When news broke in late January that more than 7,600 nurses in the United States bought fraudulent nursing degree diplomas, nursing regulatory organizations had already been working with the FBI to help uncover the scam.
At the Nursing Care Quality Assurance Commission in Washington State, the early warning signs began a year and a half ago. The organization started receiving applications for licensure with school transcripts containing uncharacteristic -- yet subtle -- differences from typical transcripts.
"This was a very sophisticated scheme," said Paula Meyer, MSN, RN, FRE, Executive Director of the commission. The applications included lists of coursework, signatures from school deans, and a seal from the school. But the commission's trained staff started noticing that the sequences of classes on some transcripts were unusual. For example, an applicant with a bachelor of science in nursing degree included transcripts with classes more typical of associate degree courses, Meyer said.
Leaders from other nursing regulatory organizations throughout the country were also starting to flag aberrations, which helped the FBI to identify the three Florida nursing schools that were involved in falsifying diplomas: Siena College, Sacred Heart International Institute, and Palm Beach School of Nursing. Twenty-five individuals were charged in connection with the scheme, which provided fake transcripts and diplomas in exchange for fees ranging from $10,000 to $15,000, according to the Department of Justice.
In Washington State, the commission identified 150 nurses with ties to the three Florida schools. Most of the nurses are still under investigation, but seven licenses have been rescinded so far. Twenty-four of the nurses were found to have legitimate licenses, said Meyer. “Some of the students were victims of the scam,” she said. “They were told that they needed to pay the money to get a diploma.”
Joy Longo, PhD, RNC-NIC, CNE, Assistant Dean of Undergraduate Programs at the Florida Atlantic University Christine E Lynn College of Nursing and an associate professor, suspects that at least some of the students did not understand that they were participating in a scam.
“When new students enter our program, they do not always know what a nursing education should look like,” Longo said. “It’s critical to teach them about the coursework and clinical training involved in different nursing degrees.” Nursing students also need to understand the importance of attending schools accredited by the Commission on Collegiate Nursing Education or the Accreditation Commission for Education in Nursing, said Longo.
A nurse attorney's perspective
According to Nancy Brent, MS, JD, RN, Nurse.com's legal columnist, those who purchased the fraudulent transcripts and nursing diplomas could face a myriad of legal charges.
"Some of these individuals are reported to be anonymously listed as 'co-conspirators' in court documents filed against those who clearly participated in the scheme to solicit and recruit individuals and issue false transcripts and documents," Brent said. "If this were not enough of a legal headache, the individuals who passed the NCLEX exam, were licensed, and who obtained employment with false credentials can face disciplinary actions by state boards of nursing."
Brent, who discussed the repercussions for falsifying nursing credentials in a Nurse.com blog, said that grounds upon which a license can be revoked, or more likely annulled, include:
- Unprofessional conduct, fraud, deceit, or misrepresentation in applying for or obtaining a license (including a renewal of a fraudulent license)
- The use of a false, fraudulent, or deceptive statement in any document connected with the licensee's practice
"The result of a revocation or annulment for the individual under these circumstances means the absolute inability to ever obtain a license to practice nursing in the future," she said. "Criminal charges may be alleged against these individuals as well. Such charges include practicing nursing without a license, fraud, and falsification of medical records."
How could they pass the NCLEX?
One important question for nursing educators and regulators is how students with fraudulent diplomas could pass the National Council Licensure Exam (NCLEX). According to news reports, 37% of the nurses who bought fake documents passed the exam. A significant number of the nurses who passed went on to secure licenses and work in healthcare settings in states including Louisiana, Washington, Ohio, New York, New Jersey, Massachusetts, Maryland, Georgia, and Texas.
Brenda Hage, PhD, DNP, ARNP, Director of the School of Nursing at Florida Gulf Coast, said it would be difficult to pass the NCLEX with no nursing school experience. "I wonder if some of these students had started programs but were unsuccessful in completing what was required," said Hage. Another possibility is that some of the students were already LPNs/LVNs, so they may have had some level of training and experience before taking the NCLEX, said Longo.
Although the scale of the recent scam -- with students paying a total of $114 million between 2016 and 2021 -- is unprecedented in the field of nursing, this is the not first time nursing transcripts have been falsified. Hage has heard from colleagues regarding situations when a sharp decrease in NCLEX pass rates was a sign that something was amiss.
In response, schools asked the board of nursing for a list of their students who sat for the exam, only to find that some of them had not been enrolled in the school and had falsified records.
Closing loopholes in the system
In response to news of the scam, nurses on social media have expressed anger about the potential danger to patients and about the blow to their profession's reputation.
"It's such a shame to think that a school of nursing could defraud the public given that nursing has been voted the most trusted profession for more than 20 years," said Ecoee Rooney, DNP, RN, AFN-C, NPD-BC, SANE-A, DF-AFN, President of the Louisiana State Nurses Association. In the 2022 Gallup poll, nursing was rated the most trusted profession for the 21st consecutive year.
"This scheme gives the impression that it is easy to become a nurse and not as rigorous as it actually is," Rooney said.
For Rooney, who started nursing school after working in public relations and communications for 10 years, the classes in her associate degree program were arduous and challenging. "Learning pharmacology, anatomy, pathology, and how to develop care plans was difficult because it was like learning a new language," said Rooney. She went on to earn master's and doctoral degrees in nursing.
Although there are many unanswered questions while investigations are ongoing, nurses are hopeful that the findings will instigate changes that reduce the risk of fraud in the future.
“This is an evolving situation, with many regulatory bodies and other organizations working together,” said Felicia Sadler, MJ, BSN, RN, CPHQ, Vice President of Quality at Relias. “It will be critical to identify what happened and put policies in place to mitigate this in the future.”
One change on the horizon that may filter out fraudulent test takers is the new NCLEX. Called the Next Generation NCLEX (NGN), it will launch April 1, 2023. The NGN test will “ask better questions to help nurses think critically when providing care, with the goal of protecting the public and achieving the best outcomes for clients, nurses, and institutions,” according to the National Council of State Boards of Nursing.
Instead of standalone questions, for example, the new test will include several questions based on a single case scenario. “The questions will require the nurse to recognize what is going on with a critically ill patient, respond, and reassess to determine if the plan is working,” said Longo.
Regulatory organizations are also exploring how to improve their systems. “It’s disheartening that there are some people who desperately needed jobs and thought this was the way to secure a nursing position,” said Meyer. “Our job is to protect the public, and we are constantly looking at our processes to make sure we are doing just that.”
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