1 Accreditation Standards and Rules and Regulations for Mississippi Nursing Degree Programs Revised July 1, 1992 Revised July 1, 1993 Amended April 1995 Amended June 1998 Amended July 1999 Revised November 2002 Revised September 2004 Revised November 2007 Office of Academic and Student Affairs 3825 Ridgewood Road Jackson, Mississippi 39211
2 TABLE OF CONTENTS I. AUTHORITY...3 II. RULES AND REGULATIONS FOR ACCREDITATION...4 III. STANDARDS FOR ACCREDITATION...5 A. ADMINISTRATIVE ORGANIZATION...5 B. EDUCATIONAL PROGRAMS...5 C. FACULTY AND/OR STAFF...7 D. STUDENTS...8 E. RESOURCES, FACILITIES, AND SERVICES...8 F. INTEGRITY...9 G. EVALUATION...9 H. CHANGES IN EXISTING NURSING PROGRAM...10 IV. CRITERIA FOR ESTABLISHING A PROGRAM OF PROFESSIONAL NURSING IN THE STATE OF MISSISSIPPI...11 STAGE 1 DECLARATION OF INTENT/NEED...11 STAGE 2 QUALIFY FOR INITIAL ACCREDITATION...12 STAGE 3 QUALIFY FOR FULL ACCREDITATION...14
3 3 I. AUTHORITY The revised "Accreditation Standards and Rules and Regulations for Mississippi Nursing Degree Programs" are promulgated in accordance with (a) and (b), Miss. Code (1991 Supp.) ' , et seq., which empowers and requires the Board of Trustees of State Institutions of Higher Learning (the Board) to: (a) Establish by rules and regulations and promulgate uniform standards for accreditation of schools of nursing in the state of Mississippi (1) in so far as concerns the eligibility of graduates of such schools to take the examination prescribed by law to become registered nurses authorized to practice the profession of nursing as registered nurses in Mississippi, and (2) in so far as concerns student nurses attending such schools being eligible to participate in any student nurse scholarship program or other program of assistance now existing or hereafter established by legislative enactment; (b) Issue to such schools of nursing upon an annual basis certificates of accreditation as may be proper under such standards. The Board, in recognizing that each unit in nursing offering nursing degree programs has individual characteristics and goals, maintains that each shall implement its own philosophy, purposes, and objectives. All programs in nursing shall be based on sound educational principles under the guidance of a competent faculty. The total program of nursing education shall meet the required standards of accreditation as prescribed by the Board. Mississippi nursing schools (units in nursing) should prepare students for nursing careers according to the type of program that they offer. Rigid conformity to a specific and fixed curriculum is not expected. Rather, the Board approves programs which are of superior caliber and encourages creative and intelligent experimentation based on sound principles.
4 4 II. RULES AND REGULATIONS FOR ACCREDITATION A. CONFIDENTIALITY OF ACCREDITATION INFORMATION All data, observations, conversations, conclusions, reports, and minutes relating to accrediting activities are CONFIDENTIAL. Acceptance of an invitation to be a visitor constitutes a contractual agreement to safeguard the confidentiality of accrediting data. B. TYPES OF ACCREDITATION The Board shall grant to a state nursing degree program one of the following types of accreditation: 1. Initial Accreditation a. Granted when the program is in compliance with all standards for a new program. Permission is granted to admit students and the next review is in the final semester of the first class in conjunction with the initial national review. b. Denied when the program does not meet all standards for a new program. The program may reapply at any time. 2. Continuing Accreditation a. Full Accreditation. All standards are met. The next review is in conjunction with the next national visit. b. Full Accreditation with Recommendations. The program meets all but one or two standards. A performance improvement plan must be submitted within three months. The program must be in compliance within one year. c. Accreditation with a statement of warning. The program does not meet three or more standards OR the performance improvement plan has not resulted in compliance with standards. A follow up focused visit is scheduled within two years. 3. Withdrawal of Accreditation. If the program is not in compliance within the time frame allowed in the Statement of Warning, accreditation will be withdrawn.
5 5 III. STANDARDS FOR ACCREDITATION All state standards must be met by all programs of nursing in Mississippi in order to be fully accredited. A. ADMINISTRATIVE ORGANIZATION 1. An organizational chart depicts the relationship of the nursing unit to the parent institution. 2. Minimum requirements for administrators are: a. Associate degree Master s in nursing from a regionally accredited institution and a minimum of one year of clinical experience. b. Baccalaureate and higher degree Doctorate with one graduate degree in nursing from a regionally accredited institution and a minimum of one year of clinical experience. It is preferred that second level administrators (i.e. Associate/Assistant Dean/Director) hold a Doctorate with one graduate degree in nursing. c. All unencumbered current license to practice in Mississippi OR a valid license from another Compact state AND satisfactory criminal history background check. 3. The administrator, with faculty involvement, has authority and responsibility for the following: a. Preparation and administration of the budget; b. Screening and recommending candidates for faculty appointments, retention, and promotion and tenure; and c. All administrative and leadership activities of the position. 4. Nursing personnel policies are not illegally discriminatory, are written, accessible, and the same as for other faculty and staff. 5. Position descriptions delineate qualifications and responsibilities of nursing administration, faculty and staff. B. EDUCATIONAL PROGRAMS 6. All programs must maintain national accreditation by an approved accrediting agency. 7. All programs must have: a. A written statement of philosophy that reflects the beliefs of the faculty, is reviewed and revised as needed, and reflects the mission of the parent institution. b. Anticipated outcomes that are consistent with the mission of the parent institution.
6 6 c. A program of learning that reflects the philosophy and outcomes, is developed by the faculty and program administrator, is organized so that knowledge and skills are progressively developed, and meets the requirements of the parent institution for graduation. d. Provision to grant credit for prior learning, consistent with the parent institution s mission and the philosophy of the unit in nursing. e. A general education component that contributes to the achievement of program outcomes. f. Written agreements with all health care facilities that must: 1) ensure faculty responsibility for students and the selection of their learning experiences 2) contain termination clauses, and 3) be periodically reviewed and revised as necessary. 8. Each course must have: a. Written measurable objectives. b. Learning experiences and instructional methods that fulfill the objectives. c. Evaluation methods and tools that measure achievement of classroom and clinical objectives. 9. Undergraduate student-to-faculty ratios must be: a. No more than 15 to 1 for total enrollment. b. No more than 10 to 1 for clinical laboratory courses. c. No more than 15 to 1 for final semester clinical capstone courses where students work one on one with a qualified preceptor. Associate Degree 10. The relationship between nursing and liberal arts/general education courses is consistent with that of the parent institution with a balanced distribution of no more than 60 percent of the total number of credit hours allocated to nursing courses. Baccalaureate 11. The relationship between nursing and liberal arts/general education courses is consistent with that of the parent institution. The majority of the course work in nursing is at the upper (junior/senior) level.
7 7 Graduate 12. The graduate curriculum builds on the knowledge and competencies of baccalaureate education in nursing and provides for attainment of advanced knowledge of nursing and related theories and application to advanced nursing practice. C. FACULTY AND/OR STAFF Faculty 13. All faculty in nursing programs must have a master's or higher degree with a major in nursing, and a minimum of one year of clinical experience as a registered nurse. Exceptions may be granted by the Board=s Director of Nursing Education within the following parameters: a. Exception faculty must be continuously enrolled in a graduate degree nursing program. b. The maximum time allowed to complete the graduate program is three years. c. Faculty exceptions are limited to a total of 15% of the teaching faculty, excluding the director OR one exception for programs with six or fewer teaching faculty. The majority of faculty in graduate nursing programs must have earned doctorates in nursing or a related field from regionally accredited institutions. Faculty without a master's in nursing may teach non-nursing courses (i.e., computer, statistics) in nursing programs where these courses are not otherwise offered at the institution. Exceptions made prior to the effective date of these standards will continue employment as exceptions. (Approval date 6/98.) 14. Faculty must implement an annual professional development plan that includes a combination of course work, continuing education presentations, or attendance at continuing education programs. The plan must have been approved by the administrative head of the program AND must total a minimum of ten contact hours per year. 15. All nursing faculty (full-time, part-time, and adjunct) must hold an unencumbered license from Mississippi OR a valid license from another Compact state AND satisfy a criminal history background check. 16. Nursing faculty are responsible for: a. Development, implementation and evaluation of the program of learning; b. Development of standards for the admission, progression and graduation of students;
8 8 c. Participation in academic advisement; d. Participation in the activities of the total faculty of the parent institution; e. Participation in professional and community activities. 17. Preceptors shall be academically/experientially prepared at or beyond the level for which the preceptor service is rendered and shall have a minimum of one year of experience. (BT Approval 7/99.) D. STUDENTS 18. Minimal admission criteria for associate degree nursing programs are as follows: a. An ACT composite score of 18 and a 2.0 grade point average. b. Students with less than the required ACT composite score must have completed a minimum of 12 semester hours, including Anatomy and Physiology, with a 2.5 grade point average before being admitted. They must have made at least a grade of C in Anatomy and Physiology courses. c. Students who have previously earned a baccalaureate or higher degree may enter without an ACT by completing all the course prerequisites to the nursing major with a grade of better and having an overall grade point average of Minimal admission criteria for state-supported bachelor of science nursing programs are as follows: a. An ACT composite score of 21. Students with the required ACT composite score must also have at least a grade of in each prerequisite course and a 2.0 grade point average. b. Students with less than the required ACT composite score must complete all the course prerequisites to the nursing major with at least a grade of and have an overall grade point average of 3.0. c. R.N. students and students enrolling for a second baccalaureate degree may enter without an ACT by completing all the course prerequisites to the nursing major with at least a grade of and having an overall grade point average of 2.5. d. Baccalaureate nursing programs in independent institutions may establish admission criteria which support the goals and aims of individual independent institutions. 20. Each school is permitted an allowance of 10 percent of the previous fall's nursing program admissions for high risk students who do not meet the criteria. 21. Policies in effect for students in nursing are nondiscriminatory and are consistent with those in effect for all students enrolled in the parent institution; policies that differ are justified by program outcomes. E. RESOURCES, FACILITIES, AND SERVICES
9 9 22. Financial support is adequate to achieve the stated outcomes for the program. 23. Salaries are sufficient to recruit and retain qualified nursing faculty. 24. Physical facilities are adequate for the needs of the program. 25. Secretarial and other support services are sufficient for the needs of the program. 26. Learning resources and facilities are comprehensive, current and accessible to students and faculty. F. INTEGRITY 27. Information about the program to the general public, students, employees, and others is clear, current, and accurate. 28. Legal limitations for licensure are printed in a current catalog. 29. Complaints about the program are addressed and records are maintained and available for review. G. EVALUATION 30. Findings from a systematic evaluation of the unit in nursing, the program of learning, graduates, and faculty are used for the program's development, maintenance, and revision. 31. The pass rate for all first writes on the registered nurse licensure examination (NCLEX- RN), regardless of where the exam was written, shall meet the following requirements. a. First write results for each calendar year shall be no less than 95% of that year s national average. Any program that has less than 95% of that year s national average for first writes must submit a written plan for improvement that notes changes made and/or planned by July 1 of the following year. b. The pass rate for first and second writes combined shall be no less than 95% pass for each calendar year. Each year will be calculated no later than 3 years from December 31 of that year and any graduate who has never taken NCLEX shall not be included in the calculation. 32. The pass rate for the nurse practitioner certification exam shall be 100% of those who have taken the exam during the first year after graduation. 33. Graduation rates shall be: a. 60% in 150% of the prescribed time for the program of study for undergraduate programs. b. 80% of the prescribed program of study for graduate programs.
10 10 H. CHANGES IN EXISTING NURSING PROGRAMS/REPORTS 34. Educational programs must submit the following reports: Action Annual Report Change in ownership Change in directors/deans Markedly altering the curriculum Adding a new teaching site National accreditation status Decision made to discontinue the program Complete annual report form Notification letter Notification letter Requirement Detailed description with review by Accreditation Committee Detailed description of educational, financial, operational, management, and physical resources to offer program withbreview by Accreditation Committee Copy of notification The Board shall be notified in writing of the intention of the controlling institution. If the remaining students continue in the program, adequate faculty and educational standards shall be maintained until the last student has completed the program. This date shall be the official closing date of the nursing program. Disposition of all students' permanent transcripts and final records shall be made in accordance with institutional policy. A representative of the Board shall visit the nursing program and assist in making arrangements for proper closure and, if necessary, for the transfer of students. An institution desiring to reopen an educational unit in nursing or a nursing program shall reapply for approval of a newly planned program. 35. The Director of Nursing Education will submit a report to the Board annually that will include: a. Admission numbers b. Enrollment and graduation numbers c. NCLEX pass rates d. Certification exam pass rates e. Graduation rates f. Student to faculty ratio g. Faculty vacancy numbers h. Graduate enrollment by clinical major and practice role i. LPN to RN enrollment j. RN to BSN enrollment
11 11 IV. CRITERIA FOR ESTABLISHING A PROGRAM OF PROFESSIONAL NURSING IN THE STATE OF MISSISSIPPI The three stages to be completed in the development of a new nursing program in Mississippi are as follows: STAGE I - DECLARATION OF INTENT/NEED Any institution considering the establishment of a state-accredited unit in nursing shall: 1.1 Submit a declaration of Intent/Need (form available from Director of Nursing Education); 1.2 Request consultation with Board staff; 1.3 Submit documentation of approval from all local and state governing/coordinating boards; 1.4 Establish a local advisory committee which includes representation from nursing educators, nursing service, health care facilities, educational agencies, and the community; provide evidence of committee involvement in planning. 1.5 Provide evidence of professional sources of advice from qualified nurse educators who are involved in administering accredited nursing programs in Mississippi and/or an approved national accrediting body; 1.6 Provide substantive evidence of need for establishment of a new program of nursing from appropriate agencies, including but not limited to local educational institutions, community organizations, local health care agencies, state Board of Nursing, state Board of Health, Mississippi Nurses Association, Mississippi Council of Deans and Directors of Schools of Nursing, and projected need from the Mississippi Office of Nursing Workforce; 1.7 Submit current catalog; 1.8 Provide the philosophy and goals of the institution; 1.9 State the institution's purpose for establishing a new unit in nursing and the type of program envisioned; 1.10 Provide evidence of full institutional accreditation by the Southern Association of Colleges and Schools, Commission on Colleges and any other pertinent accrediting body; 1.11 Provide substantive evidence of financial, physical, and clinical resources adequate for a quality program as listed in these standards and an approved national accrediting body=s standards Identify the source of potential students; and the identity of other nursing programs within a fifty-mile radius; 1.13 Indicate the availability of qualified nursing faculty;
12 Indicate the availability of suitable supporting courses in the humanities and the natural, behavioral, and social sciences; 1.15 Provide a tentative timetable for initiating the nursing program. (The time from the employment of the nursing school's director to the admission of the first class may not be less than one year.) 1.16 In the event of disapproval, the institution may review the reasons for disapproval and may decide whether to revise its plan for resubmission to the Board or to abandon its intention to establish a nursing program. STAGE II - QUALIFY FOR INITIAL ACCREDITATION (permission to admit students) During the time between receiving permission to establish a new nursing program and the filing of an application for initial accreditation, the institution should seek consultation with the Board staff and shall file a progress report with the Board staff not less than six months before the planned date of the opening of the unit in nursing. The application shall provide evidence that the following requirements have been met: 2.1 The institution has appointed a qualified nurse director at least one year before the anticipated admission of students; 2.2 Sufficient qualified faculty members for the first full year of operation have been appointed effective not less than six months before the anticipated admission of students; A minimum of four qualified faculty members is required for an associate degree program. A minimum of two of the faculty members employed must have teaching experience. One faculty member must be employed with a major and a minimum of one year of clinical experience in each of the following areas: Medical-Surgical Nursing Nursing of Children Psychiatric Nursing Maternal-Infant Nursing A minimum of five qualified faculty members is required for a baccalaureate degree program. A minimum of two of the faculty members employed must have teaching experience. One faculty member must be employed with a major and a minimum of one year of clinical experience in each of the following areas: Medical-Surgical Nursing Nursing of Children Psychiatric Nursing Maternal-Infant Nursing Community Health Nursing Credentials may be defined as: (BT Approval 4/95) Master's degree in one of the specified areas OR Master's degree in nursing with clinical focus related to one of the specified areas OR
13 13 Master's degree in nursing and certification in one of the specified areas OR Master's degree in nursing and at least five years (within the last ten) of clinical and/or teaching experience in one of the specified areas. (No more than one of the four faculty for associate degree programs or five faculty for baccalaureate programs may be employed meeting this criteria.) 2.3 The nurse director and the nurse faculty have performed the following: Developed the philosophy and objectives of the program of nursing; Planned the overall curriculum, including course descriptions and sequence Worked out the nursing department's budget; Developed and validated an organizational chart showing institutional control, relationships, and lines of authority; Developed admission, promotion, and graduation policies for nursing students including entrance requirements for the nursing program and justification if different from entrance requirements to sponsoring institution; Assessed and selected community agencies which can and will provide needed clinical learning experiences for nursing students; Planned for periodic and systematic nursing program self study. 2.4 The sponsoring institution has made provisions for the following: Quality support services including registrar, admissions, testing, counseling, student personnel services, safety and maintenance, printing and duplicating, secretarial and clerical, etc.; The health and welfare of students; Adequate campus facilities and resources such as classrooms, workrooms, offices, library resources, audiovisual materials and equipment, file and storage space, etc.; Entering into legally binding agreements with the clinical agencies selected by the nursing departmentb such agreements shall ensure that faculty have control of students and have freedom to select appropriate learning experiences for nursing students; Seeking, obtaining, and maintaining accreditation by an approved national accrediting body. 2.5 Throughout the planning and operation of the nursing program, the institution and the nursing program shall employ the state standards established by the Board. In addition to the state standards, the following requirements shall be met:
14 Faculty shall have completed specialty preparation in those fields in which they have major responsibility for course planning and teaching; Faculty shall have demonstrated clinical competence as generalists in nursing and shall maintain expertise in the practice of respective specialties; All faculty shall hold an unencumbered license to practice nursing in Mississippi; Complete and realistic faculty and staff positions shall be maintained. 2.6 A survey visit shall be made by the Director of Nursing Education and nursing education representatives three to four months before the proposed opening date The written report of this visit, application for initial accreditation, and all materials pertaining to the proposed nursing program shall be evaluated by the Accreditation Review and Evaluation Committee and recommendations made to the Director of Nursing Education The committee s recommendation will be submitted to the Board for review Written notification of the decision regarding initial accreditation shall be sent to the institution by the Director of Nursing Education. If accreditation is denied or deferred, recommendations relative to the areas needing further development will accompany the notification. STAGE III - QUALIFY FOR FULL ACCREDITATION 3.1 A survey visit will be scheduled with the Board staff during the last semester of the first class or in conjunction with the initial national site visit. All prior recommendations must have been successfully addressed. 3.2 The site visit report will be held until all graduates of the first class have taken the NCLEX-RN exam. 3.3 The pass rate on the licensing examination for the first class meets the state requirements as under Standard G The graduates have been employed in positions for which they were prepared. 3.5 If full accreditation is denied or deferred, recommendations relative to the areas needing further development will accompany the notification. 3.6 If full accreditation is denied, the program may remain on initial accreditation. 3.7 If the graduates of the program have a pass rate on the licensing examination of less than that required, the administrator of the unit in nursing will be notified that the program is in non-compliance of the provisions for receiving full accreditation.
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THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234 TO: FROM: The Honorable the Members of the Board of Regents Douglas E. Lentivech SUBJECT: Phillips Beth Israel