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NCSBN Regulatory Guidelines and Evidence-Based Quality Indicators for Nursing Education Programs

2020; Elsevier BV; Volume: 11; Issue: 2 Linguagem: Inglês

10.1016/s2155-8256(20)30075-2

2155-8264

Nancy Spector, Josephine Silvestre, Maryann Alexander, Brendan Martin, Janice I. Hooper, Allison Squires, Melissa T. Ojemeni,

Simulation-Based Education in Healthcare

Boards of nursing (BON) approval of nurse education programs is an integral part of their mission of public protection. In the United States , nursing education programs are required to be approved by the BON *In Mississippi, the registered nurse programs are approved by the Mississippi Institutions of Higher Learning and the practical nursing programs are approved by the BON. In New York, the programs are approved by the New York Board of Regents. In Idaho, programs are approved as long as they are accredited by a national nursing accrediting agency recognized by the U.S. Department of Education, though the BON takes over if that accreditation is lost. in the state where the program is officially located. The purpose of program approval is to ensure the program comprehensively covers the knowledge and skills students need to be licensed as a nurse and to practice safely as new graduate nurses, thereby providing society a competent nurse workforce. To obtain BON nursing education program approval, nursing programs must meet the nursing education standards established by their BON. Only students graduating from officially recognized and approved programs are permitted to take the the NCLEX, the official nursing licensure exam in the US and Canada. ((Spector and Woods, 2013Spector N. Woods S.L. A collaborative model for approval of prelicensure nursing programs.Journal of Nursing Regulation. 2013; 3: 47-52https://doi.org/10.1016/S2155-8256(15)30186-1Abstract Full Text Full Text PDF Scopus (4) Google Scholar). To determine whether graduates are eligible to take the NCLEX, BONs rely on verification from the nursing education program that each student has successfully completed all program requirements, including successfully meeting clinical learning objectives. BONs offer two types of nursing education program approval: initial approval of new programs before they open for enrollment and ongoing monitoring and continued approval of programs. For a new program, the approval process begins with an initial application and proposal to the BON. The BON conducts an extensive evaluation to ensure that the program has the proper facilities, resources, administration and faculty, curriculum, clinical agreements, policies, and procedures, among other requirements set forth in state regulations. The process for continued approval of established programs is based upon monitoring the programs’ performance outcomes and compliance with BON rules over time (Spector et al., 2018Spector N. Hooper J.I. Silvestre J. Qian H. Board of nursing approval of registered nurse education programs.Journal of Nursing Regulation. 2018; 8: 22-29https://doi.org/10.1016/S2155-8256(17)30178-3Abstract Full Text Full Text PDF Scopus (17) Google Scholar). BONs use different models for approving nursing programs, and nursing education rules and regulations are not always consistent across all jurisdictions. Most BONs hire graduate-prepared education consultants with experience in nursing education to make recommendations on the approval status of the nursing programs in their state. In a few states, the BON’s executive officer and board members from the BON’s education committee (or educators on the board) may make these recommendations. About half of the BONs make site visits as needed, while the other half make regular visits (National Council of State Boards of Nursing [NCSBN], 2016a). In most states, the approval status will be designated as (a) full approval when all requirements are met; (b) conditional or probationary when some, but not all, of the requirements are met; or (c) approval removal when programs fail to meet requirements of correct cited deficiencies (Spector et al., 2018Spector N. Hooper J.I. Silvestre J. Qian H. Board of nursing approval of registered nurse education programs.Journal of Nursing Regulation. 2018; 8: 22-29https://doi.org/10.1016/S2155-8256(17)30178-3Abstract Full Text Full Text PDF Scopus (17) Google Scholar). The three most common performance outcome measures used by BONs and other health profession accreditors are employment rates, graduation rates, and NCLEX pass rates (Spector et al., 2018Spector N. Hooper J.I. Silvestre J. Qian H. Board of nursing approval of registered nurse education programs.Journal of Nursing Regulation. 2018; 8: 22-29https://doi.org/10.1016/S2155-8256(17)30178-3Abstract Full Text Full Text PDF Scopus (17) Google Scholar). Although BONs use different models for approving nursing programs, the approval process is well recognized overall. Questions have arisen from nursing education experts regarding valid measures of nursing program quality. One is the use of NCLEX pass rates (Bernier et al., 2005Bernier S.L. Helfert K. Teich C.R. Viterito A. Are we using the right “gold” standard?.Community College Journal. 2005; 76: 36Google Scholar; Giddens, 2009Giddens J.F. Changing paradigms and challenging assumptions: Redefining quality and NCLEX-RN pass rates.Journal of Nursing Education. 2009; 48: 123-124https://doi.org/10.3928/01484834-20090301-04Crossref PubMed Scopus (33) Google Scholar; Taylor et al., 2014Taylor H. Loftin C. Reyes H. First-time NCLEX-RN pass rate: Measure of program quality or something else?.Journal of Nursing Education. 2014; 53: 336-341https://doi.org/10.3928/01484834-20140520-02Crossref PubMed Scopus (26) Google Scholar). Of the 36 states that require a percent of first-time pass rates,* **Fifteen states require the national pass rate or a percentage thereof.* 64% of them require an 80% pass rate (NSCBN, 2019). BONs are also questioning whether this method of measuring program performance is appropriate and asking whether other metrics exist that should amend or replace the current regulatory standards, which are set by each state. A large mixed-method study was conducted by NCSBN starting in 2017 to answer these questions and, more specifically, to identify the quality indicators of approved nursing education programs and the warning signs indicating a program may be falling below required standards for approval. The study consists of a comprehensive literature review; a national Delphi study providing data on consensus of experts in nursing education, regulation, and practice; a study analysis of 5 years’ worth of BON annual reports of nursing programs; and a study analysis of 5 years’ worth of BON site visit documents. The literature review yielded 65 relevant published articles that were reviewed and graded using the Johns Hopkins Levels of Evidence and Quality Guide. Overall, the literature review revealed a number of quality indicators and warning signs that may serve as metrics for evaluating higher education programs, although the identified articles did not provide the levels of evidence needed for making policy decisions (Loversidge, 2016Loversidge J.M. An evidence-informed health policy model: Adapting evidence-based practice for nursing education and regulation.Journal of Nursing Regulation. 2016; 7: 27-33https://doi.org/10.1016/S2155-8256(16)31075-4Abstract Full Text Full Text PDF Scopus (5) Google Scholar). For our national Delphi study, data were provided on consensus from experts in nursing education, regulation, and practice on nursing education quality indicators, warning signs when programs are beginning to fall below standards, and performance outcome measures of nursing education programs. Consensus among the experts was reached after 2 rounds of discussion. This Delphi study identified 18 quality indicators (characteristics of nursing programs that graduate safe and competent students), 11 warning signs when nursing programs begin to fall below standards, and eight program performance outcomes that nursing regulatory bodies could measure. The quality indicators fall into the categories of (a) school leadership and faculty support; (b) consistent and competent faculty; (c) quality, hands-on clinical experiences with meaningful collaboration with clinical partners; and (d) an evidence-based curriculum emphasizing quality and safety and critical thinking/clinical reasoning. Although the warning signs are similar to the quality indicators (only the opposite), there are additional ones that are of interest, including over-reliance on simulation to replace clinical experiences and refusal of clinical facilities to host clinical experiences. There were few surprises with the outcomes that were identified (NCLEX pass rates, graduation rates, employment rates, etc.). This study was a retrospective cohort study of 11,378 annual report data collected over a 5-year period (2012-2017) by 43 BONs. This quantitative analysis examined data contained within the BONs’ annual reports to learn about indicators associated with full approval of nursing education program performance and those associated with programs that have lost approval. Statistically significant characteristics of approved programs and those with ≥ 80% NCLEX pass rates included (a) national accreditation, (b) traditional or hybrid modalities, (c) longer-standing programs, (d) higher enrollment capacity, (e) multiple program sites, (f) private nonprofit or public institutions, (g) program director with a PhD, (h) licensed practical nurse/licensed vocational nurse (LPN/LVN) and bachelor of science in nursing (BSN) programs, and (i) no more than three program directors in 5 years. A marginally significant finding was that programs with more than 35% full-time faculty had ≥ 80% first-time NCLEX pass rates and full approval. Importantly, the NCLEX was viewed as a lagging indicator in this study; meaning, lower licensure examination performance was considered indicative of other program deficiencies, not vice versa. The qualitative study of 5 years’ of BONs’ site visit documents was conducted to better understand the qualifiable descriptors of why programs either become at risk for failing or do fail. After the inclusion/exclusion criteria were applied, there were 1,278 site visit reports for LPN/LVN and registered nurse (RN) programs eligible for the analysis, which included documents from programs that were on probation, under review, or did not have full approval. Two researchers used MaxQDA qualitative data analysis software to analyze the documents. Considerable, specific data on what causes nursing programs to begin to fail or fail, were found in the site visit documents. The main signal for a “site visit trigger” was NCLEX pass rates ≤80% for four or more quarters. The length of time it took to trigger a site visit related to NCLEX performance concerns varied by state regulations. Administrative processes, such as a lack of policies and procedures, were found to be problematic for nursing programs. High faculty turnover and the inability to recruit qualified faculty were linked to poor NCLEX performance. Faculty with little training in basic pedagogies was a persistent theme found in failing programs. Similarly, heavy faculty workloads and limited faculty development opportunities were also identified. Many failing programs had no overarching philosophy and curricular framework that tied the curriculum together. This gap resulted in curricula that were task-oriented, which masked the curricula as being “competency-based.” The issues identified in this study coalesce nicely with the data found in the literature, our Delphi study, and our quantitative study of annual reports. After all the evidence was collected, NCSBN invited experts from nursing regulation, education, research, and law to review the data and findings and to develop guidelines for BONs to use when approving nursing education programs that include evidence-based criteria, quality indicators, and warning signs. This study provides substantial evidence-based criteria for identifying quality indicators of successful nursing education programs as well as warning signs for high-risk programs. The quality indicators and warning signs can serve as the basis for legally defensible and evidence-based guidelines for nursing education approval.