Performance audit, Board of Nursing

              Report to the Aruona Leg~ slature
By the Audrtor General
October 1988
88- 8
PERFORMANCE AUDIT
BOARD OF NURSING
DOUGLAS R. NORTON, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OFTHt
AUDITOR GENERAL
October 31, 1988
LINDA J BLESSING, CPA
DEPuTYAUDITOR GENERAL
Members of the Arizona Legislature
The Honorable Rose M offord, Governor
Ms. Joey R idenour, President
Arizona Board of Nursing
Transmitted herewith is a report of the Auditor General, A Performance Audit of
the Arizona State Board of Nursing. This report is in response to House Bill 2222,
enacted by the 1988 Legislature.
We found that the Board needs to improve the timeliness of its complaint
investigations and communications with the State's nursing industry. In addition,
Board efficiency could be improved by adopting a staggered renewal schedule.
My staff and I will be pleased to discuss or clarify items in the report.
Sincerely,
D O U ~ RS. Norton
Auditor General
STAFF: William Thomson
Peter N. Francis
Deborah A. Klein
Lucinda A. Trimble
David J. Vidoni
Shan D. Hays
The O f f i c e o f the Auditor General has conducted a performance audit of
the Arizona State Board of Nursing ( ASBN) i n response to House B i l l 2222
enacted by the 1988 L e g i s l a t u r e .
ASBN's purpose i s t o p r o t e c t the health and welfare of the pub1 i c as i t
relates t o n u r s i n g p r a c t i c e . I t performs such functions as: 1)
establishing educational standards and a c c r e d i t i n g nursing schools; 2)
examining, l i c e n s i n g , and renewing licenses o f duly q u a l i f i e d a p p l i c a n t s ;
3) conducting i n v e s t i g a t i o n s , hearings and proceedings concerning
v i o l a t i o n s and 4) d i s c i p l i n i n g v i o l a t o r s .
ASBN Needs To l nves t i gate
Complaints I n A More Timely Manner ( see pages 5 through 11)
ASBN has taken too long to i n v e s t i g a t e many complaints f i l e d i n the past
two years, r e s u l t i n g i n delays i n d i s c i p l i n a r y actions against nurses.
Over h a l f of the 71 closed cases we reviewed took anywhere from seven
months to over a year to complete. I n a d d i t i o n , 14 of the 37 open cases
reviewed have been under i n v e s t i g a t i o n for over a year. For example, i n
October 1986, ASBN received a complaint from the Department of Health
Services a l l e g i n g that a nurse i n a nursing home l e f t a p a t i e n t i n the
sun for an extended period of time, r e s u l t i n g i n h i s death. The
i n v e s t i g a t i o n was completed and sent to the Board i n March 1987. A t that
time, the Board decided to e i t h e r set the case f o r a hearing o r o b t a i n a
Consent Agreement from the I icensee. As o f September 1988 the case
remains under i n v e s t i g a t i o n , nearly two years a f t e r the complaint was
rece i ved.
Several factors have hindered ASBN's a b i l i t y to handle complaints i n a
timely manner. ASBN's lack of an adequate complaint tracking system
r e s u l t s i n i t s i n a b i l i t y to adequately track complaints and ensure that
cases are being investigated i n a t i m e l y manner. In a d d i t i o n , high
turnover of s t a f f has contributed to delays i n conducting i n v e s t i g a t i o n s
as i t has resulted i n : 1) r e l a t i v e l y new and inexperienced s t a f f and 2)
many cases being t r a n s f e r r e d to d i f f e r e n t i n v e s t i g a t o r s two to three
times. F i n a l l y , past problems among o f f i c e s t a f f have resulted i n
further delays i n conducting i n v e s t i g a t i o n s .
One Statutory Change Would
Streaml ine Board Complaint Handl ing ( see pages 13 through 14)
A provision i n Board s t a t u t e s governing the i n v e s t i g a t i o n o f sworn
complaints could be repealed since i t i s unnecessary and could r e s u l t i n
delays i n i n v e s t i g a t i n g complaints. Currently, the Board i s required to
conduct an i n v e s t i g a t i o n when a sworn complaint i s f i l e d charging a nurse
with any a c t i o n which would be grounds for d i s c i p l i n a r y a c t i o n . However,
most health regulatory boards w i t h s i m i l a r enforcement r e s p o n s i b i l i t i e s
do not have a s i m i l a r p r o v i s i o n i n t h e i r s t a t u t e s and w i l l i n i t i a t e
complaint i n v e s t i g a t i o n s based on a l e t t e r received from a complainant.
ASBN's Fees Should
Be Increased ( see pages 15 through 18)
ASBN's current revenues are too low to cover i t s short- term needs.
According to our a n a l y s i s , due to increased expenditures for complaint
i n v e s t i g a t i o n s and legal costs, the Board w i l l run out of money by the
1990- 91 f i s c a l year unless i t s fees are increased.
To meet i t s needs through 1993, ASBN's fees should be r a i s e d . B i e n n i a l
fees of $ 37.50 and a p p l i c a t i o n fees of $ 65 and $ 80 would allow the Board
to meets expenditures for the next f i v e years. In comparison to other
s t a t e s , these fees are reasonable.
In order for ASBN to increase fees to cover i t s expenditures, i t s
s t a t u t o r y c e i l i n g needs to be increased. ASBN i s c u r r e n t l y charging the
s t a t u t o r y maximum $ 20 on renewal fees, and i s close to the l i m i t on
a p p l i c a t i o n fees. To a l l o w f o r growth i n the Nursing Board program, a
s t a t u t o r y c e i l i n g should be set above the fee levels we are recommending.
Staggering License Renewal Would
Improve E f f i c i e n c y ( see pages 19 through 21 )
ASBN's l i c e n s i n g system should be changed to provide for staggered
renewals. C u r r e n t l y , A. R. S. 530- 1642 requires that a l l licenses expire
on December 31. With 35,500 RN licenses e x p i r i n g on even years and 7,900
LPN's licenses e x p i r i n g on odd years, the volume of work can be
overwhelming for ASBN's small c l e r i c a l s t a f f . In a d d i t i o n , because of
the d i s p a r i t y i n numbers of RN's and LPN's, ASBN revenues are c y c l i c a l
w i t h a l t e r n a t i n g high years and low years.
Staggering renewal dates would spread the work and revenues more evenly,
and would reduce the need f o r temporary h e l p .
Comnunication With t h e I n d u s t r y
Needs To Be Improved ( see pages 23 through 25)
Our interviews w i t h representatives o f A r i z o n a ' s n u r s i n g community
i n d i c a t e d a strained r e l a t i o n s h i p between the Board and some members of
the industry i n recent years. The nursing industry has asked f o r
guidance and i n t e r p r e t a t i o n s on important issues which concern the
i ndust ry , but the Board's responses have been s low. I n add i t i on, ASBN' s
r o u t i n e communications have been sporadic and incomplete.
Although communication problems i n t h e past may have r e s u l t e d from
turnover i n Executive D i r e c t o r s , the current Executive D i r e c t o r i s
attempting to heal the r i f t between the Board and the community by
increasing d i r e c t communication w i t h the i n d u s t r y .
TABLE OF CONTENTS
Page
INTRODUCTION AND BACKGROUND . . . . . . . . . . . . . . . . . . . 1
FINDING I: ASBN NEEDS TO INVESTIGATE COMPLAINTS
IN A MORE TIMELY MANNER . . . . . . . . . . . . . . . . . . . 5
Complaint Investigations
H a v e B e e n S l o w . , . . . . . . . . . . . . . . . . . . . . . . 5
Several Factors Have Hindered ASBN's
A b i l i t y To Handle Complaints In A
TimelyManner . . . . . . . . . . . . . . . . . . . . . . . . 9
Recornendations . . . . . . . . . . . . . . . . . . . . . . . 11
FINDING II: ONE STATUTORY CHANGE WOULD STREAMLINE
BOARD COMPLAINT HANDLING. . . . . . . . . . . . . . . . . . . 13
Recornendat i on. . . . . . . . . . . . . . . . . . . . . . . . 14
FINDING I l l : ASBN'S FEES SHOULD BE INCREASED . . . . . . . . . . 15
Revenues Are Not S u f f i c i e n t
To Meet Expenditures. . . . . . . . . . . . . . . . . . . . . 15
To Meet Needs Through 1993,
Fees Should Be Raised . . . . . . . . . . . . . . . . . . . . 16
Statutory Ceilings Should
Beincreased . . . . . . . . . . . . . . . . . . . . . . . . . 18
Recomnendations . . . . . . . . . . . . . . . . . . . . . . . 18
Page
FINDING I V : STAGGERING LICENSE RENEWAL
WOULD IMPROVE EFFICIENCY. . . . . . . . . . . . . . . . . . . 19
Renewal System Causes F l uctuat ions
In Workload And Revenues. . . . . . . . . . . . . . . . . . . 19
Staggering Would Allow For
SmootherRenewals . . . . . . . . . . . . . . . . . . . . . . 20
Recomnendations . . . . . . . . . . . . . . . . . . . . . . . 21
FINDING V: CWUNICATION WITH THE INDUSTRY
NEEDS TO BE IMPROVED. . . . . . . . . . . . . . . . . . . . . 23
Nursing Industry Has Valid Complaints
About Board . . . . . . . . . . . . . . . . . . . . . . . . . 23
Problems May Result From Turnover
InExecutiveDirectors . . . . . . . . . . . . . . . . . . . . 24
Recomnendation. . . . . . . . . . . . . . . . . . . . . . . . 25
OTHER PERTINENT INFORMATION . . . . . . . . . . . . . . . . . . . 2 7
St. MaryVsCase . . . . . . . . . . . . . . . . . . . . . . . 27
Entry Requirements. . . . . . . . . . . . . . . . . . . . . . 32
AGENCYRESPONSE.. . . . . . . . . . . . . . . . . . . . . . . .
LIST OF TABLES
Page
TABLE 1 - State Board Of Nursing Revenues,
Expenditures, And FTEs For Fiscal Years 1986- 87
Through 1988- 89 ( Unaudi ted) . . . . . . . . . . . . 2
TABLE 2 - Disciplinary Actions Taken By ASBN
For Cornpalints Received In Fiscal Years
1986- 87 And 1987- 88 . . . . . . . . . . . . . . . . 6
TABLE 3 - Length Of Time To Complete
Investigations For Complaints Received
In Fiscal Years 1986- 87 And 1987- 88 . . . . . . . . 7
TABLE 4 - Length Of Time Open Cases Have Been
Under Investigation For Complaints
Received In Fiscal Years 1986- 87
And 1987- 88 . . . . . . . . . . . . . . . . . . . . 7
TABLE 5 - Actual And Projected Revenues And
Expenditures For Fiscal Years 1986- 87
Through 1990- 91 W i th Cur rent
Fee Structure . . . . . . . . . . . . . . . . . . . 16
TABLE 6 - Actual And Projected Revenues And
Expenditures For Fiscal Years 1986- 87
Through 1990- 91 With Recomnended
Fee Structure . . . . . . . . . . . . . . . . . . . 17
INTRODUCTION AND BACKGROUND
The O f f i c e o f the Auditor General has conducted a Performance Audit of the
Arizona State Board of Nursing. This performance a u d i t was conducted i n
response to House B i l l 2222 enacted by the 1988 L e g i s l a t u r e .
The State Board of Nursing was established i n 1921. I t s purpose i s to
p r o t e c t the health and welfare of the p u b l i c as i t r e l a t e s to nursing
p r a c t i c e . To accomplish i t s purpose, the Board performs a v a r i e t y of
f u n c t i o n s i n c l u d i n g : 1) e s t a b l i s h i n g educational standards and a c c r e d i t i n g
nursing schools; 2) examining, l i c e n s i n g , and renewing licenses of duly
q u a l i f i e d a p p l i c a n t s , 3) conducting i n v e s t i g a t i o n s , hearings and
proceedings concerning v i o l a t i o n s and 4) d i s c i p l i n i n g v i o l a t o r s .
C u r r e n t l y , there are approximately 43,000 a c t i v e and 4,460 i n a c t i v e
nurs i ng I i censes i ssued by the ~ o a r d ! "
The Board consists of nine members appointed by the Governor f o r five- year
terms. The Board members include f i v e r e g i s t e r e d nurses, two licensed
p r a c t i c a l nurses and two p u b l i c members.
Staffing And Budget
To carry out i t s f u n c t i o n s , the Board i s authorized 21 FIE p o s i t i o n s .
These s t a f f include an executive d i r e c t o r , an associate d i r e c t o r , nurse
consultants, a nurse monitoring s p e c i a l i s t , and c l e r i c a l s t a f f .
The Board receives monies for operations from the Board of Nursing Fund.
The Fund i s comprised o f fees c o l l e c t e d f o r licenses and permits, charges
for services, fines and f o r f e i t u r e s , and other miscellaneous income. The
Board receives 90 percent of fees c o l l e c t e d f o r operations, while the
remaining 10 percent i s deposited i n the General Fund. Table 1
i l l u s t r a t e s ASBN's revenues, expenditures and FTEs for f i s c a l years
1986- 87 through 1988- 89.
( 1 ) There are also approximately 5,300 nurses t h a t are delinquent i n renewing t h e i r
1 i censes.
TABLE 1
STATE BOARD OF NURSING
REVENUES, EXPENDITURES, AND FTEs
FOR FISCAL YEARS 1986- 87 THROUGH 1988- 89
( unaud i ted)
1986- 87 1987- 88 1988- 89
Actual Actual Approved
FTE Positions 19.2 19.2 21.2
Funds Avai lab l e
Balance Beginning of
F i s c a l Year $ 830,000 $ 882,000 $ 452,243
Revenues ( a) ( b) 780,500 387,245 1 ,050,500( c)
Total Funds Available $ 1 ,610.500 $ 1 ,269,245 $ 1 ,502.74- 3
D i s p o s i t i o n of Funds
Personal Services $ 411,400
Employee Related Expense 75,900
Professional and
Outside Services 56,200
Travel - State 17,200
Travel - Out- of- State 10,400
Other Operating Expenses 149,500
Equ i pmen t 7,900
Food - 0-
Operation Sub- Total 728,500 806,282 892,400
Board Relocation - 0- -- 1- 0,7 20 - 0-
Total Funds Expended 728,500 81 7,002 892,400
Balance Forward
End of F i s c a l Year - 882,00- 0 452,243 61 0,343
Total D i s p o s i t i o n
of Funds $ 1,610,500 $ 1 .269.245 $ 1 ,502,743
( a) The Board of Nursing has a b i e n n i a l l i c e n s i n g cycle.
( b) This t a b l e d e p i c t s only 90 percent of Nursing Board monies which i s deposited i n
t h e Nursing Board Fund. The other 10 percent i s deposited i n the General Fund.
( c) This amount includes estimated revenues r e s u l t i n g from a $ 10 surcharge on each
1 i cense renewal t h a t expires i n 1988.
Source: JLBC Appropriations Report f o r f i s c a l year 1988- 89.
Scope of Audit
The audit contains f i n d i n g s i n f i v e major areas:
0 The timeliness of the Board's complaint handling.
0 The need for s t a t u t o r y changes related to complaint handling
a The adequacy of the Board's license fees.
8 The e f f i c i e n c y of the Board's renewal cycle.
a The effectiveness of the Board's communication w i t h the i n d u s t r y .
During the course of our a u d i t , we developed other p e r t i n e n t information
regarding: 1) d i s c i p l i n a r y a c t i o n taken against nurses a f f i l i a t e d w i t h St.
Mary's Hospital i n Tucson ( see page 27), and 2) entry requirements for
nurses ( see page 32).
Because Executive Session minutes from July 1986 to February 1988 were
missing, we were unable to examine a l l Board records p e r t i n e n t to the St.
Mary's case. To the extent these minutes may have provided a d d i t i o n a l
information about Board a c t i o n s , the scope of our audit was impaired.
The audit was conducted i n accordance w i t h generally accepted governmental
a u d i t i n g standards.
The Auditor General and s t a f f express appreciation to the Board members,
Executive Director and employees of the State Board of Nursing for t h e i r
cooperation and assistance during the course of the a u d i t .
FINDING I
ASBN NEEDS TO INVESTIGATE COMPLAINTS IN A MORE TIMELY MANNER
The Arizona State Board of Nursing ( ASBN) has taken too long to
i n v e s t i g a t e many complaints f i l e d i n the past two years. Our review of
complaints revealed ASBNfs lack of t i m e l i n e s s i n h a n d l i n g c o m p l a i n t s ,
r e s u l t i n g i n delays i n d i s c i p l i n a r y actions against nurses. Several
f a c t o r s have hindered ASBNfs a b i l i t y to handle complaints i n a timely
manner .
We reviewed a sample of 108 complaint f i l e s f o r f i s c a l years 1986- 87 and
1987- 88, equating to approximately 22 percent of t h e complaints received
during that time period. F i f t y percent of t h e complaints reviewed
related to a nurse's p r a c t i c e , 34 percent were drug r e l a t e d complaints,
and 16 percent r e l a t e d t o a nurse's conduct(". I n a d d i t i o n , Table 2
on page 6 i l l u s t r a t e s the d i s c i p l i n a r y actions taken on the 67 cases that
were presented to the Board and o f which a f i n a l decision has been made.
Complaint investigations Have
Been Slow
During our review, we noted several cases t h a t revealed ASBN's lack of
timeliness i n h a n d l i n g c o m p l a i n t s . Of the 108 complaint f i l e s we
reviewed, 71 of the cases have been closed and 37 cases are s t i l l under
i n v e s t i g a t i o n . As i l l u s t r a t e d i n Table 3, ( page 7) over h a l f o f the
closed cases took anywhere from 7 months to over a year to complete. I n
a d d i t i o n , 14 of the 37 open cases have been under i n v e s t i g a t i o n f o r over
a year. Table 4 ( page 7 ) , i l l u s t r a t e s how long cases s t i l l under
i nves t i gat i on have been open.
Untimely i n v e s t i g a t i o n s can r e s u l t i n a nurse continuing a c t i v i t i e s t h a t
may endanger p u b l i c h e a l t h , s a f e t y and w e l f a r e . ASBN s t a f f have
( ' 1 Due t o the small sample s i z e , these figures may not accurately r e f l e c t t h e a c t u a l
number of complaints received i n each category f o r the population as a whole. I n
a d d i t i o n , these f i g u r e s represent the type of complaint as i n i t i a l l y reported,
Once an i n v e s t i g a t i o n has s t a r t e d , i t may expand t o i n c l u d e other issues such as
chemical dependency.
TABLE 2
D 1 SC 1 PL 1 NARY ACT l ONS TAKEN BY ASBN
FOR CWLA l NTS RECEl VED IN FISCAL YEARS 1986- 87 AND 1987- 88 ( a )
TYPE OF ACTION NUMBER OF CASES
Dismissal 24
Consent Agreement/
S t i p u l a t e d Order 29
L e t t e r of Concern 8
Decree of Censure
Fine
Probat ion 1
Revocation/
Cease & Desist 2( c)
( a) As o f September 9, 1988.
( b ) The Board a l s o f i l e d a l e t t e r of concern i n t h i s case.
(' 1 Each a c t i o n was imposed i n one case only.
Source: Auditor General review of complaint f i l e s for f i s c a l years
1986- 87 and 1987- 88.
i n d i c a t e d that working on older cases i s d i f f i c u l t because i t becomes
harder to make contact w i t h i n d i v i d u a l s involved i n the case, and the
s p e c i f i c s of the case may not be e a s i l y remembered by the i n d i v i d u a l s
involved. As a r e s u l t , delays i n i n v e s t i g a t i o n s u l t i m a t e l y r e s u l t s i n
delays i n d i s c i p l i n a r y a c t i o n s against nurses.
While the length of an i n v e s t i g a t i o n v a r i e s depending on t h e complexity
of the complaint, e s t a b l i s h i n g g u i d e l i n e s on t i m e l i n e s s may be
b e n e f i c i a l . For example, the Dental Board i s required by s t a t u t e t o take
i n i t i a l action on a complaint w i t h i n 150 days of beginning an
i n v e s t i g a t i o n . This timeframe i s r e l a t i v e l y s t r i c t and i n f l e x i b l e . To
a l l o w f o r greater f l e x i b i l i t y , the Nursing Board could e s t a b l i s h through
w r i t t e n p o l i c y , g u i d e l i n e s which recognize t h a t some complaints w i l l take
longer than others t o i n v e s t i g a t e .
TABLE 3
LENGTH OF TlME TO COMPLETE INVESTIGATIONS
FOR COMPLAINTS RECEIVED IN FISCAL YEARS 1986- 87 AND 1987- 88
TlME PERIOD
0 - 3 Months
NUMBER OF COMPLAINTS
Over 12 Months 9
Source: Auditor General review of complaint files for fiscal years
1986- 87 and 1987- 88.
TABLE 4
LENGTH OF TlME OPEN CASES( a) HAVE
BEEN UNDER INVESTIGATION
FOR COMPLAINTS RECEIVED IN FISCAL YEARS 1986- 87 AND 1987- 88
TlME PERIOD
0 - 3 Months
4 - 6 Months
7 - 9 Months
10 - 12 Months
Over 12 Months
NUMBER OF COMPLAINTS
0
7
6
10
14
( a) As o f September 9, 1988.
Source: Auditor General review of complaint files for fiscal years
1986- 87 and 1987- 88.
The fo I lowing cases i I l u s t rate excessive time taken to conduct
investigations.
Case One
I n January 1987, a complaint regarding the p r a c t i c e o f s i x nurses was
received. The complaint alleged that methadone was being prescribed
and administered by non- licensed i n d i v i d u a l s . This case was not
assigned to an i n v e s t i g a t o r u n t i l A p r i l 1987. I t took s i x months to
complete the i n i t i a l i n v e s t i g a t i o n . However, i n July 1987, the Board
recommended that the invest igat ion be continued. The case has since
been transferred to another i n v e s t i g a t o r . As of September 9, 1988,
the case remains under i n v e s t i g a t i o n , over one and one- half years
a f t e r date o f r e c e i p t .
Case Two
In October 1986, ASBN received a complaint from the Department of
Health Services regarding a nurse employed i n a nursing home. The
complaint alleged that one of the p a t i e n t s under t h i s nurse's
supervision had died from being l e f t i n the sun for an extended
period of time. The i n v e s t i g a t i o n was completed and sent to the Board
i n March 1987. A t that time, the Board decided to e i t h e r set the case
for a hearing or obtain a Consent Agreement from the licensee.
Furthermore, i n May 1987, ASBN received an anonymous complaint that
the nurse i n question had a problem w i t h drugs and a l c o h o l . The
complaint f i l e was reviewed i n November 1987. However, nothing more
has been done w i t h the case since that time. As of September 9, 1988
the case remains under i n v e s t i g a t i o n , nearly two years a f t e r the
complaint was received.
Case Three
In September 1987, a malpractice n o t i c e was received a l l e g i n g that a
group of nurses f a i l e d to provide appropriate nursing care which
caused i r r e v e r s i b l e b r a i n damage to a minor c h i l d . The case was not
assigned u n t i l May 1988. According to the nurse consultant assigned
to the case, t h i s case had been f i l e d as " pending". Upon the o f f i c e ' s
move to i t s new l o c a t i o n , the complaint ( along w i t h other " pending"
complaints) was found. I t was at that time that the complaint was
assigned. On October 12, 1988, f i v e months a f t e r the matter was
assigned, a l e t t e r was sent to an attorney involved i n the case.
Response to the i n q u i r y i n d i c a t e d t h a t the nurses, i n f a c t , were not
involved i n the i n c i d e n t .
Case Four
In July 1987, a nurse self- reported to ASBN regarding her drug
a d d i c t i o n . In a d d i t i o n , i t was noted that the nurse had been working
w i t h a lapsed license for nearly four months. This case was
o r i g i n a l l y assigned i n August 1987. However, nothing was done on the
case unt i l November 1987 when the case was re- ass igned. The
i n v e s t i g a t i o n was not completed u n t i l May 1988, almost nine months
a f t e r r e c e i p t .
Case Five
I n February 1987, a nurse self- reported to ASBN regarding her chemical
dependency. This case was handed down to another i n v e s t i g a t o r a f t e r
the i n i t i a l i n v e s t i g a t o r l e f t ASBN. Although the i n v e s t i g a t i o n was
s t a r t e d i n March 1987, the l a s t time the f i l e was reviewed was i n
December 1987. Since that time, the case has not progressed any
f u r t h e r .
Several Factors Have Hindered
ASBN1s A b i l i t v To Handle Com~ lain's
In A Timely Manner
Several factors have hindered ASBN's a b i l i t y to handle complaints i n a
timely manner. These f a c t o r s i n c l u d e : 1) lack o f an adequate complaint
tracking system, 2) high s t a f f turnover and 3) dissension among o f f i c e
s t a f f .
ASBN cannot adequately track complaints to ensure t i m e l y i n v e s t i g a t i o n s
ASBN does not have an adequate tracking system to ensure timely
i n v e s t i g a t i o n of complaints. C u r r e n t l y , the Executive Director assigns
and p r i o r i t i z e s complaints f o r s e v e r i t y as they are received. Each of
the nurse consultants responsible for conducting i n v e s t i g a t i o n s maintains
t h e i r own log of the complaints they have been assigned, and i t i s t h e i r
responsibi l i t y to track i t s s t a t u s . Although the c o n s u l t a n t s maintain a
log of complaints, these logs do not track the intermediary steps i n the
i n v e s t i g a t i v e process. In a d d i t i o n , the Executive D i r e c t o r , who oversees
the nurse consultants, maintains a master l i s t i n g o f a l l complaints
received. However, t h i s l i s t i n g i s not adequate f o r t r a c k i n g complaints
and ensuring that the cases are being investigated i n a timely manner.
High turnover has resulted i n delays i n conducting i n v e s t i g a t i o n s -
High turnover i n the past has resulted i n delays i n conducting
investigations for several reasons. The length of time i t takes to
become f a m i l i a r w i t h a case creates delays. I n a d d i t i o n , most of the
Board's current s t a f f i s r e l a t i v e l y new and inexperienced. Only two of
the s i x nurse consultants have been i n t h e i r p o s i t i o n for more than 18
months. I n a d d i t i o n , most of the i n v e s t i g a t o r s have not had p r i o r
i n v e s t i g a t i v e experience, and only two i n v e s t i g a t o r s have received formal
as interviewing techniques, evidence development , admi n i s t r a t i ve law and
report w r i t i n g . Moreover, Attorney General representatives indicated
that i t may be b e n e f i c i a l f o r ASBN to h i r e t r a i n e d i n v e s t i g a t o r s to
supplement the work performed c u r r e n t l y by the nurse consultants.
Second, the turnover o f i n v e s t i g a t i v e s t a f f has created several problems
for current s t a f f i n conducting i n v e s t i g a t i o n s . During our review, we
noted many cases that had been t r a n s f e r r e d to d i f f e r e n t i n v e s t i g a t o r s two
to three times. And, i n many of those cases, we found the q u a l i t y of
documentation to be poor. For instance, i n many cases, the i n v e s t i g a t o r
did not adequately document discussions or interviews conducted w i t h
i n d i v i d u a l s involved i n the case. As a r e s u l t , the length of time for a
new i n v e s t i g a t o r to become f a m i l i a r w i t h the case i s delayed due to the
lack of information contained i n the f i l e . While ASBN has recently
implemented pol i c i e s and procedures regardi ng i n v e s t i g a t i v e procedures,
these procedures do not adequately address the i n f o r m a t i o n t h a t should be
documented i n a complaint f i l e .
F i n a l l y , high s t a f f turnover has created a d d i t i o n a l cases for the current
i n v e s t i g a t i v e s t a f f . According to the current i n v e s t i g a t i v e s t a f f , each
had to take over an average of 43 cases from a previous i n v e s t i g a t o r i n
addition to t h e i r own caseload.
Dissension among o f f i c e s t a f f created delays - In the past, ASBN s t a f f
and the Board i t s e l f has experienced a great deal of dissension, which
u l t i m a t e l y resulted i n f u r t h e r delays i n conducting i n v e s t i g a t i o n s .
According to ASBN s t a f f , i n v e s t i g a t i v e s t a f f were without adequate
supervision from the period of September 1985 to November 1987. From
September 1985 to May 1987, there was a lack of cohesiveness among s t a f f
members. In a d d i t i o n , ASBN's current Executive D i r e c t o r i n d i c a t e d
feelings of h o s t i l i t y developed from the s t a f f . As a r e s u l t , i n March
1987, the Board h i r e d a consultant to review the leadership and
procedures of the o f f i c e . The consultant observed that s t a f f were not
confident of the Executive D i r e c t o r ' s leadership abi l i t i e s . In May 1987
the Executive Director was terminated, and the Board appointed an Acting
Executive D i r e c t o r , who remained i n that p o s i t i o n u n t i l November 30,
1987, when the current Executive D i r e c t o r was appointed.
RECOWENDATIONS:
1 . ASBN should develop time guidelines to establish goals for conducting
investigations.
2. ASBN should implement a more complete complaint tracking system to
determine that investigations are concluded in a timely manner.
3. ASBN should ensure that staff receive adequate investigative training.
4. ASBN should consider hiring trained investigative staff to supplement
the work performed currently by its nurse consultants.
5 . ASBN should revise i ts pol i cies/ procedures to include procedures on
f i le documentat ion.
FINDING I I
ONE STATUTORY CHANGE WOULD STREAMLINE BOARD COMPLAINT HANDLING
One change i n the Board's s t a t u t o r y p r o v i s i o n s would streamline Board
complaint handling. A p r o v i s i o n regarding t h e f i l i n g of sworn complaints
i s unnecessary and could be e l i m i n a t e d .
A. R. S. Section 532- 1664. C. provides t h a t the Board must conduct an
i n v e s t i g a t i o n when a sworn complaint i s f i l e d charging a nurse w i t h any
a c t i o n which would be grounds for d i s c i p l i n a r y a c t i o n . When a complaint
i s f i l e d w i t h the Board, the Board normally w i l l send the complaining
p a r t y a form and request that the form be completed, n o t a r i z e d , and
returned to the Board. This e x t r a step i n the complaint handling process
can cause delays i f the complaint i s not returned promptly or i f the
complaining party decides not to r e t u r n the form.
This p r o v i s i o n i s unnecessary since a sworn complaint i s not required for
the Board to i n i t i a t e a complaint. A. R. S. Section 532- 1664. A. authorizes
the Board to i n i t i a t e on i t s own motion an i n v e s t i g a t i o n i f there i s
evidence that a nurse may have v i o l a t e d the Nurse P r a c t i c e Act. Thus, i f
the Board receives a complaint, i t may i n i t i a t e an i n v e s t i g a t i o n whether
or not a sworn complaint form i s f i l e d .
Most h e a l t h regulatory boards w i t h s i m i l a r enforcement r e s p o n s i b i l i t i e s
do not have a s i m i l a r p r o v i s i o n i n t h e i r enabling l e g i s l a t i o n . For
example, the Board of Medical Examiners, the Board of Osteopathic
Examiners, and the Board of Podiatry w i l l i n i t i a t e complaint
i n v e s t i g a t i o n s based on a l e t t e r received from a complainant. These
boards can i n i t i a t e complaint i n v e s t i g a t i o n s more q u i c k l y than the
Nursing Board because they do not take the e x t r a step of requesting a
sworn complaint.
REGOMUENDAT l ON
1. The Legislature should consider repealing A. R. S. $ 32- 1664. C. which
provides for the investigation of sworn complaints.
FINDING I l l
ASBN'S FEES SHOULD BE INCREASED
ASBN's l i c e n s i n g fees should be raised to cover i t s cost of o p e r a t i o n s .
Current revenues are too low t o cover i t s short- term needs. To ensure
s u f f i c i e n t revenues, ASBN should be given an increase i n i t s s t a t u t o r y
c e i l i n g on fees.
Revenues Are Not S u f f i c i e n t
To Meet Expendi tures
According to our a n a l y s i s , the Board w i l l run out of money by the 1990- 91
f i s c a l year unless i t s fees are increased. C u r r e n t l y , the Board charges
$ 45 f o r a new license and $ 20 t o renew a i icense f o r two years. ASBN has
a b i e n n i a l l i c e n s i n g cycle and r e l i e s on carryover from even numbered
years, when RN licenses are renewed, to provide funds f o r odd numbered
years, when the less numerous LPN l icenses are renewed.'" I n recent
years, t h i s carryover has d e c l i n e d each even- numbered year t o the p o i n t
where the 1988 RN renewal would not have covered 1989- 90 f i s c a l year
needs. Although the L e g i s l a t u r e gave immediate r e l i e f by a l l o w i n g the
Board t o impose a one- time $ 10 surcharge on the 1988 RN renewal, the
e f f e c t i s only temporary. Table 5 includes t h a t surcharge and shows t h a t
the Board w i l l soon have a d e f i c i t unless a more permanent s o l u t i o n i s
found .
Because expenditures are r i s i n g f a s t e r then revenues, we also examined
whether expenditures have been adequately c o n t r o l l e d . For the most p a r t ,
ASBN1s expenditures appear reasonable. We reviewed expenditures f o r
1986- 87 and 1987- 88 t o determine whether ASBN's projected shortages could
be prevented by c o n t r o l l i n g expenditures. We found that r i s i n g
i n v e s t i g a t i v e workloads and l e g a l c o s t s account f o r much of the recent
As discussed i n Finding I V , a staggered renewal system would smooth out the Board's
revenues. It would not, however, address the f a c t t h a t t o t a l revenues are not
s u f f i c i e n t .
increases i n spending. I n f a c t , ASBN has postponed some needed changes
due t o shortage of revenues. For example, access t o the National
C o u n c i l ' s d i s c i p l i n a r y data bank could improve the Board's e f f e c t i v e n e s s
at a modest c o s t , but the funds are not a v a i l a b l e . More frequent
newsletters would improve communications w i t h the nursing community, but
p r i n t i n g and postage costs are p r o h i b i t ive under the present fee
s t r u c t u r e .
TABLE 5
ACTUAL AND PROJECTED REVENUES AND EXPENDITURES
FOR FISCAL YEARS 1986- 87 THROUGH 1990- 91
WITH CURRENT FEE STRUCTURE
Actual Actual P r o j e c t e d P r o j e c t e d P r o j e c t e d
86- 87 87- 88 88- 89 89- 90 90- 91
Beginning \
ba l ance $ 830,000 $ 882,000 $ 452,243 $ 610,343 $ 6,908
Revenues( a) 780,500 387,245 1 ,050,500 333,585 828,099
Expend i t ~ r e s ( ~ ) ( 728,500) ( 817,002) ( 892,400) ( 937,020) ( 983,871) 4
End i ng
balance $ 882.000 $ 452,243 $ 6 1 0 3 4 $ 6.908 $( 148,864 )
( a) Future revenues are based on two- year average number of transactions other than
renewals, and assume a l l c u r r e n t 1 icensees w i l l renew. The number of non- renewal
transactions handled by ASBN has remained roughly constant since the 84- 85 f i s c a l
year, and ASBN expects the number of licensees t o remain f a i r l y stable. The 88- 89
f i g u r e includes a one- time $ 10 surcharge on renewal fees.
( b ) Projections based on JLBC estimate of cost increases a t f i v e percent per year.
Source: Figures f o r 86- 87, 87- 88, and 88- 89 are from JLBC budget r e p o r t s .
Projected f i g u r e s f o r 89- 90 and 90- 91 are c a l c u l a t e d as
described i n Notes ( a) and ( b ) .
To Meet Needs Through 1993,
Fees Should Be Raised
Renewal fees of $ 37.50 and a p p l i c a t i o n fees of $ 65 and $ 80 would allow
the Board to meet expenditures f o r the next f i v e years. ( l ' These fees
are reasonable compared to other s t a t e s . National l y , b i e n n i a l renewal
fees range from a low of $ 10 to a high of $ 65. C a l i f o r n i a charges $ 40 for
renewal, and fees i n nearby New Mexico and Nevada are also comparable to
the suggested fees.
Table 6 p r o j e c t s the r e s u l t s of charging fees a t $ 37.50 for renewal
($ 17.50 more than the current fee), $ 65 for a p p l i c a t i o n by endorsement ( a
$ 20 increase), and $ 80 f o r a p p l i c a t i o n by examination ( a $ 35
increase) . ( 2)
TABLE 6
ACTUAL AND PROJECTED REVENUES AND EXPENDITURES
FOR FISCAL YEARS 1986- 87 THROUGH 1990- 91
WITH RECOWENDED FEE STRUCTURE
Actual Actua! P r o j e c t e d P r o i e c t e d P r o i e c t e d
Beainnina
Expendi t ~ r e s ( ~ ) ( 728,500) ( 817,002) ( 892,400). ( 937,020) ( 983,871)-
End i nu
( a) Future revenues are based on two- year average number of t r a n s a c t i o n s o t h e r than
renewals, and assume a l l c u r r e n t 1 i censees w i l l renew. The number of non- renewal
transactions handled by ASBN has remained rough1 y constant since the 84- 85 f i s c a l
year, and ASBN expects the number o f licensees t o remain f a i r l y s t a b l e . The 88- 89
f i g u r e includes a one- time $ 10 surcharge on renewal fees.
( b) Projections based on JLBC estimate of cost increases a t f i v e percent per year.
Source: Figures for 86- 87, 87- 88, and 88- 89 are from JLBC budget
r e p o r t s . Projected f i g u r e s for 89- 90 and 90- 91 are calculated
as described i n Notes ( a) and ( b ) .
( ' 1 Our review focused on renewal and a p p l i c a t i o n fees because they are the Board's
most important source of revenue. The Board has a number of other fees, but almost
90 percent of the Board's revenue comes from renewals and a p p l i c a t i o n s . A change
i n these two items would have the greatest impact on the Board's f i n a n c i a l
s i t u a t i o n .
(' 1 Costs of administering exams make a exam/ endorsement d i f f e r e n t i a l sensible.
Nineteen states charge higher fees f o r exams than endorsement.
Statutory Cei l ings
Should Be increased
In order for ASBN to increase fees to cover i t s expenditures, ASBN's
s t a t u t o r y c e i l i n g needs to be increased. A. R. S 532- 1643 establishes an
upper l i m i t on ASBN's fees. The actual amounts charged are set by rule
i n R4- 19- 102. ASBN i s c u r r e n t l y charging the s t a t u t o r y maximum $ 20 on
renewal fees, and i s close to the l i m i t on a p p l i c a t i o n fees. Although we
did not review other fees, the Board i s a t or near the l i m i t on a l l of
them. To allow for growth i n the Nursing Board program, a s t a t u t o r y
c e i l i n g should be set above the fee levels we are recommending. Phis
would reduce the need to return to the L e g i s l a t u r e on a continuing basis
for a fee increase, yet put reasonable l i m i t s on Board fees.
RECOUIENDATIONS:
1. The L e g i s l a t u r e should consider amending A . R . S 532- 1643( A)( 2) and
( 3) to increase the s t a t u t o r y maximums on renewal and a p p l i c a t i o n
fees.
2. The L e g i s l a t u r e should review a l l the s t a t u t o r y maximums i n A . R . S
332- 1643( A) t o determine whether other fee l i m i t s should also be
increased.
3. I f given s t a t u t o r y a u t h o r i z a t i o n , ASBN should raise i t s fees by a
s u f f i c i e n t amount to cover expenditures.
FINDING IV
STAGGERING LICENSE RENEWAL
WOULD IMPROVE EFFICIENCY
ASBN's licensing system should be changed to provide for staggered
renewals. A l l nursing licenses c u r r e n t l y expire on the same day, which
creates peaks and v a l l e y s i n both workload and revenues. Staggering
renewals would spread the work and the revenues more evenly, and allow
for more e f f i c i e n t a d m i n i s t r a t i o n of the renewal process.
Renewal System Causes F l u c t u a t i o n s
I n Workload And Revenues
Current l y , A. R. S 330- 1642 requi res that a l l l icenses expi re on December
31. RN I icenses expi re i n even- numbered years and LPN I icenses i n
odd- numbered years. I n 1988, about 35,500 RNs w i l l be due to renew; and
i n 1989, about 7,900 LPNs w i l l renew. The volume of work i n even years
i s overwhelming f o r ASBN's small c l e r i c a l s t a f f . As a r e s u l t ,
temporaries are h i r e d to a s s i s t i n processing the renewals. Even i n odd
years, the Board must employ c l e r i c a l pool h e l p d u r i n g the peak period.
This requires Board s t a f f to take time out to t r a i n and supervise
temporary employees.
I n a d d i t i o n , because of the d i s p a r i t y i n numbers of RNs and LPNs, ASBN
revenues are c y c l i c a l w i t h a l t e r n a t i n g high years and low years. For
example, i n the l a s t RN renewal year, 1986- 87, ASBN's revenue was
$ 780,500 ; wh i l e i n 1985- 86, an LPN renewal y e a r , t h e i r revenue was on l y
$ 387,000.
The uneven workload generated by the current renewal system may have
contributed to problems encountered i n p r i o r y e a r s . H o s p i t a l s are
required to v e r i f y that t h e i r nurses hold c u r r e n t l i c e n s e s , but c o u l d n ' t
do so i n e a r l y 1987 because ASBM was not up to date i n processing the
1986 renewals. Processing was so far behind that on December 30, 1986,
the Board issued a statement that i f a licensee had made timely
a p p l i c a t i o n f o r renewal, the license would not expire u n t i l March 31,
1987, even i f the renewal license was not i n h i s or her possession.
Staggering Would Allow
For Smoother Renewals
Staggering renewal dates would spread the work and revenues more evenly,
and reduce the need for temporary help. Under the staggered system used
i s some states, licensees renew during t h e i r b i r t h month, and licensees
born in even- numbered years renew i n even- numbered years. Changing to
t h i s system would provide the f o l l o w i n g advantages.
r S t a f f would handle about 1,750 renewals every month rather than
encounter year- end peaks.
r Revenues would f l a t t e n out to about $ 584,000 every year( 1' under
the current fee s t r u c t u r e .
r ASBN could use one f u l l - t i m e s t a f f member ( 2' and part o f another
s t a f f member's time to process renewals and handle requests for
renewal information, instead of using temporaries.
r ASBN would not face the problem of t r a i n i n g new s t a f f at every
renewal, since s t a f f would work on renewals continuously.
r The reduced need for temporary help would a l low ASBN to implement the
new system at l i t t l e or no increase i n cost.( 3)
( 1 ) This i s an average o f 1986 revenues of $ 780,000 and 1985 revenues of $ 387,000, taken
by adding the f i g u r e s together and d i v i d i n g by 2.
(') ASBN's associate d i r e c t o r plans t o handle 1988 renewals w i t h a t o t a l o f 2,088 hours
of temporary c l e r i c a l help. At 1,776 hours per f u l l - t i m e equivalent posi ti on ( F I E ) ,
derived by s u b t r a c t i n g vacation, s i c k leave, and other nonproductive a c t i v i t y hours
from the t o t a l annual hours f i g u r e o f 2,080, t h i s amount of temporary help t r a n s l a t e s
t o 2,088 d i v i d e d by 1,776 o r 1.17 FTE.
( 3) The hourly rates f o r temporaries i n 1987- 88 were $ 6.4676 and $ 7.2619. For 2,088
hours, t h e i r l a b o r w i l l cost a t l e a s t $ 14,683.28 ( i n c l u d i n g ERE o f 8.73 percent), and
could c o s t as much a t $ 16,486.57. Total annual cost f o r a C l e r k T y p i s t I11 i s
$ 16,250.
A staggered renewal system appears to work w e l l f o r other s t a t e s . A s t a f f
member at the Texas nursing board, which licenses almost 100,000 RNs, said
that staggering renewals improved t h e i r processing time. The C a l i f o r n i a
and New Mexico nursing boards also stagger renewal dates and reported
smooth operations.
A switch to a b i r t h d a y renewal system was recommended by Arthur Young, a
p u b l i c accounting f i r m which performed a Management Audit f o r the Arizona
Cost E f f i c i e n c y Commission i n A p r i l 1988. ASBN agreed w i t h the
recommendation, and both the Executive Director and the Associate Director
have expressed t h e i r support for the change.
RECWENDATIONS:
1. The L e g i s l a t u r e should consider amending A. R. S 930- 1642 to permit
staggering of license renewal dates.
2. ASBN should request the L e g i s l a t u r e to consider funding one a d d i t i o n a l
permanent s t a f f to handle the continuous task of processing renewals
and to eliminate the need for using c l e r i c a l pool workers for t h a t j o b .
FINDING V
COWUNICATION WITH THE INDUSTRY
NEEDS TO BE IMPROVED
The Board of Nursing needs to improve i t s communication w i t h the nursing
i n d u s t r y . Arizona nurses have complained about the Board's slow response
t o i n q u i r i e s and poor communication on Board a c t i v i t i e s . These problems
may stem from the high turnover and poor communication by past executive
d i r e c t o r s .
Nursing Industry Has
V a l i d Complaints About Board
Our interviews w i t h members of Arizona's nursing community i n d i c a t e d a
s t r a i n e d r e l a t i o n s h i p between the Board and some members of the nursing
industry i n recent years. Some industry representatives said they were
d i s s a t i s f i e d with the Board's slow responses to t h e i r i n q u i r i e s and i t s
f a i l u r e to send out newsletters and meeting agenda.
The n u r s i n g i n d u s t r y has asked for guidance and i n t e r p r e t a t i o n s on
important issues which concern the i n d u s t r y , but the Board's responses
have, at times, been slow. Nurses, i n c l u d i n g those serving as h o s p i t a l
nursing d i r e c t o r s , expressed concern that the Board might enforce some
laws or rules according t o i n t e r p r e t a t i o n s which had not been communicated
to I icensees. Because s f t h e i r lack of knowledge of some Board
enforcement p o l i c i e s , nurses said they f e l t vulnerable to Board
d i s c i p l i n a r y actions. For example, nursing d i r e c t o r s say they have
requested c l a r i f i c a t i o n of the four- year- old mandatory r e p o r t i n g law
several times, but have yet to receive an advisory opinion. A f t e r a long
delay, the Board i s now attempting to resolve the issue - i t has requested
an Attorney General's opinion, p a r t i c i p a t e d w i t h the industry i n a task
force to study the issue, and assigned i t s Legal/ lnternal A f f a i r s
committee to d r a f t an opinion.
Other quest ions which have arisen i n the past two years and have not been
answered i n a t i m e l y manner include supervision of school nurses, p a t i e n t
abandonment, and nursing AIDS p a t i e n t s . These issues are important to
the nurses involved, and the Board's delays ( eighteen months i n the school
nurse question) may place the nurses a t r i s k o f v i o l a t i n g the law.
Because ASBN's process for developing advisory opinions on these issues i s
time- consuming, i n t e r i m statements could be made to guide the industry
while awaiting a more formal response. Under t h e Board's current system,
questions are assigned to a standing committee and advisory opinions are
reviewed by the Attorney General's O f f i c e . This procedure i s designed to
permit nursing community input t o the f i n a l decision. However, a year or
more may pass before the a d v i s o r y o p i n i o n i s issued. To provide guidance
to the n u r s i n g i n d u s t r y while an advisory opinion i s under study, the
Board could prepare a memo describing i t s i n t e r i m p o l i c y . According to
the Associate D i r e c t o r of the Board o f Medical Examiners, that Board uses
a s i m i l a r method w i t h good r e s u l t s .
I n a d d i t i o n , ASBN's routine communications have been sporadic and
incomplete. ASBN has n o t published i t s newsletter on a regular schedule,
and Board agendas have not been mailed to i n t e r e s t e d i n d i v i d u a l s . The
newsletter i s an e s s e n t i a l element i n informing the nursing community of
Board decisions, d i s c i p l i n a r y a c t i o n s , and advisory opinions. The agendas
l i s t matters to be discussed a t meetings so those i n t e r e s t e d can attend
and give t h e i r views. The current Executive D i r e c t o r i s attempting to
e s t a b l i s h a regular p u b l i c a t i o n schedule for the newsletter and t o c o r r e c t
problems i n g e t t i n g out meeting n o t i c e s and agendas.
Problems May Result From Turnover
I n Executive D i r e c t o r s
Board r e l a t i o n s w i t h the industry were p o s i t i v e u n t i l May 1985, when an
Executive D i r e c t o r w i t h good i n d u s t r y rapport resigned. That D i r e c t o r had
been very accessible, and had a r e p u t a t i o n i n the nursing community for
responding q u i c k l y to questions or requests f o r i n f o r m a t i o n . A r i z o n a ' s
nurses l i k e d her so much that when she resigned, according to the current
D i r e c t o r , a p e t i t i o n was c i r c u l a t e d t o t r y to b r i n g her back. The Board
has had three D i r e c t o r s since then: an Executive D i r e c t o r who was
terminated i n May 1987, an A c t i n g D i r e c t o r and the current Executive
D i r e c t o r who was appointed i n November 1987. During t h a t time c o n f l i c t s
developed between the Board and i t s s t a f f and between the Board and
various segments of the nursing i n d u s t r y . These c o n f l i c t s resulted from
lack of communication and the d i f f e r e n t p e r s o n a l i t i e s of Board members and
s t a f f .
The Board's current D i r e c t o r , i s attempting to heal the r i f t between the
Board and the community. I n a d d i t i o n t o r e s o l v i n g problems w i t h the
Board's newsletter and meeting notices and agendas, she has increased
d i r e c t communication w i t h the i n d u s t r y . She accepts a l l i n v i t a t i o n s to
attend or speak at nursing o r g a n i z a t i o n meetings, and plans Board meetings
and educational forums outside the Phoenix area.
RECOWENDATION
1. The Board should issue p r e l i m i n a r y a d m i n i s t r a t i v e bul l e t i n s
describing i t s i n t e r i m enforcement p o l i c i e s , instead o f w a i t i n g u n t i l
formal advisory o p i n i o n s a r e ready.
OTHER PERTINENT INFORMATION
During the course of our a u d i t , we developed other p e r t i n e n t information
regarding: 1) the " St. Mary's Case" and 2) entry requirements for
nurses.
S t . Mary's Case
The d i s c i p l i n a r y action against nurses a f f i l i a t e d w i t h S t . Mary's
Hospital i n Tucson was reviewed by our o f f i c e because of the considerable
a t t e n t i o n given to the case. We received numerous l e t t e r s from nurses
concerned about how the Board handled t h i s case. In a d d i t i o n , t h i s ease
was the most controversial of the complaint f i l e s we reviewed.
In February 1988, the Board of Nursing voted to d i s c i p l i n e three nurses
from St. Mary's Hospi t a t . The Board found that nurses i n the hospi t a l l s
Burn Unit had been administering medications without proper physician
approval. Two of the nurses were also placed on probation. One nurse
had improperly removed i n j e c t a b l e valium to t r e a t her husband at home.
The other nurse was the D i r e c t o r o f Nursing at the h o s p i t a l who, although
aware of the i n c i d e n t , d i d n o t r e p o r t i t to the Board. No d i s c i p l i n a r y
action was taken against three other nurses involved i n the case,
although one received a strongly worded l e t t e r of concern.
This case has s t i r r e d considerable controversy i n the nursing community.
According to an Arizona Nursing Association Consultant, the D i r e c t o r of
Nursing involved i n the case i s a leader i n the State and well known
n a t i o n a l l y .
Case chronology - I n January 1986, the Board began receiving telephone
c a l l s complaining about nursing practices i n the Burn Unit at S t .
Mary's. Interviewed i n July 1986, s i x current and former nurses employed
i n the u n i t alleged a broad range of problems: q u a l i t y of nursing
practices i n the u n i t , d i v e r s i o n o f drugs, f a l s i f i c a t i o n of records, and
f a i l u r e o f supervisors and a d m i n i s t r a t o r s t o take c o r r e c t i v e a c t i o n . The
complaints also raised questions as to whether supervisory nurses had
v i o l a t e d the Board's mandatory r e p o r t i n g requirement.
I n November 1986, Board s t a f f met w i t h t h e Attorney General's O f f i c e t o
decide how to proceed w i t h the case. Because the Attorney General's
O f f i c e was concerned about p o s s i b l e c r i m i n a l v i o l a t i o n s , the case was
kept in- house for several months while lawyers from the c r i m i n a l
d i v i s i o n investigated and reviewed i t . Eventually, the case was handed
back over for the Nursing Board to pursue a f t e r i t was determined a basis
f o r proceeding on c r i m i n a l grounds was lacking.
I n October 1987, a c o n f i d e n t i a l s t a f f i n v e s t i g a t i v e report was submitted
to the Board for review. The Board voted to assign the case to an
independent hearing o f f i c e r .
Following a four- day hearing i n December 1987, the hearing o f f i c e r issued
h i s report to the Board recommending that f i v e of the s i x nurses,
i n c l u d i n g the Di rector of Nursing, be censured f o r administering
medications without adequate physician approval . He aI so recommended
t h a t the nurse who had improperly removed valium receive a c i v i l penalty
and be placed on probation for two years. The hearing o f f i c e r
recommended that charges against t h e s i x t h nurse be dismissed.
The Board's f i n a l order followed the hearing o f f i c e r ' s recommendations
w i t h some m o d i f i c a t i o n s . The Board voted to censure three o f the f i v e
nurses recommended for d i s c i p l i n e by the hearing o f f i c e r . I n a d d i t i o n ,
i t placed the nurse who had improperly removed valium and the Nursing
D i r e c t o r on probation for one year. Terms of t h e i r probation require
each to take a class i n medical- legal e t h i c s . No d i s c i p l i n a r y a c t i o n was
taken against the remaining three nurses.
Following the Board's f i n a l decision, t h e three d i s c i p l i n e d nurses f i l e d
an appeal i n superior c o u r t .
Concerns about the case - Based on our review of the case record and
interviews with p a r t i e s to the case, we conclude that the Board's
a c t i o n s , as a whole, were reasonable. However, several l e g i t i m a t e
concerns about the case have been r a i s e d , some of which appear to warrant
f u r t h e r i n v e s t i g a t i o n by the Attorney General and the Governor's O f f i c e .
r Timeliness - There was considerable delay between the time the
Board was f i r s t contacted i n January 1986 and the Board's meeting i n
November 1986 w i t h the Attorney General's O f f i c e . Because a l l of the
employees who worked on the case are no longer employed by the Board,
we were not able t o determine the cause of the delay. One former
investigator speculated that the case may have been set aside due to
the Board's heavy workload. The o r i g i n a l charges appeared
s u f f i c i e n t l y broad and serious, however, t o have demanded a more
timely i n v e s t i g a t i o n .
r Leak o f c o n f i d e n t i a l information - The i n v e s t i g a t i v e report on the
case submitted to the Board i n October 1987 was a c o n f i d e n t i a l
document which contained s p e c i f i c information obtained through the
s t a f f ' s i n v e s t i g a t i o n . This report was leaked to a newspaper i n
Tucson which published a series of a r t i c l e s naming the respondent
nurses and d e t a i l i n g the charges against them. The nurses d i d not
have a copy of t h i s report and, at that p o i n t , had not been provided
the information i n the i n v e s t i g a t i v e r e p o r t . Nurses we interviewed
described reading about the charges for the f i r s t time while they
were d r i v i n g from Tucson to Phoenix to attend a Board meeting. Thus,
they f e l t they had been t r i e d i n the press before they had a chance
to know the charges against them and defend themselves i n f r o n t o f
the Board. The leak had a devastating impact on the nurses
personally and t a i n t e d the Board's proceedings i n t h e i r minds from
that point on.
The i n v e s t i g a t i v e report was most l i k e l y leaked by e i t h e r a Board
member, Board s t a f f , or former s t a f f who may have had access to the
Board o f f i c e and computer. The act of leaking the report may
c o n s t i t u t e a v i o l a t i o n of Board statutes which require
c o n f i d e n t i a l i t y , and could be subject to c r i m i n a l sanction. I f a
Board member leaked the r e p o r t , the act could also c o n s t i t u t e grounds
for removal of the Board member by the Governor. ( A copy of t h i s
report has been forwarded to the Attorney General and the Governor's
O f f i c e so they can review whether legal or a d m i n i s t r a t i v e a c t i o n
should be taken regarding the leak.)
o Board contact with respondents - Following the Board's meeting i n
February 1988 when i t voted t o d i s c i p l i n e three o f the nurses, a
Board member contacted the daughter of one of the respondent nurses.
According to a sworn statement signed by the daughter, the Board
member indicated that two Board members may have had c o n f l i c t s and
should not have been involved i n the case, and that the Board was
s p l i t : three members were i n favor of the nurses and " three were out
to hang them.'' However, the Board member denies having made t h i s
statement during the conversation. The conversation also raised
concerns as to whether Board members had v i o l a t e d the Open Meeting
Law by meeting a second time without g i v i n g proper n o t i c e .
This matter was investigated by the Attorney General's O f f i c e and no
evidence of an Open Meeting Law v i o l a t i o n was discovered. The Board
member's contact w i t h the respondent nurse's daughter, at a point
p r i o r to release of the Board's f i n a l order, may have been
inappropriate. An Attorney General representative stated that Board
members are normally i n s t r u c t e d not to contact anyone to discuss
pending matters. According t o an informal opinion from L e g i s l a t i v e
Council, such conduct could c o n s t i t u t e grounds for removal by the
Governor.
0 I n v e s t i g a t i v e i n t e r v i e w s and techniques - A review of the o r i g i n a l
i n v e s t i g a t i v e i n t e r v i e w w i t h the complaining nurses i n July 1986
reveals some inappropriate statements made by the Board consultant
who investigated the case. For example, the consultant, who i s no
longer employed by the Board, stated that " when you do an incident
report i f there i s a tendency for them to disappear, I suggest that
you e i t h e r make a d u p l i c a t e o r make a copy before you turn i t i n . "
Respondent nurses argue that statements l i k e t h i s were encouragements
to complaining nurses to improperly remove h o s p i t a l records and
provide them to the Board. I t i s not the Board's p o l i c y to encourage
the improper taking of records by complaining p a r t i e s . The Board has
subpoena powers and can obtain records on i t s own a u t h o r i t y .
The same c o n s u l t a n t a l s o appeared to depart from her f a c t - f i n d i n g
r o l e by concluding on the testimony of the complaining nurses before
an i n v e s t i g a t i o n was done. For example, i n response to a quest ion as
to whether supervisory nurses should be p a r t o f the o r i g i n a l w r i t t e n
complaint, the Board i n v e s t i g a t o r s t a t e d : " Everybody that ( s i c ) was
involved was i n v i o l a t i o n . " Respondent nurses have stated t h a t they
f e l t they were considered g u i l t y by the Board before they even had an
opportunity to defend themselves.
Another concern i s t h a t the case was assigned to an inexperienced
i n v e s t i g a t o r a f t e r the i n i t i a l i n v e s t i g a t o r l e f t the Board. The
Board i n v e s t i g a t o r who took over the case was a new employee who d i d
not receive i n v e s t i g a t i v e t r a i n i n g u n t i l September 1987. Thus, she
had been working on the S t . Mary's case for almost a year before she
received any formal t r a i n i n g .
a L e t t e r of concern - Nurses were t o l d a t t h e i r interviews that the
Board can issue a l e t t e r of concern. They were t o l d that these
l e t t e r s are not Board d i s c i p l i n e and do not go i n t o the nurses'
permanent f i l e s . The l e t t e r of concern, which was approved by the
S o l i c i t o r General's O f f i c e , went to one of the nurses and i s a
sharply worded admonishment which appears to i n d i c a t e t h a t the nurse
was found to have v i o l a t e d standards of p r a c t i c e for nurses. I t
states that future complaints a l l e g i n g s i m i l a r problems could r e s u l t
i n " more serious consequences." The l e t t e r contains no language
explaining that l e t t e r s of concern are n o t d i s c i p l i n a r y actions of
the Board and are issued when there i s i n s u f f i c i e n t evidence to take
such actions. The wording of such l e t t e r s of concern was discussed
at the Board's meeting i n September 1988 and r e v i s i o n s to l e t t e r s of
concern w i l l be considered.
Respondent nurses also expressed concern that they were not adequately
informed of the charges against them when they were i n i t i a l l y interviewed
by the Board i n v e s t i g a t o r i n July 1987. Nurses were informed by the
i n v e s t i g a t o r a t t h e i r interviews i n July 1987 that complaints about
p r a c t i c e s i n the Burn U n i t had been received. S p e c i f i c charges made
against each i n d i v i d u a l nurse, however, were not enumerated. This
procedure departed from t h e Board's usual p o l i c y whereby respondent
nurses are informed of the nature of the a l l e g a t i o n s against them when
they are interviewed by the Board. The interviews were conducted i n t h i s
manner, however, on advice o f the Attorney General's O f f i c e . The Attorney
General representat ives hand l i ng the case were concerned about possible
d e s t r u c t i o n of records and d i d not want to f u l l y disclose a l l e g a t i o n s to
the respondent nurses.
Entry Requirements
For several years, national a t t e n t i o n has been focused on r e v i s i n g entry
requirements for nurses. The American Nursing Association and the
National League for Nursing have both proposed increased educational
standards for entry i n t o p r a c t i c e . The associations propose the
establishment of two levels of nursing practice - professional and
t e c h n i c a l . For a professional nurse, the minimum preparation would be a
baccalaureate i n nursing, and for a technical nurse, the minimum
preparation would be an associate degree i n nursing ( ADN).
According to proponents, the establishment of these educational
requirements for entry i n t o p r a c t i c e would standardize t r a i n i n g for
nurses who work i n an increasingly complex f i e l d . A professional nurse
would have the knowledge base r e q u i s i t e f o r a d d i t i o n a l formal education
i n specialized c l i n i c a l p r a c t i c e , nursing research, nursing
administration, and nursing education. A technical nurse would be
prepared to engage i n the technical aspects of the c l i n i c a l p r a c t i c e o f
nursing and would have the knowledge base to apply a circumscribed body
of established nursing p r i n c i p l e s and s k i l l s .
There are several arguments against increasing educational requirements.
F i r s t , there i s a nationwide nursing shortage, and an increase i n
educational requirements may b r i n g enrollment i n t o nursing programs down
even f u r t h e r . Second, the opportunity to become an RN would be
r e s t r i c t e d since the programs would have to be offered through four- year
colleges and u n i v e r s i t i e s . I f four- year degrees were required, i t would
become more d i f f i c u l t f o r i n d i v i d u a l s r e s i d i n g i n counties outside the
U n i v e r s i t y areas t o attend since many registered nurses obtain a two- year
degree at a community c o l l e g e .
Currently, North Dakota i s the only s t a t e with a BSN requirement for
registered nurses and an ADN for licensed p r a c t i c a l nurses. Arizona was
the only s t a t e considering entry requirements i n t o i t s l e g i s l a t i o n t h i s
year. In May, 1988, a 21 member task force representing a1 I members of
the nursing industry was created to d r a f t r e v i s i o n s to Arizona's Nurse
P r a c t i c e A c t . Entry requirements was one of the areas to be addressed by
the task force. However, i n September, 1988, the task force decided not
to address the entry requirement issue and other c o n t r o v e r s i a l issues i n
the upcoming l e g i s l a t i v e session because these issues had not yet been
resolved w i t h i n the task force i t s e l f .
@ ARIZONA STATE BOARD OF NURSING
ROSE MOFFORD, Governor
FRAN ROBERTS, R. N., M. S., Executive Director
October 28, 1988
M r . Douglas R. Norton
Auditor General
S t a t e of Arizona
Office of the Auditor General
2700 N. C e n t r a l , S u i t e 700
Phoenix, AZ 85004
Dear M r . Norton:
This l e t t e r r e p r e s e n t s the response of the Arizona S t a t e Board of Nursing ( ASBN)
t o the performance a u d i t conducted by the Auditor General's o f f i c e . Our
response w i l l be d i r e c t e d primarily towards t h e f i v e findings and
recommendations of the r e p o r t , comments on the areas referenced under the
s e c t i o n t i t l e d " other p e r t i n e n t information" and a b r i e f i n t r o d u c t o r y paragraph.
Introduction. The ASBN has viewed t h i s a u d i t process with enthusiasm and
a n t i c i p a t i o n . In its e f f o r t t o p r o t e c t t h e public h e a l t h , s a f e t y and welfare
through t h e r e g u l a t i o n of nursing p r a c t i c e and education, the Board acknowledges
t h a t the Agency and community a t l a r g e can only b e n e f i t from a healthy,
o b j e c t i v e evaluation. C e r t a i n l y , t h e Board f u r t h e r recognizes t h a t t h e changes,
challenges and c o n f l i c t s it has been confronted by i n the ensuing y e a r s s i n c e
the 1981 performance a u d i t , has brought the ASBN t o a highly v i s i b l e l e v e l
i n the nursing community. The Board, comprised of a group of committed, caring
and knowledgeable i n d i v i d u a l s , continues t o embrace its r e s p o n s i b i l i t y t o the
public and its concurrent support of the n u r s i n g p r o f e s s i o n .
Finding I. The Board requests t h a t the most recent d a t a be considered when
assessing the t i m e l i n e s s of complaint i n v e s t i g a t i o n s . While admittedly current
s t a f f have i n h e r i t e d " older cases'' which are d i f f i c u l t t o i n v e s t i g a t e ,
s t a t i s t i c s on F i s c a l Year ( FY) 1988 ( J u l y 1, 1987 through June 30, 1988) shed
a very p o s i t i v e l i g h t on the t i m e l i n e s s of i n v e s t i g a t i o n s . ASBN's d a t a i n d i c a t e
t h a t of the 391 complaints received during FY88, 317 have been brought t o the
Board for r e s o l u t i o n and only 74 remain under i n v e s t i g a t i o n . Of the 74 under
i n v e s t i g a t i o n , approximately 20 have been presented t o the Board and were
d i r e c t e d by the Board t o undergo f u r t h e r i n v e s t i g a t i o n o r f a c t - f i n d i n g by the
s t a f f . This i n d i c a t e s t h a t of the t o t a l number of complaints received i n FY88,
2001 WEST CAMELBACK ROAD SUITE 350 ( 602) 255- 5092 PHOENIX, ARIZONA 85015
Douglas Nor ton
81% have been resolved through some form of Board action. Further, the
Executive Director has instructed the investigative staff to expedite
investigation on any cases received prior to FY88 which have not yet been
presented by bringing these cases to the Board no later than January 1989.
The Board is pleased to include in this response that the staff turnover rate,
which hit an all- time high of 127% in 1986, has descended to less that 10%
in the past two quarters. Under new management, staff dissension is virtually
non- existent and morale and motivation is high. Additionally, as a result
of this change in administration, a complaint tracking system has been
established and will be further refined and automated through the course of
the current fiscal year.
Recommendation 1, 2 and 5. The Board, as indicated above, agrees with
these recommendations and commits to accomplishment in FY89.
Recommendations 3 and 4. Due to both great budgeting constraints and high
turnover, the Board has not been able to support the training and education
essential to staff in order to protect the public and ensure high quality
performance. In the past quarter, one staff attended the week- long
investigator's training sessions sponsored by the Commission for Licensure,
Enforcement and Regulation and two additional staff will attend in December,
1988. The Board agrees wholeheartedly with this recommendation but has
not had the financial support to proceed. While the Board additionally
agrees with a recommendation supporting supplemental investigative staff,
it voices concern regarding utilization of non- nurse personnel to
investigate. Arguments can certainly be heard for both views, however
the Board believes it is essential to employ individuals with a clear
understanding of the nursing process and patient care to perform
knowledgeable and just investigations.
Finding 11. While the Board agrees that the request for a sworn letter of
complaint is unnecessary and redundant, it wishes to clarify that investigations
of concern are not " held up" awaiting sworn complaints.
Recommendation 1. The Board agrees.
Findng 111. The data brought forth in this report substantiates the very
sincere concerns of the Board in the past year. In a responsible effort to
address this well- documented deficit, the Board submitted legislation in the
1988 session to increase the overall fee structure of the Agency. This piece
of legislation, House Bill 2222, was greatly amended through pressure from
select segments of the nursing community, to allow for a one- time surcharge
to the 1988 Registered Nurse license renewal fee and called for a performance
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audit by the Auditor General's office. Although frustrated by the delay, the
Board welcomes the objective documentation in this report which supports the
concerns expressed by the Board over a year ago.
Recommendations 1, 2 and 3. The Board is in total agreement.
Finding IV. As this response is being written, the ASBN office is receiving
approximately 2000 RN renewal application responses per day. By December 31,
1988 the Board anticipates that it will have processed over 35,000 renewal
applications over a ten week period. Reasonably stated, this process does
not make a case for staff productivity, harmony or sanity. Additionally, it
places a strain on the nursing community at large. Lastly, as indicated in
the audit report, this process plays havoc with the Agency's revenue flow.
In conclusion, the Board wholeheartedly accepts Recommendations 1 and 2.
Finding V. The Board acknowledges some problems in the area of community
communication in the past few years and appreciates the recognition given for
recent improvements. Certainly communication, especially between a profession
as large as nursing represents in Arizona and their licensing and regulatory
board, will always require careful cultivation and monitoring. While areas
critically outlined in the report such as timely newsletter publication and
agenda distribution are uncontested by the Board, issue is taken with the
overall negativity reported concerning the Board's response to requests for
advisory opinions.
The ability to issue advisory opinions was added to the Arizona Nurse Practice
Act in 1984. Since that time, over 25 opinions have been issued. As one would
expect, some questions are straight forward and simple, others have complicated
facets and far- reaching implications. The " easy ones" can be expedited through
minimal research and supplemental advisement. The more complex requests for
opinions often require comprehensive reviews of literature, discussions ( verbal
and written) with other state boards of nursing or other professional boards,
surveys to specific groups in the nursing community, consultation with
professional nursing associations and lastly, advisement for legal direction
from the Attorney General's office. In the later case, advisement may take
as long as one year's time.
While the Board supports the Auditor General's concern for placing a nurse
at risk for violating a law while an issue is undergoing research, it expresses
even greater concern for the implications created by advisory opinions reached
through less than comprehensive methods. A partial solution is found in the
recommendation for issuing preliminary administrative bulletins. Indeed, the
Board thought this recommendation by the Auditor General was so helpful, it
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u t i l i z e d t h i s process i n the October 1988 Board meeting, one month prior to
the p u b l i c a t i o n of t h i s f i n a l r e p o r t !
S p e c i f i c a l l y speaking, the process i n reaching an advisory opinion on mandatory
reporting has been arduous. The Board would l i k e t o use t h i s request as an
example of the s t e p s taken t o reach a complex advisory opinion.
In January of 1988, the Arizona Organization of Nurse Executives ( AZONE)
formally requested a l e g a l opinion from the ASBN regarding mandatory reporting.
The ASBN followed with a request for a l e g a l opinion t o the Assistant Attorney
General then assigned t o represent the Agency ( January 1988). In order t o
provide interim r e l i e f while awaiting advisement from the Attorney General's
o f f i c e , c6pies of an a r t i c l e from the December 1988 Journal of Nursing
Administration, t i t l e d " Mandatory Reporting: Legal and E t h i c a l I s s u e s , " were
d i s t r i b u t e d by the ASBN Executive Director a t the January 1988 AZONE meeting.
In the March 1988 Board meeting, seeing t h a t an answer from the AG's o f f i c e
was not i n s i g h t , t h e Board voted t o e s t a b l i s h a community based ad hoc
committee on mandatory r e p o r t i n g . A leader i n the nursing executive community
was requested by the Board t o serve as chairman of t h i s committee and t o a s s i s t
i n the s e l e c t i o n of key nurses representing both geographical areas of the
S t a t e and a wide range of nurse p r a c t i c e s p e c i a l i t i e s , a s members. In the
June 1988 Board meeting, the chairman of the Ad Hoc Committee on Mandatory
Reporting d i s t r i b u t e d t o Board members the Committee's report and presented a
a summarization of the process and recommendations outlined i n the r e p o r t .
The Board requested time t o review t h e r e p o r t and i n v i t e d the chairman t o r e t u r n
t o the July Board meeting t o respond t o questions. In t h e J u l y 1988 Board
meeting, a unanimous decision was reached t o accept the f u l l r e p o r t of the
committee. The Board then d i r e c t e d the L e g a l / I n t e r n a l Affairs Committee of
the ASBN t o d r a f t an advisory opinion on mandatory reporting ( based on ( I
recommendations from the ad hoc group) by November 1988. This process has
occurred and the f i v e page d r a f t advisory opinion on mandatory reporting w i l l
be presented t o the Board on November 18, 1988 by the chairperson of the
L e g a l I I n t e r n a l A f f a i r s Committee.
Ten months have passed since the i n i t i a l request for an advisory opinion and
the ASBN is a t a point of c l o s u r e , although no advisement has been received
from the Attorney General's o f f i c e . The Board is confident t h a t the f i n a l
opinion w i l l be one which has taken i n t o consideration components i n other
s t a t e s ' nurse p r a c t i c e a c t s , what current nursing l i t e r a t u r e i n d i c a t e s regarding
t h i s subject and widespread community input. Although c e r t a i n i n d i v i d u a l s
may have experienced f r u s t r a t i o n a t the time invested i n t h i s ten month process,
the Board believes t h i s process supports the best r e s u l t s i n protecting the
Douglas Norton
public h e a l t h , s a f e t y and welfare and a s s i s t i n g t h e nursing community i n t h e i r
need for c l a r i f i c a t i o n of the Arizona Nurse P r a c t i c e Act.
Recommendation I. As c i t e d i n the above t e x t , the ASBN f i n d s t h i s t o be
an extremely c o n s t r u c t i v e suggestion and has begun its u t i l i z a t i o n .
Other P e r t i n e n t Information - St. Mary's Case. Due t o the f a c t t h a t t h i s case
is c u r r e n t l y being reviewed i n the Superior Court of Arizona, the ASBN is unable
t o make e d i t o r i a l comments. However, one point of c l a r i f i c a t i o n is i n order
under the s e c t i o n t i t l e d Board c o n t a c t w i t h respondents. The Board member
who conversed with a daughter of a respondent nurse contacted her only a f t e r
she f i r s t made attempts, and l e f t messages, t o have him c o n t a c t h e r . The audit
r e p o r t implies t h a t t h e i n i t i a l contact was made by the Board member t o the
respondent's daughter.
Entry Requirements. Both the Arizona S t a t e Board of Nursing and the National
Council of S t a t e Boards of Nursing maintain n e u t r a l p o s i t i o n s on t h i s
long- standing nursing i s s u e .
Lastly, the ASBN, which includes board members and s t a f f , thanks you for the
thorough and p r o f e s s i o n a l e v a l u a t i o n of t h i s Agency's a b i l i t y t o meet its
l e g i s l a t i v e mandate. Your recommendations a r e c o n s t r u c t i v e and reasonable
and w i l l serve t o a s s i s t the ASBN i n our mission t o protect the public h e a l t h ,
s a f e t y and welfare through the r e g u l a t i o n of nursing education and p r a c t i c e .
Sincerely,
Fran Roberts
Executive Director