The leadership of the New Jersey State Nurses Association and the Board of Directors are very disappointed that our elected officials are not taking the ongoing issues at the Board of Nursing more seriously, which is putting the patients of New Jersey at risk. Troubles at the Board of Nursing are not just a public health crisis, they are a patient safety crisis that has been ongoing for several administrations and heighted during the past eight years.

We come to you as a nonpartisan professional association that is looking out for the best interests of the practice of nursing and the patients of New Jersey, and we are all patients.

Late last week, Gov. Chris Christie announced the appointment of 10 new members and 3 reappointments to the Board of Nursing. It is curious that we had not seen any action from this governor or previous governors to appoint any new Board of Nursing members until less than a week before this hearing. It is unfortunate Dr. Patricia Murphy, the president of the Board of Nursing, was relieved of her duties on the board effective last Friday. If she remained on the board through the end of the year to assist with the transition to the new president of the board and the new executive director, her years of experience and institutional knowledge about the Board of Nursing and nursing in New Jersey would have been an invaluable resource to those incoming positions.

Board of Nursing appointees who conduct the business of the Board and review disciplinary cases among other duties. Some of the vacant seats had been unfilled for years, and as members retired or aged off, no replacement appointments had been made. Several of the seven filled positions have expired or are ineligible for re-appointment due to term limits. It’s uncanny that all of a sudden there is a full slate of appointments and a full Board after so many years of dysfunction.

We also have seen no movement on filling the executive director position vacated by Dorothy Carolina back in July after just 13 months in the role and, as far as we know, the members of the Board of Nursing have not received any applications to review. To the best of our knowledge, there also has been no authorization for overtime to deal with the backlog of paperwork.

Staffing the Board of Nursing & Funding

Staffing at the Board of Nursing is also an issue. There is only one registered nurse, whose job it is to oversee disciplinary cases, in the role of acting executive director. The executive director position has been vacant since Dorothy Carolina resigned at the end of July. There are two part time nurses filling in to assist. The position of deputy executive director is also vacant, which puts the board in a perilous position without a qualified nurse to guide it.

Budget should not be an issue. The State of New Jersey collects more than $14.5 million in revenue, according to records we OPRA requested. We are unsure, based on the documents provided to us, how the money is spent. The nurses of New Jersey certainly generate enough money to adequately support a fully-staffed Board of Nursing with appropriate educational backgrounds and experience, the records available through OPRA do not clearly explain the finances of the Board of Nursing, they only leads to more questions.

Board of Nursing responsibilities

The Board of Nursing staff review all licensure applications, which are both paper and electronic. A new nurse must fill out an application and have it approved by the Board before they can sit for the NCLEX licensure exam. This process has been taking more than 60 days for the most recent graduating classes. This is leading to employment offers being revoked and lower NCLEX scores and/or failures because the Board is not reviewing applications in a timely fashion. After the NCLEX scores arrive at the Board of Nursing, the licenses are issued in a timely fashion because it is an all-electronic process.

To further aggravate the primary care crisis, the licensure process for advanced practice nurses (APN)’s is dragged along at the Board of Nursing. Not only do APN’s need their nursing license, they need a secondary licensure to practice as an APN after they complete their Masters or Doctoral degrees and sit for a National Certification in specialty area of practice exam. This paperwork gets bogged down at the Board of Nursing, delaying these nurses the ability to practice and help patients.

For nurses looking to come into New Jersey and practice or leave New Jersey and practice elsewhere, there are delays in the endorsement process. One case sticks out in particular because a nurse came to NJSNA desperate for assistance because she had been waiting since March for her paperwork to process to practice in another state and had not received a response by July. Due to the non responsiveness of the New Jersey Board of Nursing, other state’s Boards of Nursing are requiring that applicants get their own paperwork from New Jersey.

Contrary to a letter by former Director of Consumer Affairs, S. Lee stating there was no backlog of applications, the NJSNA has received multiple calls about wait times and has been made aware that temporary staff were sent down to help with the issue.

Delays caused by the short staffing at the Board of Nursing will magnify existing shortages in nursing, especially APN’s who are taking on larger roles in the healthcare system.

Community-based care from APN’s

Healthcare is moving back into a community-based model of care where APNs are increasingly being utilized for their skills to be primary caregivers for large segments of the population. Medical schools are not producing enough primary care doctors, which is leaving a gap in our healthcare system. APN’s are filling these gaps and providing care, especially in rural and urban communities. What will our healthcare system look like in a few years when there are not enough registered nurses?

Will this lead to a trend of unlicensed people taking up the slack which could lead to increased fall rates, medication errors other mistakes with lesser trained care providers?

There is a predicted shortage of nurses coming in the next few years when the Baby Boomer nurses retire. If we cannot get these problems at the Board of Nursing fixed, who will process the applications of the new nurses that will be coming in to take care of the patients of New Jersey? Hospitals will not be able to fill their vacancies in a timely manner and this will not only be a staffing issue, it will become a patient safety issue. Would you want an overworked nurse caring for your mother or wife in the ICU or your baby in the NICU?

Other issues

Lack of an education person on the Board of Nursing means nursing programs do not have quality supervision. There is no staff at the Board of Nursing qualified to visit programs to ensure that the standards of nursing education are being met, especially in the licensed practical nurse programs. Currently, a consultant—a doctorally prepared RN—is reviewing nursing programs and program applications, but not conducting on-site visits to educational institutions.  Another problem is that few schools are not doing thorough screenings of nursing students so graduates are running into problems when applying for their licenses.

The outsourced Board of Nursing call center frequently gives callers incorrect information about applications, continuing education requirements and other professional related issues. As it is outsourced, they send a messages to the Board of Nursing for information that never seems to get returned.

Recommendations:

• State legislators and the Governor’s office must aggressively work to fill the positions of Executive Director and Deputy Executive Director within the next 12-16 weeks.
• The current position posting contains the requirement of a Bachelor’s Degree not specific to nursing. This is a downgrade from previous position postings and must be changed to reflect the complexity of oversight of educational programs and complex issues presented before the board. This must be changed to ensure that the executive director has a higher degree. An entry level degree, and one that is not required for the discipline of nursing, is unacceptable.
• While not all work of the Board needs to be carried out by Registered Nurses, the executive director, deputy executive director and those who oversee licensing, disciplinary and education should all be Registered Nurses, preferably with a Doctoral degree and related experience.
• There must be sufficient staff within the Board of Nursing to process applications for licensure or licensure by endorsement in a timely manner. These should be regular employees of the BON and not temporary workers sent to provide a stop-gap measure.
• The effectiveness of the outsourced call center should be measured for cost, quality and accuracy. If these indicators cannot be shown, then perhaps it would be more cost-effective to bring the work back internally with a few dedicated staff members.
• Audit usage of the more than $14.5 million in revenues collected annually from Board of Nursing through licenses, permits, penalties and other services. We know 5 percent of monies collected goes to the New Jersey Collaborating Center for Nursing and $5 of each license fee, about $600,000, goes to support the Recovery and Monitoring Program. Where does the rest of the money go? The budget breakdown we OPRA requested does not clearly define how the money is appropriated.

Thank you for allowing me the opportunity to provide this input on behalf of the New Jersey State Nurses Association and the Nurses of our state.

Benjamin Evans, DD, DNP, RN, APN, president, New Jersey State Nurses Association, October 5, 2017