Existing law, the Nursing Practice Act, establishes the Board of Registered Nursing to license and regulate the practice of nursing. The act prohibits a person from engaging in the practice of nursing without an active license but authorizes a student to render nursing services incidental to the students course of study, as specified.

This bill would additionally authorize a student to render nursing services if the student is a resident of the state and enrolled in a prelicensure distance education nursing program based at an out-of-state private postsecondary educational institution, as defined, for the purpose of gaining clinical experience in a clinical setting that meets certain criteria, including that the program is accredited by a programmatic accreditation entity recognized by the United States Department of Education and that the program maintains minimum faculty to student ratios required of board-approved programs for inperson clinical experiences. The bill would require the student to be supervised in person by a registered nurse licensed by the board while rendering nursing services. The bill would prohibit a clinical agency or facility from offering clinical experience placements to an out-of-state private postsecondary educational institution if the placements are needed to fulfill the clinical experience requirements of in-state students enrolled in a board-approved nursing program.

Date of Hearing: April 23, 2025

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 1082

Author:(Flora) – As Introduced Ver:February 20, 2025

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill allows a nursing student who is a California resident and enrolled in a distance education nursing program based at an out-of-state private institution to complete clinical placements in California, if specified criteria are met. The bill also requires such students to be supervised in person by a Board of Registered Nursing (BRN)-licensed registered nurse.

This bill also prohibits clinical agencies or facilities from using an available placement for a student from out-of-state private postsecondary schools if the placement is needed by an in-state student enrolled in a BRN-approved nursing program, and requires the program to pay a fee of $100 to BRN for each student participating in clinical placements in the state.

FISCAL EFFECT:

BRN reports it anticipates 3,000 applications per year. To enable BRN to accept the fee of $100 per student, BRN staff would need to create a new profile for each individual student in its online licensing and enforcement system (BreEze), include the necessary information, and connect the payment to the student’s profile for accounting and reconciliation purposes. Furthermore, BRN estimates this bill will allow around 50 out-of-state programs to place students in California clinical positions, which would require an addition of two nursing education consultants to assess the programs’ curriculum, faculty, and resources, among other things, to guarantee that students enrolled in the out-of-state school are eligible for California licensing. BRN estimates the bill's total cost could be $805,000 in fiscal year 2026-27, and $765,000 ongoing, which would be partially offset by an estimated $300,000 in revenue for 3,000 students based on a $100 per student fee (BRN Fund).

The Department of Consumer Affairs (DCA) determined it would cost $18,000 to establish a new out-of-state BreEze transaction and a new fee code for the transaction, update the DCA search to display the student as eligible for California clinical placement, and generate a new out-of-state school clinical placement report, which will be absorbable with the redirection of existing maintenance resources.

COMMENTS:

1. Purpose. This bill is sponsored by the Nightingale Education Group. According to the author:

This bill will provide flexibility for nursing students while addressing the state's nursing shortage by potentially retaining more students within California. This bill acknowledges the challenges faced by California nursing students enrolled in out-of-state distance learning programs and offers a solution to enable them to complete their clinical education within the state. By permitting supervised clinical rotations within California healthcare institutions, the bill aims to support the educational needs of these students while addressing the state’s nursing shortage.

1. Background. Nursing education generally contains both classroom and clinical components. Clinical experience is supervised, hands-on experience providing patient care and an opportunity to apply theory to practice. In California, both theory and clinical experience are required for licensure as an RN. To allow students to gain clinical experience, existing law exempts students from licensing requirements while providing nursing services through a BRN-approved education program. There is no exemption for students enrolled in non-BRN-approved nursing education programs, including students who live in California but attend distance-learning nursing education programs based in other states.

In-state students enrolled in non-BRN-approved distance programs must move to other states during their course of study to obtain the required clinical experience if they wish to immediately qualify for licensure in California upon graduation. This bill seeks to avoid requiring those students to move or travel for clinical experience by expanding the license exemption, though specifically limited to students enrolled in non-BRN-approved distance education nursing programs that are accredited by other entities.

1. Opposition. BRN opposes this bill, citing concerns over program oversight and clinical impaction. Regarding program oversight, this bill benefits education programs that BRN has not approved, and BRN notes such programs are eligible to receive BRN approval, in which case their students would be able to do their clinical training in California. Further, California’s supply of clinical placements is already strained, and BRN states it could not monitor or enforce compliance with the requirement that in-state students not be displaced.

1. Prior Legislation.

SB 1015 (Cortese), Chapter 776, Statutes of 2024, required BRN to study and recommend standards regarding how approved schools of nursing or nursing programs manage or coordinate clinical placements and to annually collect, analyze, and report information related to management of coordination of clinical placements.

AB 2578 (Flora) and AB 1292 (Flora), of the 2023-24 Legislative Session, were substantially similar to this bill. AB 2578 was held on the Senate Appropriations Committee suspense file and AB 1292 was held on this committee’s suspense file.

SB 1042 (Roth), of the 2023-24 Legislative Session, would have required (1) health facilities and clinics to work with representatives from a nursing school or programs, upon request, to meet the clinical placement needs of the school or program; (2) nursing schools and programs to report specified clinical placement data to BRN; (3) BRN to assist schools or programs in finding clinical placement slots; and (4) health facilities and clinics to report specified clinical placement data to the Department of Health Care Access and Information. SB 1042 was held on this committee’s suspense file.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing:

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Marc Berman, Chair

ABPCA Bill Id:AB 1082

Author:(Flora) – As Introduced Ver:February 20, 2025

SUBJECT: Nursing: students in out-of-state nursing programs.

SUMMARY: Authorizes an unlicensed nursing student who is enrolled in an out-of-state distance education nursing program to provide supervised nursing services that are incidental to the course of study for purposes of gaining clinical experience.

EXISTING LAW:

1. Regulates the practice of nursing under the Nursing Practice Act. (Business and Professions Code (BPC) §§ 2700-2838.4)
2. Establishes the Board of Registered Nursing (BRN) within the Department of Consumer Affairs (DCA) to administer and enforce the Nursing Practice Act until January 1, 2027. (BPC § 2701)
3. Prohibits the practice of nursing without holding a license which is in an active status issued under the Nursing Practice Act, except as otherwise provided, and specifies that every licensee may be known as a registered nurse (RN) and use the title “R.N.” (BPC § 2732)
4. Requires an applicant for licensure as an RN to complete the education requirements established by the BRN in a program in this state approved by the BRN or in a school of nursing outside of this state which, in the opinion of the BRN, offers an education that meets the BRN’s requirements. (BPC § 2736)
5. Defines “an approved school of nursing” or “an approved nursing program” as one that (1) has been approved by the BRN, (2) gives the course of instruction approved by the BRN, covering not less than two academic years, (3) is affiliated or conducted in connection with one or more hospitals, and (4) is an institution of higher education. (BPC § 2786(a))
6. Requires the BRN to determine by regulation the required subjects of instruction for licensure as an RN and (1) include the minimum units of theory and clinical experience necessary to achieve essential clinical competency at the entry level of an RN and (2) require all programs to provide clinical instruction in all phases of the educational process, except as specified. (BPC § 2786(c))
7. Authorizes a student to render nursing services if those services are incidental to the course of study of one of the following:
8. A student enrolled in a BRN-approved pre-licensure program or school of nursing. (BPC § 2729(a))
9. A nurse licensed in another state or country taking a BRN-approved continuing education course or a post-licensure course. (BPC § 2729(b))
10. Requires a nursing program to obtain approval from the BRN for the use of any agency or facility for clinical experience, and requires the program to take into consideration the impact that an additional group of students would have on students of other nursing programs already assigned to the agency or facility. (California Code of Regulations, Title 16, § 1427)
11. Prohibits an institution of higher education or a private postsecondary school of nursing, or an entity affiliated with the institution or school of nursing, from making a payment to any clinical agency or facility in exchange for clinical experience placements for students enrolled in a nursing program offered by or affiliated with the institution or private postsecondary school of nursing, as specified. (BPC § 2786.4)
12. Defines an “out-of-state private postsecondary educational institution” as a private entity without a physical presence in this state that offers distance education to California students for an institutional charge, regardless of whether the institution has affiliated institutions or institutional locations in California. (Education Code § 94850.5)

THIS BILL:

1. Authorizes a student who is a resident of this state and enrolled in a pre-licensure distance education nursing program based at an out-of-state private postsecondary educational institution to provide nursing services to gain clinical experience in a clinical setting if the following are met:
2. The program is accredited by a programmatic accreditation entity recognized by the United States Department of Education.
3. The BRN has not otherwise approved the program.
4. The student placement does not impact any students already assigned to the agency or facility.
5. The program does not make payments to any clinical agency or facility in exchange for clinical experience placements for students enrolled in a nursing program offered by or affiliated with the institution or private postsecondary school of nursing.
6. The program qualifies graduates for licensure under the Nursing Practice Act.
7. The program maintains minimum faculty to student ratios required of BRN-approved programs for in-person clinical experiences.
8. The program pays a one-time fee of $100 to the BRN for each student who participates in clinical experience placements in the state.
9. Requires a student providing services under this bill to be supervised by an RN while rendering nursing services.
10. Prohibits a clinical agency or facility from offering clinical experience placements to an out-of-state private postsecondary educational institution if the placements are needed to fulfill the clinical experience requirements of an in-state student enrolled in a BRN-approved nursing program.
11. Specifies that, for purposes of the authorization under this bill, “out-of-state private postsecondary educational institution” means a private entity without a physical presence in this state that offers distance education to California students for an institutional charge, regardless of whether the institution has affiliated institutions or institutional locations in California.

FISCAL EFFECT: Unknown. This bill is keyed fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the Nightingale Education Group. According to the author, “This bill will provide flexibility for nursing students while addressing the state's nursing shortage by potentially retaining more students within California. This bill acknowledges the challenges faced by California nursing students enrolled in out-of-state distance learning programs and offers a solution to enable them to complete their clinical education within the state. By permitting supervised clinical rotations within California healthcare institutions, the bill aims to support the educational needs of these students while addressing the state’s nursing shortage.”

Background. Nursing education generally contains two components, classroom theory and clinical experience. Clinical experience is supervised, hands-on experience providing patient care, providing an opportunity to apply theory to practice. In California, both theory and clinical experience are required for licensure as an RN.

To allow students to gain clinical experience, existing law exempts students from licensing requirements while providing nursing services through a BRN-approved education program. There is no exemption for students enrolled in non-BRN-approved nursing education programs, including students who live in California but attend distance-learning nursing education programs based in other states.

However, students who attend out-of-state programs must have their education evaluated for equivalency with state requirements, including clinical experience. Those who do not meet the requirements will be denied or considered deficient and required to complete additional remedial education or training.

As a result, the in-state students enrolled in non-BRN-approved distance programs must move to other states during their course of study to obtain the required clinical experience if they wish to immediately qualify for licensure in California upon graduation. This bill seeks to avoid requiring those students to move or travel by expanding the license exemption, though specifically limited to students enrolled in non-BRN-approved distance education nursing programs that are also accredited.

BRN. The BRN is a licensing entity within DCA and is responsible for administering and enforcing the Nursing Practice Act, which is the chapter of laws that establishes the BRN and outlines the regulatory framework for the practice, licensing, education and discipline of RNs and advanced practice registered nurses. The BRN is also one of the few licensing boards that actively approve and regulate educational programs that offer the degrees necessary for licensure. In-state programs that offer a course of instruction leading to an RN license must seek approval from the BRN to operate. As of March 2025, the BRN’s website (https://www.rn.ca.gov/education/enrolldata.shtml) reports a total of 200 approved RN programs, including 108 Associate Degree in nursing (ADN) programs, 74 Bachelor of Science in nursing (BSN) programs, and 18 Entry-level Master's (ELM) programs.

Prior Related Legislation. AB 2578 (Flora) of 2024 was identical to this bill except that AB 2578 would have required the out-of-state school to submit annual reports to the BRN. AB 2578 was held on the Senate Appropriations Committee suspense file.

SB 1015 (Cortese), Chapter 776, Statutes of 2024, required the Board of Registered Nursing (BRN) to study and recommend standards regarding how approved schools of nursing or nursing programs manage or coordinate clinical placements and to annually collect, analyze, and report information related to management of coordination of clinical placements.

SB 1042 (Roth) of 2024 would have required health facilities and clinics to work with representatives from nursing schools and programs, upon request, to meet the clinical placement needs of the school or program; requires nursing schools and programs to report specified clinical placement data to the BRN; required the BRN to assist schools or programs in finding clinical placement slots; and required health facilities and clinics to report specified clinical placement data to the Department of Health Care Access and Information (HCAI). SB 1042 was held on the Assembly Appropriations Committee suspense file.

AB 1292 (Flora) of 2023 was substantially similar to this bill. AB 1292 was held on the Assembly Appropriations Committee suspense file.

AB 1577 (Low) of 2023 would have required hospitals that offer pre-licensure clinical training slots to work in good faith with community college nursing programs to meet their clinical training needs. AB 1577 died pending a hearing in the Senate Health Committee.

AB 2684 (Berman), Chapter 413, Statutes of 2022, which was the BRN’s 2022 Sunset Review bill,^[1] made several changes to address the lack of clinical placements, including establishing a lower 500 minimum number of clinical experience hours, authorizing clinical placements to take place in the academic term immediately following theory, prohibiting nursing schools and programs from paying for clinical placements, and requiring the BRN to utilize data from available regional or individual institution databases in collecting information related to the number of clinical placement slots available to nursing students.

AB 2288 (Low), Chapter 282, Statutes of 2020, in response to the COVID-19 pandemic, authorized the director of an approved nursing program, during a state of emergency, to make requests to the BRN for the following: 1) the use of a clinical setting without meeting specified requirements; 2) the use of preceptorships without having to maintain specified written policies; 3) the use of clinical simulation up to 50% for medical-surgical and geriatric courses; 4) the use of clinical simulation up to 75% for psychiatric-mental health nursing, obstetrics, and pediatrics courses; and 5) allowing clinical placements to take place in the academic term immediately following theory.

AB 1015 (Blanca Rubio), Chapter 591, Statutes of 2021, required the BRN to incorporate regional forecasts into its biennial analyses of the nursing workforce, develop a plan to address regional areas of shortage identified by its nursing workforce forecast, as specified, and annually collect, analyze, and report information related to the number of clinical placement slots that are available and the location of those clinical placement slots within the state.

ARGUMENTS IN SUPPORT:

Nightingale Education Group (sponsor) writes in support:

Under the current nursing regulations, the reality for many California residents is that they are forced, while enrolled in distance education programs domiciled outside of California, to fulfill clinical experiential learning requirements in other states, where they are required to relocate for several weeks each semester to fulfill the mandatory on-ground practical components of their education. This creates a costly and cumbersome reality where students must travel at their own expense, leaving their families, homes, and employment, for weeks at a time every semester for the duration of their nursing program. Additionally, during these travel rotations these students are developing relationships with, and actively being recruited by, healthcare facilities in other states who offer compelling benefits to relocating, thus worsening California's nursing shortage.

The Covid-19 pandemic elevated the nursing shortage to crisis levels, with UCSF recently reporting that the state's hospitals are short the equivalent of more than 40,000 full-time nurses, and as the state’s population ages, the shortage is often felt more urgently in non-hospital settings such as long-term care/skilled nursing, dialysis, outpatient clinics, etc. While myriad California residents are ready and willing to meet this shortage by training to become nurses, many California nursing education programs are not able to meet the demand of incoming applicants. The San Francisco Chronicle recently reported on the extreme exclusivity of many of the state's nursing programs in a time of staffing crisis, stating that multiple University of California campuses (UC Irvine and UCLA) have an acceptance rate of only 1%, which as the article stated, is "...even more selective than getting into Yale" (6.53% acceptance rate). Now is not the time for more exclusive enrollments, now is the time to create greater access to this much needed profession.

For many California nursing education program applicants, work schedules, family life, finances, and other priorities now make distance nursing education their only option. Unfortunately, many other students have chosen not to pursue their education at all because options in their local areas are either severely limited or non-existent. [This bill] would allow these students to enroll in readily available blended distance education programs (online education + local on-ground experiential learning), offered by colleges and universities across the country that provide education opportunities meeting the students’ lifestyle and financial needs.

Distance education provides many benefits for California nursing students including, open enrollment without waiting lists or lottery systems, less expensive education costs relative to traditional on-site counterparts, substantial savings on gas, car maintenance, room and board, and childcare, and many others. In addition to the personal benefits for students, the economic benefits experienced by communities when residents stay and work at local businesses during school and after graduation are immeasurable. Rural communities are especially affected by economic pressures, and due to cost and space constraints, traditional on-site colleges and universities are simply not able to meet the needs of these cities and towns. Distance education programs provide much-needed workforce development options for under-served communities, especially for critical services such as nursing and healthcare.

ARGUMENTS IN OPPOSITION:

The Board of Registered Nursing writes in opposition for two reasons:

1. Program oversight:

…every state has its own unique NPA that sets the framework for how nurses are prepared and able to practice within that state. This includes different standards and rules related to nursing education, licensure, scope of practice, and discipline. Out of state nursing programs are eligible to receive the same Board approval that is granted to in state schools. Doing so would allow out of state programs to have their students to conduct clinicals in California.

Instead, the bill would require the out of state programs to be accredited by a programmatic accreditation entity recognized by the United States Department of Education. This is problematic for two reasons. First is that, unlike program approval, program accreditation does not ensure that a nursing program adheres to pertinent laws and regulations. Program accreditation is a voluntary process in which a private, nonprofit organization evaluates a nursing program from a national perspective to see if they meet general standards of the profession, they do not check for compliance with state law.

Second, the US Department of Education is charged with recognizing accrediting agencies and the standards they use to evaluate programs. However, the President of the United States signed an Executive Order to close the Department of Education and return authority over education to the States and local communities. Closing the Department of Education will leave accrediting bodies without any type of oversight unless and until California establishes a mechanism for providing oversight at some point in the future.

1. Clinical impaction:

Board members also expressed concern with the negative impact this bill would have on California’s already strained supply of clinical placements. The bill sponsor alone has thousands of California residents enrolled in their nursing programs. Given that that is only one of numerous out of state programs that would be eligible to have their students conduct clinical placements in California under this bill, the potential for clinical displacement is significant.

The bill states that a clinical agency or facility cannot schedule a clinical experience placement with an out-of-state private postsecondary educational institution if the placement is needed to fulfill the clinical experience requirements of an in-state student enrolled in a board-approved nursing program. However, the Board does not have any jurisdiction over health facilities and would not be able to monitor or enforce compliance with this provision.

There are various reasons why a California resident may choose to enroll in an out of state private distance education program, including a more flexible schedule that better accommodates their and their family’s unique needs. Residents also may choose to enroll in out of state nursing programs because they are unable to get into their local nursing programs in a timely fashion due to long wait lists. One of the key contributors to these long wait lists is the limited supply of clinical placements. Clinical impaction is so severe in parts of the state that the Board has had to deny new nursing programs, new campus locations and reduce enrollment increase requests to mitigate the displacement of current students.

Allowing out of state nursing programs to grow and utilize clinical placements in California without going through the same upfront Board approval process that our in-state nursing programs must go through creates an unfair advantage and impedes the ability of in-state programs to grow and reduce those same waitlists for California residents.

POLICY ISSUES FOR CONSIDERATION:

1. Lack of Clinical Placements. During the BRN’s 2022 Sunset Review, both this committee and the Senate Business, Professions and Economic Development Committee raised, and continue to work on, the issue of the availability of clinical placements for nursing students. The availability of student placements for clinical experiences is based on the willingness of clinical facilities, such as hospitals or clinics, to accept and teach students.

While there are no requirements that clinical facilities accept students, many willingly accept students because it is necessary for the workforce and can help with recruitment. However, the facilities must have staff that is qualified to teach and supervise students. As a result, clinical placements are often difficult to find, and currently, clinical placement availability is severely lacking. Unfortunately, students who are unable to obtain their clinical placements before the end of the term either have to drop out or receive an incomplete. Under either circumstance, the student would have to repeat the course.

This bill may complicate that problem by authorizing nursing students who are enrolled in out-of-state distance education programs to compete for already limited clinical placements. To reduce the chance that a student enrolled in an in-state program is displaced from a clinical placement, this bill contains language previously recommended by this committee requiring clinical facilities to give preference to students enrolled in an in-state program.

1. Education Quality. The BRN and stakeholders argue that out-of-state schools may not meet the standards of in-state schools that require BRN approval. However, there are already California students enrolled in out-of-state programs, and these students must be approved by the BRN as meeting California requirements. Once approved, they must still pass the licensing exam, the NCLEX. If the BRN finds them deficient, they must take approved remedial courses before they may take the NCLEX.

Similarly, students who have attended a program in another state and obtained a license in that state can obtain a California license after the BRN reviews their education when applying for a license by endorsement. As a result, the only difference between the California nursing students affected by this bill and students and nurses who apply to the BRN is that they are located in California.

1. Federal Accreditation. This bill would only apply to students enrolled in out-of-state nursing programs that are accredited by a programmatic accreditation entity recognized by the United States Department of Education. As the BRN notes, there is an executive order that aims to close the department. While closing the department would require an act of Congress, that act is also a possibility. However, if that were to happen, and a nursing program was accredited by an accreditor no longer recognized by the department because the department did not exist, then that program would not be able to use the exception under this bill.
2. Fairness. The BRN and stakeholders argue that granting the benefit under this bill to out-of-state nursing programs, which do not have to pay a $40,000 fee to obtain BRN approval or go through the rigorous approval process, is not fair to approved in-state nursing programs.
3. Enforceability. The BRN and stakeholders note that this bill contains various conditions and prohibitions but does not designate an agency to enforce them. However, it is possible to seek a court order to enforce the law through an injunction (Code of Civil Procedure §§ 525-526; BPC §§17200-17210).

Implementation Issues:

Timing. The BRN is scheduled for its sunset review next year. If this bill passes this committee, the author may wish to include a sunset date that aligns with the BRN’s sunset date, January 1, 2027, so the impacts of this bill can be discussed through the end of the legislative session and whether the exception granted under this bill should be extended.

REGISTERED SUPPORT:

Nightingale Education Group (sponsor)

REGISTERED OPPOSITION:

American Federation of State, County and Municipal Employees, AFL-CIO

Association of California Nurse Leaders

Board of Registered Nursing

CA Organization of Associate Degree Nursing Directors South

California Association of Associated Degree Nursing

California Association of Colleges of Nursing

California Nurses Association

California State University, Office of the Chancellor

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301

1. The sunset review process provides an opportunity for the DCA, the Legislature, the boards, and interested parties and stakeholders to discuss the performance of the boards, and make recommendations for improvements. Each year, the Assembly Business and Professions Committee and the Senate Business, Professions, and Economic Development Committee hold joint sunset review oversight hearings to review the boards and bureaus. For more information, see the background paper on the BRN’s 2022 Sunset Review, accessible at: https://abp.assembly.ca.gov/jointsunsethearings. ↑