MedPod Deep Dive: More Problems With For-Profit Nursing Schools

The following is a transcript of the podcast episode:

Rachael Robertson: Hey everybody. Welcome to MedPod Today, the podcast series where MedPage Today reporters share deeper insight into the week's biggest healthcare stories. I'm your host, Rachael Robertson.

Today, we're bringing you the next installment of our deep dive into for-profit nursing schools. If you haven't listened to part 1 of this series yet, I'd recommend you start there, especially if you don't know a lot about for-profit nursing schools.

In that episode, MedPage Today's Washington Correspondent Shannon Firth shared a basic overview of the shortcomings of for-profit nursing programs. She also told us about Stratford University in Virginia, a for-profit nursing program that suddenly shuttered in 2022.

Shannon is back again to tell us about two more case studies, one in Florida and one in Arizona. And both of them demonstrate issues with for-profit nursing schools. So welcome back, Shannon!

Shannon Firth: Hi, Rachael!

Case Study 2: HCI College

Robertson: Let's turn to Florida, where you wrote about HCI College, which, like Stratford in Virginia, also wasn't totally upfront with its students about its situation. Tell our listeners about HCI.

Firth: So first, just a bit of context about Florida. Florida has ranked dead last of any state in the country on the NCLEX (National Council Licensure Examination) -- the national nursing licensure exam -- for at least the past 6 or 7 years, and not even by a slim margin. It was roughly 18 percentage points lower than the national average in 2020 and 2021. And then Rachael, do you remember that Operation Nightingale scam from last year?

Robertson: That was a huge nursing scandal, right? What exactly happened again there?

Firth: Basically, nursing program operators and recruiters were caught selling fake nursing school diplomas and transcripts. That took place in Florida, too. So Florida has its fair share of nursing issues.

HCI College is one more example. HCI College was originally named the Health Career Institute. It was put on probation by the Florida Board of Nursing sometime around February 2018 and it looked to be on the verge of closing. But just a few months later, HCI applied to open a new nursing program. The catch? It had the same instructors, curriculum, facilities, course catalog, and nursing director as its existing program, according to a lawsuit filed by former students. Florida actually has a law that says the nursing board has to reject any program application from an applicant who already has a program on probation. But, that didn't happen. In October 2018, the state's nursing board approved this supposedly "new" nursing program.

Robertson: What?! So they essentially opened the same program ... again. That's completely wild.

Firth: I agree! It's kind of nuts. But it gets even more wild. Let me break it down for you. By law in Florida, nursing schools have to disclose their pass rates to prospective students. Because HCI had opened a "new program," its disclosure form states that in 2018, it had no students, and therefore no prior NCLEX pass rates to speak of. But in reality, NCLEX pass rates at HCI's old program were super low -- around 40% and 50%. That means only 4 to 5 of every 10 students who graduated were actually able to get their license and become nurses.

I spoke with Eileen Connor, a lawyer who represents several HCI students who said that because of HCI's supposedly new program, it was "almost like they had a clean slate when they actually had terrible passage rates, terrible completion rates, and they didn't have to tell anyone that." In 2019 HCI's old nursing program closed and its new program began accepting students. That same year, it changed its name from the Health Career Institute to HCI College.

Robertson: They really did get a clean slate. What other kinds of problems did you notice?

Firth: So apart from playing this sort of shell game with its poor pass rates, the students also accused the school of trying to inflate those pass rates by using a high-stakes exit exam to weed out all but the very top students. Students weren't told the type of exam they'd be taking, nor were they told the threshold for passing, and some took the exam in the evening after a full day of class. When the students did try to challenge these policies, saying they clashed with HCI's own rule book, they were ignored.

Rebecca Freeman, one former student who was told she failed the exit exam, said "it was the same stone wall everywhere you went ... Oh we're so sorry about your luck." Freeman now has about $12,000 in out-of-pocket expenses, and owes about $20,000 in federal loan debt because of these high-stakes exit exams. Again, these are exams that prevented her and allegedly dozens of other students from graduating and sitting for the NCLEX.

I spoke with Pedro De Guzman, president and CEO of HCI College, and he disputed these claims. Regarding the surprise nature of the exit exam format, that was a step the school took to "protect the integrity of our program," he told me.

"Sometimes the students aren't happy with the toughness of the program, but we don't make apologies for that," he said.

Robertson: Why didn't students know about these issues with HCI, like the low NCLEX pass rates and secretive high stakes exams? Or that the school's previous program had been shuttered? It sounds like students were really in the dark.

Firth: So Colleen Auer, the same litigator in Arizona I mentioned in our earlier podcast, said that the problems with for-profit schools are a "well kept secret." There's a lack of basic transparency around admissions rates, retention rates -- that's how many students complete the program and how many drop out -- and of course, in this case, NCLEX pass rates. That's information that every member of the public should have access to in one easily accessible place, Auer argued. It's a huge problem and it's easily remedied, she said.

Robertson: I think we also need to address the elephant in the room: where the heck are regulators in all of this?

Firth: It's really hard to know what the nursing board was thinking when it made some of these decisions. What Connor, the lawyer representing HCI students, told me is that the board seems to have the power and responsibility to monitor nursing programs, but they may lack the resources to do so effectively. When I started reporting this series, I wrote about how each state has its own Nurse Practice Act, which among other things, determines how much authority and autonomy nursing boards have.

Back in 2009, in response to concerns about a nursing shortage and complaints of bias against for-profit programs, Florida lawmakers changed the Nurse Practice Act and made it easier for new programs to get approved -- including for-profit ones. I spoke with Polly Pittman, PhD, professor of health policy and management at George Washington University. And she said that Florida law "took away all the teeth of the Board of Nursing."

Willa Fuller, executive director of the Florida Nurses Association, said the legislature was set on turning out more nurses, which really bothered her. She told me "imagine if they said that about doctors ... let's just open a medical school on every corner."

After the law change, there was an explosion of new nursing programs and a steep drop in NCLEX pass rates. Jessie Colin, who was a member of the Florida Board of Nursing from 2005 to 2015, told me it felt like the board was playing Whac-a-Mole. It would close one failing program only to see it pop up again under a different name or address. The Florida legislature has passed multiple bills since 2009 trying to course correct. But as you can see, the problems with for-profit nursing schools in Florida appear to be ongoing.

And HCI College? It's still kicking.

Robertson:What a wild web of problems. Now let's head to the southwest for one more case study.

Case Study 3: Aspen University

Robertson: Now for our final case study, Aspen University, a for-profit nursing program in Arizona that had a slew of issues. Shannon, what happened at Aspen University?

Firth: So Rachael, in late 2017, Aspen University obtained approval to open a nursing program from the Arizona State Board of Nursing. Its first cohort of students started the following summer in 2018. But less than 2 years later, in 2020, the nursing board began receiving complaints. Aspen students described a "toxic and punitive" program culture and said they were basically having to teach themselves. So, the nursing board investigated. They found some red flags. Aspen's leadership changed 5 times in 4 years. And until the summer of 2021, grades were based mostly on open-book tests. Plus Aspen had the lowest NCLEX pass rates in all of Arizona. And the school, in the entire time that it had been open, never provided adequate direct clinical care hours.

Robertson: Wow, that sounds like a lot of problems. What did the nursing board do with these findings?

Firth: Aspen was placed on probation in March of 2022. It couldn't enroll new students until it raised its NCLEX scores to at least 80%, which, mind you, is the floor for a program to keep its approval in Arizona. Within months, Aspen realized that was not going to happen and volunteered to relinquish board approval of its nursing program if it could offer a teach-out. So teach-outs are a common practice for struggling schools. Under a teach-out, program enrollment stops, but current students are allowed to complete their coursework. The nursing board agreed to allow Aspen to continue for 2 more years, or until its students graduated, whichever happened first.

But the nursing board's agreement included an important caveat – an emergency pull cord of sorts. It states that the nursing board has the right to close the school almost immediately if Aspen is not providing "minimum instruction and learning opportunities."

Robertson: So let me get this straight. With a teach-out, the school is not allowed to enroll new students. However, current students have a chance to finish their degree. Was Aspen able to do a teach-out like it wanted?

Firth: Well, let's just say things got a bit more complicated, Rachael. In February 2023, the nursing board yanked hard on that pull cord because it was hearing new complaints from students and clinical partners. One student told the nursing board, "I don't feel like I'm safe to practice." Plus, the board still had other lingering concerns. Here's what Carolyn Jo McCormies, president of the Arizona Board of Nursing, had to say about Aspen's NCLEX scores. Now this is from a recording of a special meeting of the nursing board, so the audio is a little rough.

Carolyn Jo McCormies: So looking at first time pass rates ... the program's scores have not improved. In fact, they consistently decreased as time has gone forward throughout these changes that have been implemented.

Firth: So despite whatever changes Aspen had made, their NCLEX scores were going down, not up. Jenny Erkfitz, Aspen's program director, said the school just needed more time. Erkfitz also brought up another point. Here's Erkfitz in that same meeting.

Jenny Erkfitz: In Arizona, we know there's an acute nursing shortage. Our remaining 400 students are desperately needed in our profession. They are assisting, they are working hard to be safe, effective nurses, and as well as any one of these, I would be willing to serve alongside with them in public.

Firth: So in this special meeting, the nursing board is having to answer the same question I wrestled with in my reporting: what do you do with a failing nursing program?

Robertson: It sounds like the nursing board is in a lose-lose situation. What were Aspen students thinking, though?

Firth: Well, in reporting this story, I spoke with students with different viewpoints. One former student, Meta Mitchell, a veteran and mom, had been kicked out of a different nursing program, but was accepted at Aspen. She only had positive things to say about her experience at Aspen and now works as an operating room nurse in Phoenix. I also spoke with Sarah Adler, who at the time of my reporting was one of the nearly 400 Aspen students fighting to keep the program open. She said she'd had plenty of meaningful clinical experiences, including in an actual hospital. And she argued that if the NCLEX really is the gold standard meant to determine whether students can practice safely, "why not allow us the opportunity to take the test?"

Some experts I spoke to actually answered that question. They said other professions, like paramedics, have skills tests as well as written tests. Because the NCLEX is only a written test, nursing boards really rely on nursing programs to help deliver the kinds of experiences and learning that can't be measured on an exam. Another Aspen alum, Ali McNeill, got her license but told me she felt so unprepared at her first job that she had to ask them for extra orientation. She also texted friends who graduated from other nursing programs to ask basic questions about things she felt she should have known. Finally, I spoke with former faculty like Tammy Drewitt, who was Aspen's director of clinical simulation for several years. She said the school got greedy. "They wanted the money from the students, but they didn't invest the money in making sure that we could provide what they were paying for."

Robertson: It sounds to me like Aspen students here, no matter where they stood on the teach-out, were stuck in the middle. What ultimately happened to Aspen's nursing program?

Firth: So do you remember that special meeting in February 2023? At that meeting, Aspen's leadership told the nursing board all the changes they'd made to the program. They said, look, we've improved faculty training, we've implemented one-to-one NCLEX coaches, expanded access to clinical rotations, and we're making sure students get a range of clinical experiences. But the nursing board remains skeptical. It voted unanimously to advance measures that could close the school, but it had to wait 10 days before taking a final vote to shut down the program.

In the meantime, Aspen's lobbyists have been talking with the legislature, Aspen students launched a petition demanding they be allowed to complete the teach-out. And then, Aspen's lawyers sued the nursing board. On March 21, 2023, a judge in Maricopa County granted Aspen a temporary restraining order, which blocked the board from immediately closing the school. The next day, the governor of Arizona sent a letter to the board asking it to find common ground with Aspen. And the day after that, Aspen and the nursing board reached a settlement agreement. On March 23, Aspen dropped its lawsuit and the nursing board agreed to let the teach-out happen. Of course, the nursing board made certain stipulations. Aspen had to hire an education consultant and meet "minimum standards" -- including having proctored exams. So in this case, lawmakers essentially took over the nursing board's process and decision making abilities.

Robertson: That is quite the saga. The nursing board wanted to do their job and police their own profession, but it sounds like lawmakers and judges ended up kind of taking over. What would you say the take-home message is here?

Firth: So one takeaway is the nursing board has only as much power and autonomy as the legislature and Governor allow it to have. If the legislature doesn't approve of what the nursing board is doing, that power can be taken away. Another key message is that this field needs so much more transparency. When trying to choose a school, I've seen prospective students on Reddit and Facebook looking for information. It should not have to be that way. All prospective students should know the NCLEX pass rates, completion rates, and acceptance rates of the programs they're considering.

Lastly, in response to program leaders using the nursing shortage as an argument for graduating students from a struggling program, I'll share what Rayna Letourneau, executive director of the Florida Center for Nursing, told me. "We need more qualified nurses. That doesn't necessarily mean that we need more nursing education programs."

Robertson: Thank you for your reporting on this Shannon.

And that's it for part two of our deep dive into "What's The Matter With For-Profit Nursing Schools?" featuring MedPage Today's Washington Correspondent Shannon Firth. While we certainly covered quite a bit of ground in the past two episodes, Shannon stories detail even more case studies and I totally recommend you check out her stories, which we've again linked in the show notes. (Part one: context; part two: Stratford University; part three: HCI College; and part four: Aspen University.)

This episode was hosted and produced by me, Rachael Robertson, with sound engineering by Greg Laub. If you like what you heard, leave us a review wherever you listen to podcasts, and please hit subscribe if you haven't already (Apple, Spotify).

MedPod Today is a production of MedPage Today. For more information about the show, check out medpagetoday.com/podcasts.

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