How Qualified is Qualified? Nancy Spector, PhD, RN Director of Education, NCSBN March 12, 2007

1. How Qualified is Qualified?Nancy Spector, PhD, RNDirector of Education, NCSBNMarch 12, 2007

3. Mission of NCSBN The National Council of State Boards of Nursing (NCSBN), composed of Member Boards, provides leadership to advance regulatory excellence for public protection.

4. Director of Education • Provides leadership and networking opportunities to our education consultants • Staff the Practice, Regulation and Education Committee • Attend all national nursing education conferences • Speak, publish on NCSBN’s education initiatives

5. Resources www.ncsbn.org Go to Programs and Services and Education Papers Available: • Position Paper on Clinical Experiences • White Paper on PN Scope of Practice • Evidence-Based Nursing Education for Regulation • Systematic Review of Nursing Education Outcomes • White Paper on State of the Art of Approval Processes nspector@ncsbn.org

6. Systematic Review of Nursing Education (Adapted from Polit and Beck (2004) and Gallagher (2003) • Level I – Properly conducted RCT, systematic review or meta-analysis • Level II – Other studies, such as quasi-experimental, correlational, descriptive, survey, evaluation, and qualitative • Level III – Expert opinion or consensus statements

7. Systematic Review Databases Used • CINAHL • Medline • ERIC Keywords: • Education, nursing, teaching, education research, learning methods, learning strategies, research-based education, outcomes of education

8. Systematic Review Criteria • Educational outcomes • Identify a design • Sample described • Comparison being studied or objective (qualitative studies) • Report of results • Not limited to U.S., though must be in English

9. Results • 25 useable studies • 23 Level II • 3 Level I • Analysis includes citation, sample, comparison, procedures, key results, strengths and weaknesses, and implications for boards

10. Key Findings • Deliberate Practice (Ericcson, 2004 seminal paper; Angel et al., 2003; Benner) • Supervision by qualified faculty who provide feedback and opportunities for reflective practice (5 studies; Examples include Platzer et al., 2000; Bjørk and Kirkevold, 1999) • Clinical experiences with actual patients (Angel et al., 2003) • Collaboration with interdisciplinary teams (White’s 5 themes) • Opportunities to gain confidence, build relationships, develop critical thinking (Yates et al., 1997) • Online and simulation valuable (Greenhalgh, 2001; Issenberg, 2005)

11. NCSBN’s Elements Study Design – Two Rounds • 410 Nursing Programs • 7,497 New Graduates

12. NCSBN Elements Study Model

13. Instrument • Reliability – internal consistency of each item=0.87-0.91 • 12 clinical components - Cronbach’s Alpha=0.87 • 11 classroom components – Cronbach’s Alpha=0.91 • Validity • Content: Advisory panel, PR&E Committee, Education Consultants • Concurrent: Relationship between perceived outcomes=p<.0001

14. Gaps in Nursing Education from Elements Study (reported by students) • Administer medicine to groups of patients • Delegate tasks to others • Supervise care by others • Knowing when and how to call the physician (also in Carnegie Study)

15. Gaps in Nursing Education from Elements Study (reported by faculty) • Content not being taught consistently • Use of information technology (8.4% of programs) • Evidence-based practice – 11.7% of programs • Critical care – 9.1% of programs • Interdisciplinary elements – 32.5% of programs • Only 55.9% of programs allow students to call MDs

16. Significant Relationships: Curricular Elements and Perceived Adequacy of Preparation • Higher percentage of faculty who taught both didactic and clinical • Taught use of information technology and evidence-based practice • Integrated pathophysiology and critical thinking throughout the curriculum • Taught population content separately

17. Significant Relationships: Faculty-Student Interactions (Perceived Preparation) • Answer questions about content • Assist with classroom projects • Answer questions during clinical activities • Assist with clinical skills • Demonstrate skills in clinical activities • Provide current information in the classroom

18. EBNER Recommendations • Adjunctive teaching methods • Promote faculty-student online interaction • Facilitate learning simulation • Combine online and traditional strategies • Assimilation to the role of nursing • Provide interdisciplinary experiences • Provide experiences for role of the nurse • Provide team building experiences

19. EBNER Continued • Deliberate experiences with actual patients • Provide experiences for relationship building with patients • Provide clinical experiences with actual patients • Provide experiences for gaining confidence • Provide opportunities for reflection • Provide feedback • Faculty-Student Relationships • Faculty teach clinical and didactic courses • Faculty are available to demonstrate and assist with skills • Faculty assist with classroom projects • Faculty are available to answer questions • Faculty provide current information

20. EBNER Continued • Teaching Methodologies • Integrate critical thinking into the curriculum • Use critical thinking strategies • Integrate evidence-based practice into the curriculum • Integrate pathophysiology into the curriculum • Teach population courses separately • Require students to demonstrate skills before performing them on patients

21. NCSBN’s Transition Study (2007)Dr. Suling Li

22. 2007 Transition Study –Least Competent Areas • Appropriately use research findings • Meets client’s cultural needs • Strategically delegate and supervise others • Recognize when demands exceed capability • Manage time and workload effectively • Use information technology to enhance care • Synthesize from multiple sources - Dr. Suling Li

23. Transition Study Practice Errors – New Nurses • Charted on wrong record – 55.2% • Medication errors – 43.2% • Contribute to treatment delays – 39.3% • Missed physician/provider order – 38.5% • Client falls – 34.9% • Error in performance of skills – 28.2% • Misinterpreted physician order – 23.8% • Client elopement – 13.3% • Avoidable client death – 1.1% - Dr. Suling Li

24. New Nurses Make Significantly Fewer Errors When: • More competent in clinical reasoning • More competent in communication and interpersonal relationships - Dr. Suling Li

26. Transition Study • Transition programs: • Significantly higher competency levels • Significantly more competent in communication • Significantly more able to recognize limits - Dr. Suling Li

27. Perceived Stress • “Felt overwhelmed with patient care responsibilities” • “Feared harming patient due to inexperience” • “Felt expectations unrealistic” - Dr. Suling Li

28. Transition Programs • Decreased stress; therefore decreased errors • Best when program addressed specialty knowledge • Improved retention - Dr. Suling Li

29. Next Steps • February Transition Forum • Lessons Learned for future

30. Collaborative National Projects • Quality and Safety Education for Nurses (QSEN) • RWJF • Faculty and Advisory Board – collaborative across disciplines, organizations, and nursing • May/June Nursing Outlook article • www.qsen.org • April 2007 – Begin program participation on how to teach

31. QSEN Competencies • Patient centered care • Teamwork and collaboration • Evidence-based practice • Quality improvement • Safety • Informatics

32. NCSBN Question Studies support qualified faculty who provide feedback and opportunities for reflection… BUT What do we mean by “qualified faculty?”

33. Data Collection • AACN Master’s Essentials & DNP Essentials • Primary focus of master’s education clinical role • DNP a practice degree

34. Data Collection • CCNE • “Faculty members are academically and experientially qualified in sufficient numbers” • “Faculty outcomes demonstrate achievement of the program’s mission, goals, and outcomes…” • Chief Nurse Administrator • Registered nurse with a graduate degree • Faculty are a resource of the program and enable meeting mission, goals, and outcomes of program

35. Data Collection • NCSBN’s EBNER • As above, findings imply master’s degree: • High level interaction with students • Assist with application of current nursing knowledge • Knowledge of demonstration of skills • Ability to apply critical thinking, evidence-based practice, information technology

36. Data Collection • NCSBN’s Elements Study (Li & Kenward, 2006) • 24.2% of faculty in LPNVN programs had masters degrees; 73.4% in RN programs had masters or PhDs • 50.8% of LPN/VN programs & 82.1% of RN programs used preceptors • 20% of clinical experiences with preceptors • Means of student/faculty ratios, across settings, was 6.3 to 9.4

37. Data Collection • NCSBN MB Profiles (current online; not all boards respond) • For LPN administrators: 16 master’s; 19 bachelor’s or other • For RN administrators: All doctorate or master’s, except for 2 BSN (both diploma programs) • For LPN faculty: 6 master’s; 32 BSN or other • For RN faculty: 2 doctorate; 26 master’s; 10 baccalaureate (diploma 14 master’s and 9 baccalaureate)

38. Data Collection • NLNAC • 50% faculty in LPN/VN have master’s degree; remaining working toward it • RN minimum MSN (or with rationale) • All programs faculty student ratios sufficient • Part-time vs. full-time faculty adequate for objectives • Nurse administrator has authority over curriculum; LPN administrators with a graduate degree; BSN administrator doctorate; ADN or diploma administrator graduate degree • Adjuncts contract to teach specific course or component • Curriculum hours for LPNs & diploma programs meet board of nursing’s requirements; ADN 60-72 semester credits; BSN majority of coursework in upper division

39. Data Collection • NLN • All faculty should have structured preparation for faculty role • Competence measured by education, certification, faculty development, mentoring • Academic nursing education is a specialty area and an advanced practice role

40. Faculty Qualifications Survey • N=36 • Faculty shortage • 0 – None • 3 – Local or regional • 20 – Across the state, but manageable • 12 – Across the state, and very bad • 0 – Severe

41. Specific Actions Taken –Collaboration is the way to go!

42. Statewide consortiums • Oregon Consortium for Nursing Education (OCNE) • Statewide curriculum • Regional simulation areas • Shared faculty resources • Discussions of a faculty database • Statewide clinical placement software • Discussion re: joint appointments (salary bargaining) • Hawaii is setting one up at university and community colleges; legislation in process

43. North Carolina • Funding has provide an increase in programs to prepare faculty • Clinical teaching associate role to move practitioners into joint positions • Working toward common simulation facilities and shared faculty resources

44. Louisiana-RN • Partnerships with clinical agencies allowing RNs to work as faculty, provided they meet board criteria • Initiatives mandated by governor

45. California • Supply and Demand Commission; legislative mandate to fund master’s degree candidates • California Institute for Nursing & Health Care (CINHC) is working on a statewide project to build educational capacity, with attention to quality preparation • Thought leaders to build consensus and collaborative efforts • Development of White Paper

46. Missouri • Clinical Faculty Academy • 2-day institute • Enrolled in graduate school • Outcome data • Hospital associations are partnering with nursing programs; faculty are in graduate programs • Has allowed increased capacity of nursing programs

47. Texas • Recommended to legislature statewide plan to increase graduates • Board of nursing accepts proposals for pilot programs • Faculty waivers

48. Other • Faculty waivers (eighteen fewer than 10%; four 11-20%; three 21-30%; must apply for with rationale) • Bills to seeking increased faculty salaries • Legislators funding of faculty scholarships • Many states are fighting the lowering of the requirement to BSN • States vary on simulation; most no rules; when they do it varies from 15% to 30%

49. Degree Minimum Requirements in this Survey • RN Program administrators: 2 doctorate; 31 master’s; 1 no requirements • RN faculty teaching didactic: 33 master’s; 7 BSN; 1 ADN or diploma • RN faculty teaching clinical: 24 master’s; 12 BSN; 2 ADN or diploma • RN faculty in simulation: 16 master’s; 8 BSN; 4 ADN or diploma; 5 none • RN preceptor: 3 master’s; 9 BSN; 10 ADN/diploma; 5 none

50. Next Steps