused personally at least twenty
days prior t o the time fixed for the hearing.. . .
Following a hearing, the Board may revoke or suspend the nurse's license pursuant
t o A. R. S. section 32- 1663, subsection D and A. R. S. section 32- 1664, subsection F.
The Auditor General's audit found that 1) the Board has investigated some
allegations which were not filed with the Board as sworn cornplaints 2) the Board has filed
its own sworn complaint, and 3) sworn complaints, filed by either the complainant or the
Board, a r e not always included in the notice of hearing presented t o the nurse involved in
- L the corn~ la- int,
In addition, the Board has ordered t h a t some nurses, in addition t o being suspended,
serve a period of probation and fulfill other requirements such as participating in a drug
treatment program or reporting perisdically t o the Board.
* Subsequent i n v e s t i g a t i o n found t h a t the above statement of condition was
not f a c t u a l .
QUESTIONS PRESENTED:
1. Does the Board have the authority t o investigate allegations which a r e not
originally filed as sworn complaints?
2. If not, what are the ramifications to the Board and the license holder if such
investigations have been undertaken?
3. Is the Board required t o include a sworn complaint in its notice of hearing
served on an accused nurse, or does the inclusion of the facts in the hearing notice 0
constitute fulfillment of the statutory requirements?
4. If required, what are the ramifications t o the Board and license holder if notices
do not include a sworn complaint?
5. Does the Board have authority t o order a period of probation, or take other
disciplinary action short of suspension or revocation of a license? Does the Board have
the authority t o order a period of probation following a period of suspension?
6. If not, what are the ramifications t o the Board and license holder if such
disciplinary action has been taken?
ANSWERS:
1. A. R. S. section 32- 1606, subsection B, paragraph 3 provides that the Board shall:
mxamine, license and renew the licenses of duly qualified applicants, and
c o d u c t hearings upon charges calling for suspension or revocation of a
license or accreditation of schools of nursing, as provided in this chapter,
and for proper cause may deny, suspend or revoke licenses or accreditation
of schools of nursing. ( Emphasis added.)
" Where a s t a t u t e confers powers or duties i n general terms, all powers and
duties incidental and necessary t o make such legfslation effective at?
included by implication." Sutherland, Statutes and Statutory Construction
section 55.04 ( 4th ed., Sands, 1972).
The purpose of the various statutes regulating the practice of medicine in its
different branches is to protect the public aminst those who are not properly qualified t o
engage in the practice of medicine.' - B ztt. y- --. --- .; Ariz--- o-- na State Dental Board, 57.~ 1- iz. 2 39,
1 12 P. 2d 870 ( I 94 I). The power t o invesagate ailegations is incidental and necessary for
the Board t o be able to deny, suspend o r revoke- licenses and protect the public from
unqualified nurses. The Board has the implied power to investigate allegations before it
makes a formal charge in a sworn complaint. A sworn complaint is necessary, however,
before an accused nurse is served with notice of a hearing. A. R. S. section 32- 1664,
subsection B. ( See answer 3.)
A. R. S. section 32- 1664, subsection A does not limit the power to investigate
allegations to cases in which a sworn complaint has been filed with the Board. Nor does
this section prohibit the Board from filing sworn complaints. A. R. S. section 32- 1664,
subsection A simply provides that the Board is required t o investigate sworn complaints
charging a licensee with any conduct specified in A. R. S. section 32- 1663, subsection D
that are filed with the Board.
2. See answer 1.
3. A. R. S. section 32- 1664, subsection B provides that:
If the investi~ ationi n the opinion of the board reveals reasonable grounds
to support the ; barge the b& rd shall appoint a time and place for rhearing
t h e m a t t e r and shall cause notice thereof, together with a copy of the sworn
complaint, to be served on the accused personally at least twenty days prior
t o t h e time fixed for the hearing. ( Emphasis added.)
The use of the word " shall" i n t h e above subsection imposes a mandatory directive
on the Board to cause a copy of the sworn complaint to be served with the notice on the
@ accused. It is an elementary principle of statutory construction that each word in a
statute will be given effect. Sutherland. Statutes and Statutorv Construction section
46.06 ( 4th ed., ~& ds, 1972); S t a t e v. ~ u ~ e ' r i ocro u r t for ~ a r i c o ~ a ~ ~ o1u13n Atr~ iz,. 248,
550 P. 2d 626 ( 1976). The words of a statute are to be given their common meaning unless
< i t appears from the context or otherwise that a different meaning is intended. ROSS v.
Industrial Commission, 112 Ariz. 253, 540 P. 2d 1234 ( 1975).
D
4. The function of this office i n connection with performance audits by the
Auditor General is to provide legal research and statutory interpretation. It would be
inappropriate for this office to apply legal principles to a question which asks what the
impact of a particular administrative action would be if the result would imply the same
conclusion in all cases. A subjective application of the law can only be done on a
I, case- by- case basis and is properly left to the administrative authority in the first
instance arid to the courts in the second.
5. Administrative agencies have no common law or inherent powers. Their powers - a r e t o be measured by the statutes under which they operate. Kendall v. Malcolm, 98
D
Ariz. 329, 404 P. 2d 414 ( 1965).
*. --
A. R. S. section 32- 1664, subsection F provides that "/ af the accused is found guilty
by the board of any of the actions set forth in section 32- 1663, subsection D, the board
may revoke or suspend the license." ( Emphasis added.) See also A. R. S. section 32- 1606,
subsection B, paragraph 3. The Board only has authority to revoke or suspend the license
D
of an accused nurse who is found guilty of any of the actions set forth in A. R. S. section
32- 1663, subsection D. The Board does not have authority to order a period of probation
or take other PJ:--' ' . e - ! Z ~ ~ G2! 1 3I." t ci ~; i~ peii. i:& O ; i rev3cai; iori of 2 :? zL~ L? SCi I ", he
accused is found guilty of any of the actions set forth in A. R. S. section 32- 1663,
subsection D.
. .
I)
The Ecxrira h ~ nstm - 2 c'isci--: Icii; i; i : e?; su,:-: c. dspe;. nderi o. repoked licenses, h. 8. S.
section 32- 1664, subsection G provides that "/ a" / denied license may be issued and a
revoked or suspended license may be reissued after the denial, revocation or suspension in
the discretion of the board."
A. R. S. section 32- 1606, subsection A provides that "/ Vhe board may adopt and
revise rules and regulations necessary to carry into effect theprovisions of this chapter."
The Board has adopted a rule regarding reinstatement of licenses. Arizona Code of
Administrative Rules and Regulations ( A. C. R. R.) R4- 19- 45 provides that:
A. A nurse whose Iicense to practice nursing has been suspended for a
period of time shall automatically be reinstated at termination of the period
of suspension as established by the Board if the stipulations in the order
have been met.
B. A nurse whose license to practice nursing has been denied or revoked,
may make application to the Board after a period of two years for the
issuance of a denied license or reissuance of a revoked license under the
following terms and conditions:
1. An application shall be submitted in writing, verified under mth, and
shall contain therein or have attached thereto substantial evidence that the
basis for denial or revocation has been removed and that the issuance of a
license will no longer constitute a threat t o t h e public health or safety.
2. The Board shall consider the application and may designate a time for
the applicant to appear at a regularly scheduled meeting of the Board so
that evidence of qualification and competency to practice can be presented.
3. After reviewing the evidence and deliberating the matter, the Board
may grant the applicant a temporary permit to practice for a time period
specified, or the Board may deny the application.
4. The Board may require that the applicant complete a specified period
of supervised practice. On completion of the supervised practice period, the
Board will consider the evaluation of the applicant's performance. In
narcotic cases, the Board may require periodic psychological or psychiatric
evaluations and reports, urinalysis, and affidavits concerning narcotic use.
These conditions must be met before an application is co~ sidered.
The Board may require that an applicant for issuance of a denied license or
reissuance of a revoked license complete a specified period of supervised practice before
an application is considered. A. C. R. R. R4- 19- 45, subsection B, paragraph 4. Under this
rule, the Board may also require participation in a drug treatment program and periodic
reports t o t h e Board. The rule does not specifically provide that the Board may require
similar terms and conditions for reinstating suspended nurses. Rather A. C. R. R.
R4- 19- 45, subsection A provides that if the suspended nurse has met the stipulations in
the order of suspension reinstatement is automatic at the termination of the period of
suspension. Stipulations ( conditions for reinstatement) in suspension orders may include
satisfactory completion of a period of supervised practice.
6. See answer 4.
CONCLUSIONS:
1. The Board has the implied authority to investigate allegations which are not
originally filed as sworn complaints.
2. See answer 1.
3. The Board is required to include a sworn complaint in its notice of hearing
served on the accused nurse.
4. It is not appropriate for this office to answer this question for the reasons set
forth above.
5. The Board only has authority to revoke or suspend the license of an accused
nurse who is found guilty of any of the actions set forth in A. R. S. section 32- 1663,
subsection D. The Bcard has more discretion in reinstating suspended licenses and
reissuing revoked licenses. The Board may require that certain conditions be met before a
suspended license i s reinstated or a revoked license is reissued.
6. See answer 4.
cc: Gerald A. Silva
Performance Audit Manager
APPENDIX I V
PRELIMINARY RECOMI+ ENDATIONS:
1981 NURSING MANPOWER STUDY
-.. qe . r- b C iaaor 5 r c ? zdr:: ci? ation r3: a : f : ri: qna qursrs ' noic3tas : ha: ' n ~ c c : t : s n r l : , i : : ' 3 ' ; i r e n- cec 3 ;: i ? : ne
'.? 71 ' ~ 1 1 - r : r e ? moicy? e : cs:::$ ns recorr2a : o be , ac3nc. 731s - eo- esenri 3n 2 . ; j e r c ~ n : ircr? as? : vpr : re cur- enc ;; col,
sf ? ur: es. :?. aflqes : n i ? a a i , ; ror<: ng : sna; t; ons, ind ~ u o l f c3o itc: s " iqnc 3t: r: c; 23 : 3 : , 3 c S 7Na5 tca iS3 : ? ' r 8 ; 2 a i c ::
: ae ' wC? * no are : brren:: y not rcrY: ng. : nus, ?: in: r, ating : he zsrrent '; ngrt? ge I' qsr;? i. '
' jniess : arr? nr : ranas 3nd 7 r a c t i x s : re : nznqea icwever, it : 5 prsjeczaa x a t > y : % 5 , Aryrcna ~ 1 1 : 2xcer: encz 3 ; cor: ace 3 i
Je?,~ e: n 1,3i0 : o !. 3ZG i! d'; s r ~ o o d c: 2 : ercen: ~: nei j200iy. ; he ; r? j? ctea : 390 icor: fali i s ? st: qared ~ 3 : e ; e% een
i,? iO 3na 1, iSS ; N';, s r i 2 : o 2ercen: ~ f : he j u o o l : ~ .
Sasea I n : aesa : roj? c:: Gns. i t i i imoor? ant i n a t i r i z 3 n a lmoiement 4ctions - now # n: ck n l i l Jr? vent z ievere ihortaqe $ P i b r s i n g cersonnei i n x i s : E C ~ ~ P . ; t i s f o r i n i s reascn :- a: ~ r e i i n i n a r yr ecsnmenbat! cns j r o : r? sented ;' r r? vlew Ins :; men:.
These ina otner : ert: nent rzc3menaar: 3ni i c r 3 c t i o n w1? 1 : e : omoiled 3no findi; 2cd for ~ uo11cat: on 3y 3earemoer i: 61.
? EZZFME? ICAT'! CN 1.
TIt.; TI3' 4 ) C : 572T:: dICE :$ UNC:!. J Y ' IU? f:'( G ! U ;;: Z-'>{ A
- h, a: : he ; avernor 3 i : r?: nna
;. E s ~ 2 o l i i nz 2eTanent t a u n c i i : n , Yurs: ng crarged with r s s c o n s i b i l i ~ y3 nd author+? y : o:
2 . j d e n t i f y 7etr. oos f 3 r imoi5menting tne recsiimendanons s f the Ar: zana ' I? lrs: ng Yanoower : dvisor/ C~ unc: I;
5 . i d e n t i i y current ~ c t i c n sa nd sutcsmes needed : o , nee[ : he s u ~ o l ~ ~ / a e m afnsdr x r s i n g services i n , Arizona; and,
c. leveloo long range > Ian8 znich v i l l ensure , Arizonans 3CCesi to nursing j e r v i c z s ~ n ndur sing ? ducation.
1. Concinue t9 i n c l i i d e lursss on :? until;, toar6s. comnittees, task f3rces. 2nd Advisory bodies which are cndrged : o
? ian, srganize, i n d imolement heai th care s e r v i c r s .
That ! he 4r;: ona l L ? ~ i s : a t u r e
I. ? rovide funding ? 3r the i s v e r n o r ' i Council on 4ursinq charged ' with responsibi I i t y and a u t h o r i t y to:
a. i d e n t i f y methods f 9 r inolementing : he recornendations o f the Arizcna : iursinq , wanpower Advisor1 Council;
5 . i d e n t i f y c u r r e n t actions and autcomes neeaed t o rr. esc the sucply/ dhand f o r nursing services i n Arizona; Ind,
c. develop long range clans which v i l l ensure Arizonans access t o nursing s e r ~ r i c e s and nursinq aducaiicn.
2. Ccctinue to include nurses on council, boards, c c m i t t e e s , t a i k iorces, and ad*+ isor/ bcdies which are charged
: o ?; an, orgrnize, and implavent health care services.
1. E. la1uate the corntonents of tne q u a l i t y o f ' w o r k - l i f e that have been i c e n t i f i e d as impacting ucon r e c r u i n e r l c ,
recention, and joo s a t i 5 f a c t i o n ; and, c m i t t o changes to::
a. assur2 : hat s a l a r y l b e n e f i t s t r l i c t u r e i s c m o e t i t i v e w i t h cornoarable ~ r c f e s i f o n s and csmensbrlte k i t h respon-s
i b i l i t i e s , w i t n c o n s i a e r a t i o n g i v e n t o educational pre9arat: on and p n i e s s i o n a l experience.
b. create an snvironmenr lrhich f o s t e r s professional nursing p r a c t i c e i n c l u d i n g conceots s f c o l l a b o r a t i v e p r a c t i c e ,
career iadaer5, and primary nursing;
c. incoreorate conceots ~ n ydra ctices i h i c h f a s t e r p a r t i c i p a t : o n i n decisions a f f e c t i n g the i n d i v f d u a l , the
? rofessionai 2nd work environment, and o a t i r n t care;