Continuous quality improvement is a vital component in nursing education as well as in the clinical setting. With this in mind, a comprehensive review was undertaken by the faculty during the eighth year of the highly successful accelerated nursing program in a small liberal arts college. The college administration gave support to the project by providing release time for 2 faculty project leaders. The purpose of the project was to review the program as well as to share the findings, make recommendations for curriculum changes, and provide information to nurse leaders in the clinical practice settings of outcomes.
The accelerated second-degree nursing program was considered to be successful, with excellent graduation rates and National Council Licensure Examination for Registered Nurses (NCLEX) pass rates. The program had been in existence for more than 7 years, with highly competitive admissions and high student satisfaction. Many of the applicants indicated that they knew a graduate of the program and were influenced to seek admission because of the personal endorsement. As is common in a busy nursing division, large quantities of data were collected on an ongoing basis, but not systematically analyzed. In addition, limited qualitative graduate feedback regarding the program was available. Therefore, a quality improvement project was designed to review existing metrics and collect additional data in order to capture experiences of the graduates.
Accelerated nursing programs were developed in response to the nursing shortage. The first program was offered by St Louis University in 1971.1 By 1988, there were 10 programs in the United States, and by fall 2011, the number of programs had increased to 246.2 The Accelerated Entry Level to Nursing (ACCEL) program at this small liberal arts college was the first accelerated second-degree baccalaureate program in the Boston area and the second in Massachusetts.
Research on accelerated programs has included comparison of traditional and accelerated graduates,3-7 outcomes evaluation,8,9 profiles of graduates,10,11 and attrition.12 Rosenberg et al13 provided information on admissions interviews. Although they admit that they cannot draw any comparison because they began interviewing with the inaugural class of second-degree students, they have determined that the process is worth the cost. Rico et al14 investigated best clinical and classroom teaching strategies for accelerated students are best based on principles of adult learning. With an awareness of the literature, a comprehensive program review began.
DESCRIPTION OF THE PROGRAM
The ACCEL program is housed in a small liberal arts college located in suburban Boston. The nursing division, which is accredited by the American Association of Colleges of Nursing, includes a traditional baccalaureate program, as well as a large RN (registered nurse)-to-BS (bachelor of science) program on 2 campuses and a master’s degree in nursing program. The ACCEL program, culminating in a BS degree with a major in nursing, is designed for highly motivated adult learners who have a baccalaureate degree in any field. It is a 16-month cohort-based model scheduled over 2 to 3 days per week for 3 of the 4 semesters. The cohort enters in January. The 1-summer session consists of a clinical immersion experience of 3 days per week and 1 day of classes. Although students are only on campus or in the clinical area 2 or 3 days a week for 3 semesters, the program is considered to be full time. The program format allows students to limit the number of days on campus, which works well for students who have family or work responsibilities, but those same responsibilities may sometimes interfere with the time necessary for a rigorous accelerated nursing program.15 The nursing faculty recognizes that the ACCEL students are dramatically different from the traditional students and tailors the curriculum and teaching methods to these students, utilizing principles of adult learning theory.
The curriculum of the ACCEL program was approved by the Massachusetts Board of Registration in Nursing prior to admitting the first class. The ACCEL students enter the program with a bachelor’s degree in another field, an undergraduate grade point average of 3.0 or higher, and prerequisite science grades of B− or better. Because these students are academically strong, they are able to engage in a fast-paced curriculum with many courses in a compressed format. The prerequisite and related science courses are identical to the traditional program requirements. While planning the curriculum of ACCEL, faculty paid considerable detail to coordinating content areas to maximize learning and reduce repetition. This same attention to detail and collaboration among the faculty have enabled the curriculum to adjust as needed to meet the student’s learning needs. Therefore, the first-semester courses (NSG 2000: Health Assessment; NSG 2012: Simulations in Clinical Judgment and Evidence-Based Nursing Interventions; NSG 2200: Pathophysiology; NSG 2053: Nursing Care of Children; and NSG 2042: Nursing Care of Adults 1) are well coordinated in content, coursework, and examinations. NSG 2042: Nursing Care of Adults 1 is a blend of 2 introductory courses in the traditional program (NSG 2014 Conceptual Basis for Nursing Practice and NSG 2041 Nursing Care of Adults 1) and as such is a very content laden course.
The ACCEL curriculum (Table 1) include the first semester where students engage in coursework, including assessment, and simulation laboratories. There are no clinical placements during the first semester. During the summer (second) semester, in addition to the didactic content for pharmacology and maternity, students are placed in clinical immersion experiences in medical-surgical nursing, maternity, and pediatrics. The third semester includes evidence-based practice (nursing research) and community health and mental health. Both of these 2 courses include clinical and classroom learning. The final clinical experience in ACCEL incorporates medical/surgical nursing, leadership, and management skills to integrate concepts taught in Nursing Care of Adults II and Synthesis of Nursing Practice. The expected outcomes of the program are identical to the traditional and RN-to-BS programs. Although the courses may differ slightly from the traditional program, the content is basically the same.
The first cohort entered in January 2004 and graduated in May 2005. A total of 196 students have graduated through May 2011, with graduation rates ranging from 94% (2007, 2008) to 72% (2010). After the low year of 72%, the graduation rate increased to 85% in 2011. The overall graduation rate is 84% through cohort 7 (Table 2). The NCLEX pass rate has consistently been 96% to 100%. The Nursing Division collects extensive data, setting benchmarks to measure various quality indicators. Composite data for cohorts 1 through 7 indicate a program satisfaction score of 4.89 (with 4 being satisfied and higher numbers indicating a higher degree of satisfaction). No cohort scored less than 4.25. A graduate’s likelihood of recommending the program is assessed using the Likert scale, with 4 being moderately likely to 7, extremely likely. The composite for this is 5.23, with a range of 4.45 (cohort 5) to 5.98 (cohort 3) (Table 2).
INTRODUCTION TO PROGRAM REVIEW
The program has been successful, with applicants greatly exceeding the capacity of the program and excellent program outcomes including NCLEX results. However, there were some areas of the program that faculty thought needed to be changed to incorporate program requirements as outlined in the most recent American Association of Colleges of Nursing Essentials for Baccalaureate Nursing and the Quality and Safety Education for Nurses competencies. The nursing division faculty were working toward the goal of ensuring that all of the new competencies were included in each of the prelicensure programs as well as the RN-to-BS program. The data examined in a comprehensive manner included the following:
- demographics, applicant, and graduation data (Table 3);
- survey of the first cohort of students—2005;
- educational benchmark surveys completed by the Division Outcomes Committee annually as part of the evaluation process of all of the nursing programs; and
- students’ assessment of how they have met the outcomes of the nursing program, which is done as a component of their capstone seminar class.
A program review was undertaken by 2 faculty members who had extensive experience in leading and teaching in the program. Data that were collected in the fall of 2011 included the following:
- SurveyMonkey data from graduates of all cohorts and
- focus group data from graduates and faculty.
In addition to data analysis, the report included recommendations for program enhancements, additional curriculum changes, and suggestions for continued program assessment.
Data analysis revealed that applications had remained consistently high, with the most recent cohort at the highest ever (Table 3). The total number of men in the first 7 cohorts was 57 for 24.4% of all entering students; 45 men graduated, accounting for 23% of the graduates. The graduation rate for men (79%) was lower than that for women (86%). A total of 36 ESL (English as second language)/minority students have been enrolled through the first 7 cohorts accounting for 15.4% of all students. Unfortunately, these students had a significantly lower graduation rate (61%) when compared with the total graduates (85%). The retention of the ethnically diverse student has been progressively difficult. The involuntary attrition in 2009, 2010, and 2011 graduates consisted of the more ethnically diverse students as compared with a lesser degree in the earlier years (Table 4).
A SurveyMonkey link was sent to all graduates from the first 7 cohorts with an incentive of being entered into a drawing for $25 to complete the survey by the end of 1 month. From 2005 to 2011, there have been a total of 196 graduates in 8 cohorts; 194 surveys were sent via e-mail with a return rate of 62 (32%). Open-ended responses were collected on demographics, areas of prior degrees, place and area of employment, and Likert scales on satisfaction of courses in the curriculum.
Regarding overall satisfaction with the program, 75% of the 53 respondents who answered this question were either very satisfied or extremely satisfied. The other 25% were satisfied. No respondents indicated that they were dissatisfied. More than three-fourths of the respondents indicated that the cost of the program was reasonable.
Only 11% of the 55 respondents indicated that the clinical time in the program was sufficient. More than half of the respondents indicated that the amount of clinical time in the program was not enough or definitely not enough; 31% felt that the clinical time was almost enough.
Of the 62 respondents, 45 were female (73%), and 17 were male (27%). This closely paralleled the gender profile of the graduates. Undergraduate degrees (n = 47) included but were not limited to psychology/sociology (n = 10), biology (n = 7), kinesiology or movement science (n = 4), health science (n = 2), anthropology (n = 2), English (n = 2), nutrition, social science, cardiopulmonary science, government, accounting, political science, journalism, hotel management, criminal justice, East Asian studies, management information systems, and mechanical or biomedical engineering. Regarding graduate education (n = 46), 14 graduates (23%) do not plan on attending graduate school at this time; 9 (15%) have graduated or are enrolled in an MSN program. Of those who have graduated or are enrolled in a master’s program, 6 are nurse practitioners. Twenty-three graduates (38%) plan on MSN in the future.
Regarding employment, 47 responded to SurveyMonkey. In addition to data collected through SurveyMonkey, data gathered from graduates who have made personal contact with the program coordinator and or faculty are included. Graduates from 2005 to 2009 (n = 34) are mostly employed at major Boston teaching medical centers in acute and intensive care settings. These include Massachusetts General Hospital, Children’s, Brigham and Women’s Hospital, Veteran’s Administration Medical Center, Jordan Hospital, Lahey Medical Center, Newton-Wellesley Hospital, Cape Cod, South Shore, and Franciscan’s Children Hospital. Six graduates reported that they are working out of state. Of the early graduates, only 1 reported being unemployed. Of the 2010 graduates (n = 13) who answered this question, all are employed in various health care centers. Of the 2011 graduates (n = 12), there are 4 who responded that they are not employed in health care. The total number of known employed graduates for 2011 is 13 of the 29.
Graduates from all cohorts described themselves as motivated individuals with determination and excellent organizational skills. They complemented the cohort model as well as the organization of the program and use of adult learning theory. Their experience in other health care positions was also seen as a positive influence to their program success and employment opportunities, adding that they bring expertise from other disciplines, professions, and life experiences.
Each of the 4 focus groups was composed of a constituency that has a unique knowledge of the ACCEL program. The groups were classroom faculty, Nursing Resource Center faculty and staff, recent program graduates (class of 2011), and distant graduates (classes of 2005, 2006, and 2007). All groups consisted of 4 participants with the exception of the Nursing Resource Center group (3 participants). In the faculty group, the classes taught included pharmacology, medical-surgical nursing, maternity, pediatrics, and mental health nursing. Some of the faculty had also worked with these students in the clinical setting. Because of the difficulty of scheduling a focus group for clinical faculty, informal interviews were conducted with several part-time clinical instructors who had taught ACCEL students for more than 1 semester.
The focus group of graduates with the most clinical experience based their evaluation on the clinical and curriculum components of the program as it impacted their ability to transition to practice. The graduates were in agreement that the program prepared them well for employment overall. Curriculum content was viewed as being comprehensives and the importance of a strong health assessment course and the concept of case management was relevant for practice. Clinical issues raised included the need to provide more simulation in order to reach a comfort level and more clinical exposure to become more connected to the team in their clinical experiences. Also, a one-on-one experience would have been beneficial for better socialization into their first job. From the graduate’s perspective, the clinical immersion semester was seen as most helpful.
Analysis of the data provided by the multiple sources resulted in programmatic and curricular recommendations. Whereas some of the recommendations could be acted upon by the program coordinator, others needed nursing faculty approval, and some needed approval from the Division of Continuing and Graduate Studies, the administrative home of the program. All of these factors influenced the timeline for implementation of the recommendations.
Programmatic recommendations included the following:
- Offer an optional 100-hour practicum that would occur after completion of the fourth semester. Students had consistently requested a practicum. Making it optional would allow the program to continue with the 16-month format, which makes it competitive with other programs, but would offer those students who want a practicum an opportunity to have this clinical experience to expose students to more employment opportunities in the acute care settings.
- Decrease cohort size from 32 to 30. Most of the clinical sites were now limiting group size to 6. The cohort should be a multiple of 6 to facilitate efficient use of clinical faculty.
- Increase nursing care of older adults from 1 credit to 2 credits. This would align the ACCEL course with the traditional curriculum. This would increase the total number of credits in the program by 1.
- Provide academic support for ESL/minority students in various ways including structured study groups run by students and meeting with advisor on a scheduled basis for performance review and encouragement. ESL/minority students had a significantly lower graduation rate. The importance of recruiting and retaining greater ethnic diversity in the nursing education programs requires continued examination of the personal and educational needs of ethnic minority students as well as the barriers to successful completion of nursing degrees.
Curricular recommendations included the following:
- Increase the time allocation for Simulations in Clinical Judgment from 1.5 hours to 2 hours. Debriefing and reflecting after a simulation are essential to critical thinking and clinical reasoning. Concerns included scheduling because of the extensive use of that facility and a need to adjust faculty workload.
- Move pediatrics to the summer semester. This would mean that the content would be taught in the same semester that the students are in the pediatric clinical setting.
- Split pharmacology into 2 courses (2 credits for the first course and 1 credit for the second course), with one course taught in the first semester and the other taught in the fourth semester. Currently, pharmacology is taught in an intensive summer session. Aligning the content topics could easily be done if it was taught in the spring semesters when adult nursing is taught. The first-semester course would replace Nursing Care of Children, which would be moved to the summer semester. Summer course credits would be reduced from 11 to 10, and fourth-semester credits would be increased from 9 to 10.
Other recommendations concurred with accrediting bodies and included creating an immersion model for the last semester medical-surgical clinical rotation, introducing students to the clinical setting in the first semester, incorporating content specific to Health Policy and Finance into Synthesis of Nursing Practice, increasing the utilization of ACCEL graduates as experts who can assist new graduates in transitioning into practice, and incorporating genetics and genomics concepts into the curriculum in Adult Health II.
Anecdotal evidence obtained since the beginning of the program strongly supported the addition of clinical hours. In response to students’ requests prior to this survey, additional clinical opportunities on 4 occasions during intersession or after graduation had been offered. Students’ review of this additional experience was extremely positive. The first experience for the 2005 graduate was done as an independent study prior to graduation in an ICU setting. For 2011 graduates, 2 students completed their program and did an internship after graduation. One student did a nonclinical independent study in a major teaching hospital during her last semester.
These recommendations are useful for schools interested in offering an accelerated program. However, new and existing programs may benefit from this model and current recommendations from this review.
The strengths of the program include the competitive nature of admission, rigor associated with the curriculum, and the associated success in the practice setting. Further study, after employment, is needed to compare the traditional BSN with the accelerated program success in employment. Additional variables to consider would include comparison of settings of employment, the effect of additional clinical time before or after graduation, time requirements for orientation, and types of leadership or specialty position achieved.
SUMMARY AND CONCLUSIONS
This extensive program review, although time consuming, clearly indicates the importance of continuous quality improvement, even when things are considered to be running smoothly. Although some may subscribe to the theory “if it’s not broken, why change,” it may be that it is more important to continually assess programs in order to better meet ongoing accrediting guidelines. This program review also demonstrates the importance of collecting extensive data for future evaluation. The review enlightens both practice and education, raising the awareness of how well these students do in employment settings because of their maturity and life experiences, an area that requires further investigation.
While each nursing program will have unique characteristics and constraints, the general process for a program review and the necessity of continuous quality improvement to maintain relevance are universal. It is an essential component in maintaining connections between education and practice. This is important as we move toward impending nursing shortages and changes in how we deliver care. The ACCEL nursing program is a successful and cost- and time-reasonable model, designed to bring multidisciplinary professionals into nursing.
The continuous review of nursing programs and sharing of information with the practice settings encourages partnering with practice to enhance the education of nurses for career success. In educating second-degree students, the nursing profession benefits from the addition of professionals from other disciplines who have undergone a rigorous program.
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