California challenges relevance and fairness of state board exam W The California Board of Registered Nursing is pressuring the National Council of State Boards of Nursing to make changes in the RN licensing exam, saying it should be more “job related.” The board is taking issue both with the current exam and a new comprehensive exam, which will first be given in July 1982. The State Board Test Pool Examination has been used for licensure of RNs since 1944, and all states have adopted it. The Council is respon- sible for the state board exam.

California has a fair employment law stating that a licensing board may not set a licensing requirement that has an “adverse impact” on any group protected in the law, unless the practice can be demonstrated to be “job re- lated.” Groups are protected for race, creed, color, national origin or ancestry, sex, age, medical condition, or physical handicap. For a licensing requirement to violate this law, it would have to have both an “adverse impact” on one of these groups and be not “job re- lated.”

In January, the nursing board released a study of the exam done by another state agency, the Department of Consumer Affairs. “Not unexpectedly, substantial adverse im- pact on most groups protected by the law was found for most parts of the examination,” said Barbara Brusstar, RN, the board’s executive secretary.

“Adverse impact” was determined by com- paring scores and sociological information for those who took the exam in Anaheim, Calif, in

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July 1980. Most protected groups had passing rates less than 80% of a “highest scoring group.” The study report said this is “the most generally applied method” for determining ad- verse impact. Now the exam must be proven job related, or it will be in violation of California law, the nursing board said.

“Our choices are working to change the test or developing our own test,” Brusstar said. “Right now we are working with the National Council because we see that as preferable. If the exam is not job related, then it shouldn’t be used in the rest of the country either.“

National Council Executive Director Eileen McQuaid, RN, was flying to Los Angeles to meet with the board Feb 19. In support of the exam, she said she would be referring to a 1979 study commissioned by the American Nurses’ Association showing that the exam is a measurement of adequate knowledge for beginning nursing practice. She added that California is the only state raising this type of question.

The validity study established that “it is nurs- ing we’re testing,” Ray Showalter, associate executive director of the National Council, ex- plained. Researchers first identified actual or potential practice problems that nurses en- counter. These were translated into behaviors and organized into a simulation exam given to students before graduation in 1977. Their per- formance on this exam was then compared to their transcripts from clinical courses and their scores on the state board exam. “A great deal of comparability” in the three areas was found,” he said, ”so we have a basis for saying the exam is valid.”

The nursing board’s action is an outgrowth of a general philosophy of California Gov Jerry Brown to remove what he believes are artificial

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barriers to the professions. The movement has worn a “consumer” badge, but many nurses have seen it from a different perspective. In 1979, they rallied to help defeat Senate Bill 666, which would have removed the RN major- ity on the board of nursing and created a “career ladder” allowing nursing assistants to become practical nurses, and practical nurses, in turn, to become RNs without further educa- tion. The bill’s sponsor said she wanted to reform a “bureaucratic maze” and increase access for minorities. But many nurses saw it as an attempt to erode their professional au- tonomy and educational standards.

Now the California challenge has national implications, because the state board exam is being revised. In January, the state’s delegate voted against the National Council’s specifica- tions for selecting a testing agency that will develop exams to be given after July 1982. (A plan for the first revised comprehensive exam, to be given that month, has been approved.) The testing agency specifications were passed, but California still vows to press for changes.

The State Board Test Pool Examination for RNs, used in all 50 states plus Guam, the Virgin Islands, and the District of Columbia, is currently given in five clinical parts, with five scores. The new exam will be comprehensive, with one score.

The new format is organized according to the nursing process, not the current five-part medical model. “The nursing process cuts across all ages and disease conditions,” so it seemed logical to have one score, Showalter said. “That shows the candidate knows nurs- ing or does not know nursing.”

Each jurisdiction sets its own passing scores and rules for repeating the exam by those who fail. That will not change. Many states now allow unsuccessful candidates to repeat only the parts they fail, providing they pass all five parts within a specified time. With the new exam, those who fail will have to repeat the whole exam.

The question boils down to what “job re- lated” means. Pursuing the answer, the California nursing board said it would continue discussions with the National Council.

The climate is shifting for federal regu- lations. But by the end of February, officials in

the Health Care Financing Administration (HCFA) were unsure what, if any, effect Presi- dent Reagan’s new policies would have on the pending Medicare rules for hospitals. These include the proposal that would permit OR technicians and practical nurses to circulate during surgery.

Reagan froze pending rules from Jan 29 to March 29 so his staff would have a chance to evaluate them. Then Feb 19, he issued new procedures designed to weed out regulations that are unnecessary or too costly. HCFA off i- cia1 Irene Gibson said the agency was still analyzing these new policies.

About the freeze, she said the hospital regu- lations “had been set back anyway until the first of next year,” so she did not see a direct effect. She thought HCFA might have to do a cost analysis on the pending regulations, since that was a requirement of the Feb 19 state- ment.

Blue Cross-Blue Shield has recommended that its 11 0 member plans, covering one out of two Americans, adopt “action plans” to pro- mote ambulatory surgery. Eliminating room and board charges, same-day surgery could save as much as 30% to 50% compared with inpatient surgery, the Blues estimate.

Although no precise figures are available, the health insurer says 2,000 of the nation’s 7,000 hospitals might offer outpatient surgery. In addition, there are about 100 freestanding centers, independent of hospitals. All Blue Cross plans cover hospital outpatient surgery, and 46 plans pay for surgery in freestanding centers. Physician’s fees are covered by Blue Shield regardless of where surgery is per- formed.

As examples of ways to encourage outpa- tient surgery, the Blues cited projects in five areas. North Carolina and Washington, DC, are focusing on public education. California has identified 700 procedures that could be performed in same-day settings. Greater New York and Arizona plans are using financial in- centives to shift outpatient surgery to the most economical setting.

Patricia Patterson Associate editor

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