Nursing Clinical Hours

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LEGISLATIVE BUDGET BOARD STAFF JANUARY 2009 TEXAS STATE GOVERNMENT EFFECTIVENESS AND EFFICIENCY 419

DEFINE AND TRACK CLINICAL PRACTICE HOURS FOR

PROFESSIONAL NURSE EDUCATION PROGRAMS

Education programs for training registered nurses require

students to complete a defined number of clinical practice

hours to be eligible to sit for a licensure examination

administered by the Texas Board of Nursing. ese clinical

practice hours are taught at external, independent medical

care facilities. Texas institutions of higher education that

provide training for potential registered nurses do not have

direct control over the provision of these clinical practice

hours.

e Eightieth Legislature, 2007, enacted legislation to

increase the number of registered nurses by increasing the

number of graduates of professional nursing programs. e

eorts were largely focused on elements within the direct

control of these institutions. ere has not been an assessment

of the ability of Texas health service provider facilities to

provide the clinical practice hours required to meet these

state goals. e eort to increase the number of nursing

graduates could be stymied by limitations on available clinical

practice hours that institutions are able to access. Establishing

a method for tracking available clinical practice hours and

specifying a standard range of hours required for certification

would increase the possibility that state funds devoted to

increase the number of registered nurses would be used

e ciently.

FACT AND FINDING

Locating su cient clinical practice hours for students

of professional nursing programs is a growing concern

among directors of registered nurse education

programs in Texas.

CONCERNS

Many professional nurse education programs in

Texas cannot provide an estimate of available clinicalpractice hours in their area. Without this information,

these programs may not possess su ciently precise

information about the capacity constraints they face

to guide their decision making.

Professional nurse education programs do not have

su cient information to link clinical practice hour

availability to faculty hiring decisions. State eorts

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to increase the number of registered nurses may

direct funds to expand capacity at institutions of

higher education that cannot access su cient clinical

practice hours.

Texas Board of Nursing rules on required clinical

practice hours for licensure as a registered nurse allow

institutions wide latitude in the amount of clinical

practice hours they require for a degree. is allows a

wide disparity by institution in the number of clinical

practice hours required for a nursing degree. is

disparity may contribute to an ine cient allocation

of clinical practice hours.

RECOMMENDATIONS

Recommendation 1: Amend the Texas Health and

Safety Code to establish a database of available clinical

practice hours at the Center for Nursing Workforce

Studies in the Department of State Health Services.

e center would be required to report unused clinical

practice hours to institutions of higher education

yearly and to report biennially to the Legislature on

the systemic distribution of unused clinical practicehours.

Recommendation 2: Amend the Texas Occupations

Code to direct the Texas Board of Nursing to amend

its rules to establish a range for the number of clinical

practice hours required to be licensed as a registered

nurse in Texas.

DISCUSSION

Institutions of higher education produce graduates by using

capital (in the form of building and facilities) and labor (in

the form of instructors and sta) on students. For themajority of degrees awarded by these institutions, the labor

and capital required are completely self-contained in the

institution and, along with the institutions productivity,

determine a production function. Institutional policies, state

statutes, and other directives can be used to modify the

production function and influence the quantity of degrees

awarded.

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420 TEXAS STATE GOVERNMENT EFFECTIVENESS AND EFFICIENCY LEGISLATIVE BUDGET BOARD STAFF JANUARY 2009

DEFINE AND TRACK CLINICAL PRACTICE HOURS FOR PROFESSIONAL NURSE EDUCATION PROGRAMS

For a select group of disciplines, however, the degree

production function is not self-contained within the

institution. Many of these disciplines are in allied health

fields. For a student to graduate with a qualification in these

disciplines, the degree requirements include clinical practice

hours under supervision by a health service provider. us,

the production function for these degrees also includes health

service provider facilities not under the control of the

institution or the state. As a result, the number of graduates

in some allied health fields is potentially constrained by

elements of the production function that are external to the

institution.

Registered nursing was one specific allied health field that

was the subject of significant attention by the Eightieth

Legislature, 2007. is activity occurred after a series of

reports showed a growing shortfall in the number of registered

nurses (RNs) in Texas over the next two decades. Figure 317

shows a list of legislative acts from 2007 relating to nursing

education. Senate Bills 138 and 139 represent systemic efforts

to improve nursing education and to increase productivity

within the confines of institutions of higher education.

Senate Bills 201 and 289, conversely, are more narrowly

tailored approaches to the issue of ensuring the supply of

suffi cient clinical practice hours.

Efforts by the Texas Legislature to increase the productivity

of the institutions portion of nursing education could be

stymied by limitations on clinical practice hours that

institutions are able to access. To examine the extent of this

potential constraint, Legislative Budget Board staff conducted

a survey of professional nursing education programs at public

institutions of higher education in Texas. e survey requested

information on a variety of questions related to clinical

practice hours. As of September 2008, 49 percent (36 of 74)

of nursing programs provided a response to this survey.

CONCERN FOR CLINICAL PRACTICE HOUR AVAILABILITY

Figure 318 shows the response to two survey questions that

asked whether clinical practice hours pose a constraint to

nursing education programs.

e survey responses to the first query in Figure 318 showthat institutions are concerned about the issue of clinical

practice hour availability. Seventy-seven percent of programs

surveyed either slightly or strongly agreed with the statement

that finding suffi cient clinical hours for our students has

been a challenge. Only 20 percent of programs disagreed

either slightly or strongly with this statement.

Survey respondents also see clinical practice hour availability

as a challenge that will grow in the future. Ninety-one percent

of respondents agree with the statement, I am worried about

finding suffi cient clinical space in the future. Only 6 percent

of respondents disagreed with the statement. Taken together,the responses to two questions in Figure 318 indicate that

clinical practice hours are a current and growing constraint

to nursing education programs.

UNCERTAINTY OF INSTITUTIONS CAPACITY CONSTRAINTS

Institutions that attempt to expand the number of professional

nursing graduates produced by their program face a complex

production decision. ey have to balance the interest of

potential students in the area, the constraints imposed by

their faculty staffi ng and physical plant, and the availability

of clinical practice hours that are within a reasonable distance

of their students.

Institutions were asked how many unused clinical practice

hours were available at local facilities. Few of the programs

surveyed could estimate these resources. Seventy-four percent

of institutions did not provide an estimate of clinical practice

hours available to them in their local area. is result suggests

that while professional nursing education programs are

generally aware of the issue of clinical practice hour

availability, they may not possess suffi ciently precise

information about the capacity constraints to guide their

decision making.

RELATIONSHIP OF ADDING FACULTY

MEMBERS TO PRODUCING ADDITIONAL

PROFESSIONAL NURSE GRADUATES

Professional nursing education programs were asked the

number of additional graduates their program could produce

if they were able to use all clinical practice hours available to

them. e percentage increase by program is shown in

Figure 319.

FIGURE 317

LEGISLATIVE ACTIONS TO IMPROVE PROFESSIONAL NURSE

EDUCATION, EIGHTIETH LEGISLATURE, 2007

LEGISLATION DESCRIPTION

Senate Bill 138 Incentives to promote retention and graduation

Senate Bill 139 Improve nursing program curricula

Senate Bill 201 Tuition exemption for clinical preceptors

Senate Bill 289 Allows part-time faculty for clinical instruction

SOURCE: Legislative Budget Board.


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irty-nine percent of programs were unable to estimate

how many more graduates they could produce using existing

clinical practice hours. irty-nine percent of programs

projected modest increases in graduates (50 percent or less),

while 18 percent of programs projected potential increases of

over 100 percent. In general, programs that projected larger

percentage increases in professional nurse graduates were of

smaller scale than those that projected smaller percentage

increases.

Figure 320 shows the number of additional faculty members

programs estimated they could use given existing clinicalpractice hours. Forty-one percent of programs were unabletoprovide this estimate.

Many programs do not have clear information linking the

availability of clinical practice hours to their potential to

produce additional professional nursing graduates. us,

state efforts intended to increase the number of RNs may

direct state funds to expand capacity at institutions of higher

education that do not have suffi cient clinical practice hours

available in their area. Conversely, the state may not be

providing suffi cient funds to institutions in areas that have

this capacity.

Recommendation 1 would amend Section 105 of the Texas

Health and Safety Code to establish a database of available

clinical practice hours at the Center for Nursing Workforce

Studies. Under Health and Safety Code 222.005, the

Commissioner of the Department of State Health Services

(DSHS) has the authority to require reports of hospitals. eamended Section 105 would require these facilities to report

annually overall clinical practice hour capacity and the usage

of these hours by institution of higher education to the

center. e center would be authorized to exempt hospitals

from this requirement if they are not able to provide clinical

practice hours to professional nursing students. e center

would be required to report unused clinical practice hours to

FIGURE 318

OPINION OF PROFESSIONAL NURSING PROGRAMS ON CHALLENGE OF PROVIDING CLINICAL PRACTICE HOURS,

SEPTEMBER 2008

OPINION

FINDING SUFFICIENT CLINICAL HOURS FOR OUR

STUDENTS HAS BEEN A CHALLENGE.

I AM WORRIED ABOUT FINDING SUFFICIENT

CLINICAL SPACE IN THE FUTURE.

Strongly agree 18 22

Slightly agree 9 10

Neither agree nor disagree 1 1

Slightly disagree 5 2

Strongly disagree 2 0

TOTAL 35 35

NOTE: One respondent did not answer these questions.


FIGURE 319

PERCENTAGE INCREASE IN PROFESSIONAL NURSE

GRADUATES POSSIBLE WITH EXISTING CLINICAL

PRACTICE HOUR CONSTRAINTS, SEPTEMBER 2008PERCENTAGE INCREASE IN

NUMBER OF GRADUATES NUMBER OF PROGRAMS

Do not know 13

0% to 25% 3

26% to 50% 10

51% to 75% 0

76% to 100% 1

More than 100% 6

TOTAL 33

NOTE: Three respondents did not answer this question.


FIGURE 320

NUMBER OF FACULTY MEMBERS NEEDED TO REACH

CLINICAL PRACTICE HOUR CONSTRAINT, SEPTEMBER 2008

ADDITIONAL FACULTY MEMBERS

NEEDED TO REACH CLINICAL

PRACTICE HOUR CONSTRAINT NUMBER OF PROGRAMS

Do not know 14

0 2

1 2

2 3

3 4

4 4

5 or greater 5

TOTAL 34

NOTE: Two respondents did not answer this question.SOURCE: Legislative Budget Board.


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422 TEXAS STATE GOVERNMENT EFFECTIVENESS AND EFFICIENCY LEGISLATIVE BUDGET BOARD STAFF JANUARY 2009


institutions of higher education yearly, enabling currently

constrained programs to identify and pursue underutilized

resources. In addition, the center would be directed to report

biennially to the Legislature on the systemic distribution of

unused clinical practice hours available for professional

nursing education. is report would identify specific

programs that could be targeted for capacity increases based

on their access to additional clinical practice hours.

VARIANCE OF REQUIRED CLINICAL PRACTICE HOURS

e number of clinical practice hours for an RN qualification

is not designated by the Texas Board of Nursing (BON).

Board of Nursing Rule 215.9 simply states that:

[t]here shall be a rationale for the ratio of contact hours

assigned to classroom and clinical learning experiences. e

recommended ratio is three contact hours of clinical learning

experiences for each contact hour of classroom instruction.

Professional nursing education programs were asked how

many clinical practice hours were required by degree path at

their institution. Figure 321 shows the distribution of clinical

practice hours required for the three most common paths to

a professional nursing degree offered by these programs.

On average, 1,162 clinical practice hours were required for

the four-year Bachelor of Science in Nursing (BSN) degree

offered by universities and health-related institutions. ese

programs required between 855 and 1,350 clinical practice

hours, a variance of 58 percent.

Two-year Associate of Science in Nursing (ASN) degrees

offered by community colleges required fewer clinical practice

hours than degrees at four-year institutionson average

1,012 hours. ese programs required between 576 and

1,280 clinical practice hours, a variance of 122 percent.

Finally, an Associate of Science degree that allows a licensed

vocational nurse (LVN) to meet the licensure requirements

of an RN required an average of 675 clinical practice hours.

ese programs required between 448 and 1,170 clinical

practice hours, a variance of 161 percent. Note that these

675 average hours were in addition to the minimum 840

clinical practice hours required for LVN certification under

BON Rule 214.

e lack of specificity in BONs regulation of RNs has

allowed institutions wide latitude in the amount of clinical

practice hours they require for a degree and this may

contribute to an ineffi cient allocation of clinical practice

hours. Each of the degree paths shows a pattern of variation

that raises concerns. Some BSN programs may be varying to

the high side, imposing additional constraints on clinical

practice hours in their areas. Some ASN programs may be

requiring too few clinical practice hours for the RN

qualificationfour programs surveyed were below the 840

clinical practice hours required of licensed vocational nurses.

Finally, the very wide distribution of LVN-to-RN

requirements suggests that this path may pose a significantly

higher burden on clinical practice hour resources than

traditional education pathways.

Recommendation 2 would amend Section 301.157 of the

Texas Occupations Code to direct BON to establish a range

on the number of clinical practice hours that would be

required to be licensed as a RN in Texas. e range is to be

established by BON in consultation with institutions ofhigher education that provide professional nursing education

programs to provide reasonable flexibility for difference in a

programs mission. e range may vary by degree path used

to attain the professional nursing qualification and reasonable

provisions to grandfather existing students are to be

allowed.

FIGURE 321

CLINICAL PRACTICE HOURS REQUIRED BY THREE PROFESSIONAL NURSING DEGREE PATHS, SEPTEMBER 2008

DEGREE PATH

LESS THAN

700

701 TO

800

801 TO

900

901 TO

1000

1001 TO

1100

1101 TO

1200

MORE THAN

1200 AVERAGE

4-Year Registered Nurse (BSN) 0 0 1 4 0 1 2 1162

2-Year Registered Nurse (ASN) 3 1 1 5 3 7 1 1012

Licensed Vocational Nurse to

Registered Nurse (ASN) 11 4 2 0 0 1 0 675



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FISCAL IMPACT OF THE RECOMMENDATIONS

Recommendation 1 can be met through existing appropria-

tions to DSHS.

Recommendation 2 can be met through existing appropria-

tions to BON.

e introduced 201011 General Appropriations Bill does

not address the recommendations of this report.

Documents

Nursing Clinical Hours