1 1 Protecting the Public: Ensuring Nursing Education Quality Jean E. Johnson and Christine Pintz George Washington University November 2013 This paper was commissioned for the National Academy of Education project on Evaluation of Teacher Education Programs: Toward a Framework for Innovation, which was funded by the National Science Foundation. It was presented at a workshop in Washington, DC, February 25, Any opinions expressed in this paper are those of the authors and not those of the National Academy of Education or the National Science Foundation.
2 2 INTRODUCTION The challenge for every educator is how to prepare students for their future profession. In addition to the concerns and efforts of educators responsible for the quality of learning experiences, there is significant public interest in the outcomes of educational programs, particularly in fields that prepare students to serve the public. Quality of educational programs becomes a matter of public policy. The purpose of this paper is to offer insights into how the nursing profession works to ensure the quality of educational programs in hope that there will be useful examples for teacher preparation programs given the many similarities between the professions of nursing and teaching. Both nursing and teacher education programs prepare students to serve the public in critical service professions. Both are primarily female professions that are not highly paid for their services. Both professions require a knowledge and skill base in which competency can be measured. Both have a system of regulations governing their practice that is state based. The hope is that, given some of the similarities shared by these professions, the experience of quality assessment of educational programs in nursing will contribute to informing policy decisions for teacher preparation. Nursing and teacher preparation programs differ in the way outcomes of graduates are measured. Some policy makers and educators are advocating for the evaluation of teacher preparation programs using national student test scores. This suggests that there is a direct link between student performance and teacher preparation programs. While there is legitimacy to this effort, nursing has not tried to link patient outcomes to educational programs. Establishing a direct link is a challenge because of the many confounding variables in patient care. Nurses care for literally hundreds of patients in a year with many other health professionals involved in care. Physicians, physical therapy, diagnostic testing services, and others have an impact on patient outcomes. Moreover, on any given day at least two or three nurses are responsible for a single patient s care and in a week there could be up to 14 or 15 different nurses responsible for that patient. In addition, there are many different environmental factors that can influence care. Demonstration of quality of care has become a requirement and health care agencies of all types must collect and report performance measures with payment being linked to many of the measures. While quality of patient care is primarily associated with the clinical setting, there is a robust structure developed within nursing education to ensure, to the extent possible, that educational programs prepare competent and safe nurses. This structure is presented in this paper. BRIEF OVERVIEW OF NURSING Nursing has evolved over several centuries with modern nursing emerging from hospital-based programs to university-based educational preparation (ANA, 1965). Nursing is the largest health care workforce, with approximately 3.8 million licensed
3 3 registered nurses (RNs) (NCSBN, 2012c). As of 2010 about 9 percent were male with about 25 percent of all nurses being from an underrepresent group (DHHS, 2013). The median salary for staff RNs is $63,944 and the mean age is 46 years with nearly 50 percent of the workforce close to retirement (Bureau of Labor Statistics, 2012; DHHS, 2013). There are currently three paths to becoming an RN, which is the entry level into nursing. The pathways are as follows: Diploma programs are typically 3 years in length with the program based in a hospital. This had been the dominant form of nursing education until the 1960s. Today only 6.9 percent of nurses are diploma prepared (DHHS, 2013). Community college based programs are typically 2-3 years in length and offer entry-level RN education. These programs were developed in 1962, when there was a severe shortage of nurses and a shortened program was proposed to educate nurse technicians. University- and college-based programs are usually 4-5 years in length and include liberal arts courses, community health, research, and others that are not typically offered in the other pathways. In addition to the university-based entry RN program, accelerated programs have emerged that are tailored to individuals who already have a bachelor s degree in another area and want to pursue nursing. The accelerated programs are months. Some accelerated programs offer students a master s degree within a 3-year, full-time program. To practice as an RN, a candidate must graduate from an approved or accredited program and pass the national licensure exam called the National Council Licensure Examination for Registered Nurses (NCLEX-RN). There is another category of nurses that have additional education and function in a more independent capacity than entry-level nurses. These nurses are educated at the graduate level and are referred to as advanced practice registered nurses (APRNs). Nurses who belong to the APRN group are nurse practitioners, certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists. This category of nurses has fostered heightened quality monitoring because of their independent practice responsibilities. In addition, there are nurses with graduate education that do not fall within the APRN category. These nurses generally provide systems-level care rather than direct patient care and include public health, informatics, and administrative nurses. Nurses in leadership positions or those in academia often have a terminal degree. The most prevalent doctoral degrees among nurses are the Doctor of Nursing Practice, the Doctor of Philosophy, and the Doctor of Education. ENSURING EDUCATIONAL QUALITY IN NURSING: INTEGRATED APPROACH The quality of nursing education is promoted through an integrated approach. Several elements influence the program evaluation process (see Figure 1).
4 4 Licensure and Regulation Accreditation Certification Standards: Professional Educational Nursing Educational Quality Transition to Professional Practice Figure 1. Elements that influence the nursing education program evaluation process. Standards Although there are no prescribed nursing curricula, nursing schools must integrate national nursing standards along with the school s mission into their programs of study. These national standards are the basis for nursing education and are established by national nursing education organizations and national professional organizations. There are two national organizations dedicated to nursing education: the National League of Nursing (NLN) and the American Association of Colleges of Nursing (AACN). The NLN was established in 1893 and was the first nursing organization. The NLN and its accrediting arm, the NLN Accrediting Commission (NLNAC), publishes the NLNAC Standards and Criteria (2013). The majority of NLN-affiliated schools are at the associate degree level. The AACN was founded in 1969 and focuses on nursing education at the baccalaureate, master s, and doctoral level. The AACN publishes the AACN Essentials series, which delineates standards for developing undergraduate, master s, and Doctor of Nursing Practice curricula. These standards are called The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008), The Essentials of Master s Education in Nursing (AACN, 2011), and The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006). The AACN Essentials are developed through an iterative process where stakeholders have input in the final standard. For example, the Master s Essentials (AACN, 2011) were revised recently. The AACN board of directors formed a task force
5 5 charged with revising the previous Master s Essentials. The task force used a national consensus-building process to develop the new standards and held forums to elicit constituent input. Draft versions of the Master s Essentials were made available for review and comment. After rigorously soliciting feedback, the new Master s Essentials were approved by the board and then the AACN membership. Nursing schools that are members of the AACN now must review and potentially revise their master s curriculum so that their programs are aligned to the new standards. In addition to educational standards, professional standards are set by professional nursing organizations. The American Nurses Association (ANA) publishes the Scope and Standards of Practice, which represents the values and priorities of the nursing profession. Most nursing schools choose to incorporate these standards into their prelicensure programs. This document outlines the role and responsibilities of registered nurses and define[s] the nursing profession s accountability to the public and the outcomes for which registered nurses are responsible (ANA, 2010b, p. 1). These standards not only inform nursing education, they provide the foundation for nursing practice. The Scope and Standards of Practice are framed around the elements of the nursing process, which are assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Within each standard are competencies that further delineate the knowledge and skills that the nursing student must develop. For example, within the assessment standard, nurses must be competent in identifying barriers (e.g., psychosocial, literacy, financial or cultural) to effective communication and makes the appropriate adaptation (ANA, 2010b, p. 32). In addition to national standards for general practice, there are standards developed by specialty organizations. A specialty has been defined by the American Nurses Association and includes characteristics such as having a well-derived knowledge base particular to the practice of the nursing specialty, representation by an organization, and identifying a need and demand for itself (ANA, 2010a). The organizations that govern advanced practice registered nurses all have standards that must be incorporated into curriculum. These organizations include the National Organization of Nurse Practitioner Faculty (NONPF), the American College of Nurse Midwives, and the American Association of Nurse Anesthetists. NONPF publishes Core Competencies for Nurse Practitioners, which nurse practitioner faculty can use to define content for courses and to determine student outcomes. Other specialty organizations are focused on a specialty within nursing practice. Examples of specialty organizations include the American Association of Critical Care Nurses, the Hospice and Palliative Care Nurses Association, and the Association of Public Health Nurses. The standards that the American Association of Critical Care Nurses (AACN-2) publishes for acute and critical care builds on the ANA s Nursing: Scope and Standards of Practice. For instance, the Scope and Standards uses the broad categories of nursing process (assessment, diagnosis, outcomes identification, planning, implementation, and evaluation) as the framework for practice and the AACN-2 builds on specifying a competency, for example: Interventions are responsive to the uniqueness of the patient and family and create a compassionate and therapeutic environment, with the aim to promote comfort and prevent suffering (AACN, 2008). When incorporating this competency, curriculum should provide
6 6 opportunities for the student to learn about pain and symptom management, appreciation of diverse patient contexts and situations, and providing a caring approach to patients. Nursing standards may be developed to address a problem in health care delivery. For instance, the Quality and Safety Education for Nurses (QSEN) project provides educational content that prepares nursing students in health care quality and patient safety. This initiative was developed in response to the problem of medical errors and lack of quality in health care that was outlined in the late 1990s in two Institute of Medicine reports, To Err is Human (IOM, 1999) and Crossing the Quality Chasm (IOM, 2001). The QSEN project developed competencies for undergraduate and graduate nursing students. The competencies are further delineated into specific knowledge, skills, and attitudes (KSAs). The KSAs can be developed into learning objectives and learning activities to help nursing students achieve proficiency in providing safe and high-quality care. These competencies are now integrated into the AACN Essentials. To learn more about nursing standards, Table 1 provides a list of nursing organizations that develop standards for nursing practice and education. The list is not all inclusive but provides some examples. Accreditation According to the American Nurses Credentialing Center (ANCC) accreditation is a voluntary process by which a nongovernmental agency grants a time-limited recognition to an institution, organization, business, or other verifying agency that it has met pre-determined and standardized criteria (ANCC, 2013). Nursing schools are accredited by either one of two national organizations. The NLNAC is the accrediting organization affiliated with the NLN. This organization accredits all levels of nursing education [Licensed Practical Nurse, diploma, associate degree, baccalaureate, master s, and Doctor of Nursing Practice (DNP) programs] though it is are primarily focused on the accreditation of associate degree programs. The Commission on Collegiate Nursing Education (CCNE) is the accreditation organization associated with the AACN. CCNE accredits baccalaureate, master s, and DNP programs. In addition to national accreditation for degree programs, there is accreditation by specialty organizations. The Council on Accreditation of Nurse Anesthesia Educational Programs accredits nurse anesthesia programs and the Accreditation Commission for Midwifery Education accredits nurse midwifery programs. Most accrediting bodies have similar criteria for accreditation. They focus on all aspects of a school of nursing, including Students: student learning, student outcomes, student satisfaction; Faculty: qualifications, scholarship and clinical practice; Institution: mission and governance, financial resources, and educational resources; and
7 7 Program outcomes: retention and persistence, graduation rates, licensing and certification pass rates, and employment rates. Nursing accrediting organizations have placed increasing emphasis on outcomes of learning. There is an expectation that schools can demonstrate that students have achieved the learning outcomes identified by the school, both program-level outcomes and individual student learning outcomes. Schools are increasingly incorporating simulation into the curricula to help students learn psychomotor and cognitive skills and to demonstrate competency in those areas. Simulation has an advantage over the clinical setting because conditions can be controlled by the instructor and structured to promote critical thinking. Simulation can also provide students with a wider range of experiences than can be found in the clinical site. In addition to a focus on outcomes, nursing schools must demonstrate that there is a continuous quality improvement process in place. Schools must collect data on outcomes and demonstrate that outcome data can be analyzed and used to improve the delivery of education and services. Outcomes data include pass rates on national exams, demonstration of skills attainment such as care of a patient on a ventilator and infection control measures, as well as critical thinking skills demonstrated during simulation testing such as assessing and intervening on a postsurgical patient who suddenly experiences shortness of breath. The accreditation process begins with the development of a self-study that addresses accreditation standards. The self-study must provide evidence that the school meets the accreditation criteria. After the self-study has been reviewed by the organization, an accreditation review team visits the school to confirm the evidence that was provided in the self-study. An accreditation review committee reviews the self-study report and the accreditation site visit team report and a decision on whether to accredit is made. The current trend in nursing accreditation is to focus on the quality improvement process and not strict adherence to rigid standards. Accreditation organizations have dual missions, protecting the interests of the profession as well as protecting the public. By undergoing accreditation, schools demonstrate to the public that there is sufficient expertise and resources to ensure safe and competent graduates. Licensing of Nurses All practicing nurses are required to be licensed. In the late 1800s there was serious concern about the variability of nursing education that ranged from on-the- job training to 3 years of supervised education. The first requirement for mandatory licensure was established in New York in 1947 (Benefiel, 2011; Comer, 2007). The primary purpose for licensing is to protect the public (NCSBN, 2011). The license signifies that a person is granted permission to engage in the practice of nursing because that person has the knowledge and skills to practice as a nurse. Licensing also
8 8 prohibits those who are not licensed from calling themselves a nurse and providing nursing care. Licensing is regulated through state boards of nursing. Even though each state has a board of nursing, everyone that applies for licensure must have passed an exam that is given by the National Council of State Boards of Nursing (NCSBN) so that nursing is regulated at the state level, but the licensing exam is a national exam. The NCSBN establishes the pass rate that applies to all examinees regardless of what state the person is seeking licensure. The exam is pass/fail. The relationship between NCSBN and state boards of nursing is that NCSBN is a membership organization of state boards. As such, the state boards established the mission and goals of NCSBN and agreed that a national exam was in the best of interest of the public by defining a baseline of competence that is uniform. A national standard also is important because of the mobility of nurses; it allows state boards to license nurses based on a nurse being licensed in another state. In addition, it is costly to develop a valid, reliable, psychometrically sound, and legally defensible exam, and individual state boards of nursing do not have the resources to do this. Requirements for licensure include the following: Successful completion of an accredited nursing program, Passing the standardized NCLEX-RN, Application to a state board of nursing, and Passage of a criminal background test if required (this is variable based on the state but is being required by increasing numbers of states). Construction of the licensing exam is based on a rigorous process. The framework for the exam is based on four core client needs: (1) a safe and effective care environment, (2) psychosocial integrity, (3) physiological integrity, and (4) physiological adaptation. A practice analysis is conducted every 3 years by surveying 12,000 nurses about 141 activities that relate to the four areas noted above and are defined as core to nursing practice (NCSBN, 2013a). Specific examples of activities reflective of a safe and effective care environment include ensuring a patient has an advance directive, being able to delegate work, and protecting client rights. The results of the survey are analyzed and a test plan is developed. Item writers go through extensive training and create a bank of questions. All questions go through a content analysis, and statistical and psychometric testing. Once the items have been analyzed and exam questions selected, each question is given the same weight in the exam. The questions are primarily single-answer multiple choice but NCSBN is beginning to introduce alternative test questions such as multipleanswer and true-or-false questions. State boards of nursing are the arbiters of who practices nursing. Their functions include providing initial licensure as well as renewal of a license. To protect the public from potentially negligent nurses, they review disciplinary cases and have the authority to revoke licensure. In addition, if continuing education is required for licensure, the state board monitors this requirement usually through a sampling of licensed nurses. Not all state boards require continuing education.
9 9 The requirements for licensure and the scope of nursing practice are operationalized through the state-based nurse practice acts. These practice acts establish the regulation by which nurses are governed. Although every state practice act is different, there are commonalities across states such as the requirement to pass the NCLEX for licensure. Each state reviews its regulations on a periodic basis that opens the door for changes in scope of practice. Having to go state by state is a challenge when there is a major change in nursing such as with the development of the nurse practitioner (NP) role in the 1960s. To accommodate the need for nurse practitioners at a time when there was a shortage of primary care providers, regulations in every state had to be changed to recognize the ability of NPs to diagnose and treat patients. In addition to the functions noted above, state boards of nursing also review educational programs. This has been a source of contention between accrediting bodies and state boards. Accreditors see the dual review as a sign of not trusting the accreditation process as well as a waste of resources. State boards have wanted to make sure details of the curriculum and outcome measures meet national standards that are based on professional organization standards that as described above are more specific than the accreditation standards. However, a process of negotiation has been taking place to review the specificity of accreditation and come to an agreement about how state boards and accrediting agencies can work more efficiently together. Currently educational programs have to send periodic reports to both state boards of nursing and accrediting bodies with the formats being different, adding a burden to the educational programs. To address each stakeholder s concern, nursing has brought together representatives of each constituency to discuss this and other issues. The Licensure, Accreditation, Certification and Education group has the purpose of being able to rationalize and strengthen the regulatory system overall. State boards of nursing monitor educational programs by monitoring the pass rate on NCLEX of each school public and private. Most states have set a benchmark that triggers a review of a program and possible withdrawal of approval. For instance, Virginia has established a benchmark of 80 percent. If a program falls below having an 80 percent pass rate for their graduating class 2 years in a row, the program is placed on warning and must complete a self-study followed by a site visit by members of the state board. Once a nurse is licensed in a particular state, if he or she moves to a different state that nurse can be licensed by providing proof of licensure in the original licensing state. Every state has reciprocity for licensure so that nurses do not have to take the NCLEX every time they move from one state to another. In fact, nurses may never have to take another exam in their entire career once they are licensed. This issue has been consistently debated in terms of how to ensure long-term competency of the workforce. Currently, there are few advocates for periodic retesting, leaving the competency issue to employers. Advanced practice registered nurse licensure is relatively new. After decades of discussion, a new APRN national regulatory model was established in 2008 and states are
10 10 in the process of adopting this model, calling for a second licensure for APRNs (nurse practitioners, certified nurse midwives, certified registered nurse anesthetists, and clinical specialists) (AACN-2, 2008). Given the level of accountability in APRN practice (for instance, nurse practitioners establishing their own practice), state practice acts require oversight by the board of nursing and, in some cases such as in Virginia, a joint Board of Nursing and Board of Medicine. Since the mid-1980s state boards have required APRNs to be certified by passing a national certifying exam and then being approved for practice by state boards. The new regulatory model clarifies the terminology so that all states will require licensure as an RN and licensure as an APRN so that APRNs will have two licenses, reflecting the different scope of practice at each level. In addition, APRNs must complete continuing education requirements and practice for a specified amount of time. A difference between RN and APRN licensure is that whereas both have to renew licenses with the state board of nursing, only APRNs also have to renew their certification with the national certifying bodies that administer their exam and submit clinical practice hours and proof of required continuing education. If an APRN moves to a different state, as long as the APRN meets the educational requirements, has passed a national certifying exam, and has completed all continuing education requirements, she or he does not have to sit for another certifying exam. If the APRN does not meet the state requirements, she or he may have to take additional courses and/or retake the certification exam. Certification of Specialty Practice Certification is recognition of specialty practice that has a fairly narrow focus, such as oncology, transplant nursing, adolescent psychiatric-mental health, home health, diabetes management, and cardiac rehabilitation. There are currently more than 60 certification exam areas (in addition to the certifying exams for APRNs required for licensure) and 17 certifying organizations (ABSNC, 2013). The primary certifying agency is the American Nurses Credentialing Center, which is a subsidiary of the American Nurses Association. It is important to note that whereas APRNs have to pass a national certifying exam, APRNs are licensed by a state board. The certification of specialty practice does not lead to licensure by state boards. Specialty practices are not regulated by state boards of nursing but are managed largely by professional organizations. State boards have taken the position that they do not want to get into the details of specialty practice partly because of limited resources but also because of concern about flexibility of the workforce to meet specific health needs and to facilitate nurses moving into new areas of practice. The evolution of specialty practice is that a patient care need develops within the health care system, a small group of nurses begins to practice in that area, and, if the area of practice expands, there is then usually concern over variability of skills of nurses practicing in that area. An organization reflecting the interests of the specialty practice develops and writes standards that are national in scope accompanied by a way of determining whether someone has met those standards. Common ways that certification can be granted is by
11 11 examination or submission of a portfolio of work that addresses how the applicant meets the standards. The characteristics of specialty practice were described earlier. To ensure adequate rigor in the certification process, the Accreditation Board for Specialty Nursing Certification (ABSNC), formerly the American Board of Nursing Specialties (ABNS), was created to certify certifying bodies. Certifying bodies have to submit standards and processes for recognizing a nurse s expertise in a specialty area to the ABNS. The ABNS has itself set standards for certifying bodies, including itself. While study of the impact on patient care is limited, there is a growing body of evidence related to specialty areas of care that recognizes the positive impact on patient outcomes when they are cared for by certified nurses (Blegen, 2012; Kendall-Gallagher et al., 2011; Krapohl et al., 2010). Transition to Professional Practice As nursing school graduates transition to professional practice, there is a final check on the quality of educational programs that occurs within the agencies that employee new graduates. Employers have a stake in the quality of graduate nurses because they are ultimately responsible for the quality of care provided in their facilities. Employers have recognized that a new nurse may not be fully ready to take on the work of an experienced nurse. Most large health care institutions have initiated substantive orientation programs and many have introduced residency programs to help nursing graduates take on the responsibilities of an RN (Berkow et al., 2008). Of great concern is the very high turnover rate among nurses in their first year of practice. The estimated cost of turnover of one nurse is estimated to be double the salary of that nurse and for each percent increase in the turnover rate the estimated cost to the hospital is $300,000 (Atencio et al., 2007; Hunt, 2009; PriceWaterhouseCoopers, 2007). The nurse residency is now being promoted nationwide as a way to reduce turnover and create a supportive environment for new nurses. Standards have been established for residencies that include a specific educational component as well as each resident having a mentor. These programs have significantly reduced the turnover rate for new nurses (Goode et al., 2009; Trepanier et al., 2011). Educational programs and clinical agencies communicate about clinical training for nursing students in several ways. The first level occurs between the nursing faculty and staff nurses. For RN education, nursing faculty are at clinical sites with the students so they directly supervise the students and can assess their strengths and weaknesses. The faculty collaborate with the staff nurses who also work directly with the student so there is another assessment of student performance. In addition to the faculty and staff relationship in the clinical setting, the clinical coordinator or program director of the nursing program communicates with the clinical site educator. The clinical site educator collects comments and assessments of students from staff and shares them with the education program liaison. In turn, the education program liaison will share issues with the clinical site.