SELF STUDY TEMPLATE Standards for Accreditation of Baccalaureate and Graduate Degree Nursing Programs

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SELF STUDY TEMPLATE Standards for Accreditation of

Baccalaureate and Graduate Degree Nursing Programs



The mission, goals, and expected aggregate student and faculty outcomes are congruent with those of the parent institution, reflect professional nursing standards and guidelines, and consider the needs and expectations of the community of interest. Policies of the parent institution and nursing program clearly support the program’s mission, goals, and expected outcomes. The faculty and students of the program are involved in the governance of the program and in the ongoing efforts to improve program quality.

I-A. The mission, goals, and expected student outcomes are congruent with those of the parent institution and consistent with relevant professional nursing standards and guidelines for the preparation of nursing professionals.

Elaboration: The program’s mission statement, goals, and expected student outcomes are written and accessible to current and prospective students. A mission statement may relate to all nursing programs offered by the nursing unit or specific programs may have separate mission statements. Program goals are clearly differentiated by level when multiple degree programs exist. Expected student outcomes are clear and may be expressed as competencies, objectives, benchmarks, or other language congruent with institutional and program norms.

The program identifies the professional nursing standards and guidelines it uses, including those required by CCNE and any additional program-selected guidelines. A program preparing students for specialty certification incorporates professional standards and guidelines appropriate to the specialty area. A program may select additional standards and guidelines (e.g., state regulatory requirements), as appropriate. Compliance with required and program-selected professional nursing standards and guidelines is clearly evident in the program.

Program Response:

Research College of Nursing (RCN) is the parent institution for both the undergraduate and graduate programs; thus, as a single purpose institution, the mission and expected outcomes of the College are the same as for the programs. The mission of RCN is “to educate students as professional nurses who provide safe, quality health care. Through a commitment to excellence in nursing education, this academic community promotes development of the individual as a scholar and leader dedicated to providing service to the greater society” (ERI-1).

The mission drives the development of undergraduate and graduate student learning outcomes, course objectives and learning activities (Appendix I-A). Learning outcomes are statements that describe expected student behavior at the end of the nursing program. Faculty crafted the outcomes to fulfill the college mission and to reflect professional standards for each program (ERI-2, ERI-3). In addition the


mission guides decisions regarding policy development, resource allocation, co-curricular activities and faculty expectations related to teaching, scholarship and service.

For the RCN-Rockhurst University (RU) joint undergraduate program it is critical that both missions are aligned with expected student learning outcomes (ERI-4). When RU revised its mission, core values and strategic plan in 2008, RCN was included in the “Town Hall” meetings that the president of RU facilitated with college faculty. The vice-president of mission and ministry at RU also engaged in this dialog which provided our faculty with the opportunity to have input into the RU mission statement. As a member of the RU President’s Cabinet, the dean shared the revised RCN mission with Cabinet members who are key academic administrators. The associate dean for academic programs of RCN also shared the mission with the RU Academic Affairs committee. The dean presented the revised mission to members of the council for the joint nursing program which includes five representatives from RU including the vice-president for academic affairs, the registrar, the vice-vice-president for finance, and two faculty (ERI-5). Alignment with the mission and six core values of Rockhurst was the major focus of discussion.

The Essentials of Baccalaureate Education for Professional Practice (AACN, 2008) and The Essentials of Master’s Education in Nursing (AACN, 2011) provide the foundation for the undergraduate and graduate programs. These standards guide program development, implementation and evaluation and provide the framework for inclusion of the essential knowledge and skills necessary for entry level and master’s prepared nurses. The following professional standards and guidelines supplement the Essentials documents.

Baccalaureate program:

Nursing: Scope and Standards of Practice, 2nd edition (ANA,2010) (OSI-1) Guide to the Code of Ethics for Nurses (ANA, 2010) (OSI-2)

Nursing’s Social Policy Statement (ANA, 2010) (OSI-3)

Quality and Safety Education for Nurses Competencies (QSEN, 2005) (

Graduate program:

The Advanced Practice Nursing Core Curriculum

Domains and Core Competencies of Nurse Practitioner Practice (NONPF, 2012) (ERI-6) Criteria for Evaluation of Nurse Practitioner Programs (NTF, 2012) (ERI-7)

Adult-Gerontology Primary Care Nurse Practitioner Competencies (AACN/NONPF/Hartford, 2010) (ERI-8)


The Clinical Nurse Leader Core Curriculum

Working Statement Comparing the Clinical Nurse Leaderand Clinical Nurse Specialist Roles: Similarities, Differences and Complementarities (AACN, 2004) (ERI-10)

White Paper on the Education and Role of the Clinical Nurse Leader (AACN, 2007) (ERI-11) The Nurse Educator Core Curriculum

Core Competencies for the Nurse Educator with Task Statements (NLN, 2005) (ERI-12) The RN-MSN Baccalaureate Specialty Curriculum

The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008) (ERI-13)

The Executive Practice and Health Leadership Curriculum

Scope and Standards for Nurse Administrators, 2nd ed. (ANA, 2009) (OSI-4) AONE Nurse Executive Competencies (AONE, 2005) (ERI-14)

The most recent addition to the graduate program is the RN-MSN track. The Essentials of Baccalaureate Education for Professional Practice (AACN, 2008) and The Essentials of Master’s Education in Nursing (AACN, 2011) (ERI-15) were utilized for curriculum development. Students in this track may select one of three emphases for completion of the degree: clinical nurse leader (CNL), nurse educator (NE) or

executive practice and health care leadership (EPHL). The first cohort of students began in Fall 2012.

I-B. The mission, goals, and expected student outcomes are reviewed periodically and revised, as appropriate, to reflect:

professional nursing standards and guidelines; and the needs and expectations of the community of interest.

Elaboration: There is a defined process for periodic review and revision of program mission, goals, and expected student outcomes. The review process has been implemented and resultant action reflects professional nursing standards and guidelines. The community of interest is defined by the nursing unit. The needs and expectations of the community of interest are reflected in the mission, goals, and expected student outcomes. Input from the community of interest is used to foster program improvement. The program afforded the community of interest the opportunity to submit third-party comments to CCNE, in accordance with accreditation procedures.

Program Response:

The RCN Comprehensive Assessment Plan (CAP) Section I.A describes the assessment of the mission, student learning outcomes and congruence with selected standards and guidelines (ER16) (Appendix I-B). The assessment committee, consisting of an elected group of faculty, monitors the evaluative

process, collectively reviewing the particular documents and analyzing them for content and congruence; reflection of professional standards and consistency; and expectations of the community of interest. For example, the undergraduate curriculum committee (UGCC) initiated a task force in September 2009 (ERI-17) to revise the mission, philosophy and student learning outcomes based on the revised The Essentials of Baccalaureate Nursing Education for Professional Practice (AACN, 2008). Through the fall semester


faculty discussed drafts of the student learning outcomes and mission statement. In March 2010 the mission statement was approved (ERI-2) and in May 2010 (ERI-3) the revised student learning outcomes were approved.

During the 2010-11 and 2011-12 academic years, faculty revised all undergraduate course objectives. After the revision of the mission statement, faculty reviewed the philosophy and purposes statements for congruence. Faculty determined that The Essentials documents serve as the framework for both

undergraduate and graduate curricula, rendering the philosophy outdated. Following further discussion faculty determined that the purposes statement was also outdated and redundant. The philosophy and purposes were discontinued following this discussion (ERI-18).

The graduate curriculum committee (GCC) is in the process of revision of all graduate course objectives and content based on the revised The Master’s Essentials (AACN, 2011). The GCC approved revision of MSN student learning outcomes and the elimination of track-specific outcomes (ERI-19). Faculty are now mapping content in all graduate courses to determine redundancy and omissions (ERI-20).

The college’s community of interest includes all students, faculty, staff, clinical agency partners, RU, employers, regulatory bodies such as the Missouri State Board of Nursing, accrediting bodies, alumni, the governing board, and external funding agencies. The ability of RCN to meet its stated mission and

program outcomes is directly related to an understanding of its community of interest’s needs and expectations. For example, the UGCC includes representation from our practice partner; Research Medical Center (RMC) .The College has a strong academic-practice partnership with RMC. The dean meets with the chief nursing officer monthly to share feedback about mutual needs. Because the chief nursing officer and the dean wish to promote student and staff engagement in evidence –based projects, two senior nursing faculty implemented a center for nursing research and innovation in July of 2010.The college supports their salaries for a portion of their full-time workload. This support provides a mutually beneficial opportunity--faculty are actively engaged in research and staff are provided support to initiate evidence-based projects.

Another example of feedback from the community of interest is the implementation of the CNL track. Four hospitals in the Hospital Corporation of America (HCA) MidAmerica Division expressed interest in the development of a CNL track. Faculty determined it to be consistent with the college mission and approved the track in December 2008. The implementation of a Dedicated Education Unit (DEU) in Spring 2013 also resulted from college faculty feedback on the need for innovative models of clinical education. The recently implemented RN-MSN track was developed in response to the Institute of Medicine report (ERI-21) to provide opportunities for professional nurses to advance their nursing education. In particular, the track was designed to address the nursing faculty shortage by offering a


nurse educator focus. The college governing board provides a means to gather critical feedback from members who represent alumni, the healthcare community, higher education, and the college’s partner, RU.

In addition, a critical source of input from the community of interest are those data collected through course/clinical evaluations and other surveys such as the AACN/Educational Benchmarking, Inc. Exit Assessments (EBI) and alumni surveys. Feedback from faculty comes regularly through participation in committee meetings and FGA. The annual course review process for each undergraduate and graduate course provides important feedback as well. Until 2011-12, the annual course review form included a section on general information and a larger component on evaluation. While useful, faculty believed it unwieldy; thus a revision of the format was initiated in 2011-12. Faculty and student course evaluations are used to drive targeted changes for the next academic year (OSI-5). For instance, feedback from undergraduate students led to the approval of NU 3852 Global Perspectives in Public Health which meets the liberal core requirement for a global perspectives course (ERI-22). Faculty feedback from the

Employee Engagement Surveys (EES) (OSI-6) about the teaching-learning environment resulted in the updating of six classrooms with state-of-the art audio-visual equipment and SMART Boards in 2010. The community of interest has been invited to submit third-party comments to CCNE in accordance with accreditation procedures (ERI-23).

I-C. Expected faculty outcomes in teaching, scholarship, service, and practice are congruent with the mission, goals, and expected student outcomes.

Elaboration: Expected faculty outcomes are clearly identified by the nursing unit, are written, and are communicated to the faculty. Expected faculty outcomes are congruent with those of the parent institution.

Program Response:

The expected faculty outcomes of teaching, scholarship and service are identified in the RCN 2012-13 faculty handbook (OSI-7) and are consistent with the mission of the college. Appointment and promotion criteria for faculty are clearly delineated and are based on the three foci of the faculty role. The college does not have a tenure process; however, the faculty affairs committee (FAC) developed the promotion policy and process which the FGA approved. Faculty seeking promotion are advised to follow the guidelines for submission of their portfolios. In the past, the associate dean for academic programs provided guidance for faculty. Since this role has been eliminated, senior faculty members who have successfully completed the promotion process provide guidance to assure criteria are followed. The dean provides the final recommendation which is submitted to the president for approval.

The dean and the program directors introduce new faculty to their roles relative to teaching, scholarship and service in the initial orientation phase. The program directors as well as course and clinical


coordinators provide support throughout the first year of teaching which has been effective in terms of providing an overview. But based on faculty feedback, program directors and the dean determined that a more thorough orientation to structure, governance and faculty roles was necessary. Thus, in fall of 2012, a mentoring program for the six new faculty was implemented. New faculty now meet monthly with the dean and program directors. A needs assessment was conducted and topics for each meeting were identified (ERI-24). Evaluation of this process will be conducted at the end of the academic year.

Each year faculty develop goals related to teaching, scholarship and service, document evidence of how they met these goals, and identify goals for the next academic year. These goals are submitted to the dean. The dean and each faculty member meet to discuss faculty progress, areas for growth, and resource needs. In addition to goal development, faculty will be engaged in a 360 assessment based on the college’s core values: building caring and successful relationships, professionalism, leadership, teamwork, diversity/inclusivity, integrity, enjoyment/satisfaction and communication. The FGA and the staff advisory council developed and approved these core values in November 2011 (ERI-25). The dean and the three program directors participated in the assessment process in March 2012. Faculty will begin the assessment process in January 2013. The results of the assessment process will support

professional development planning as well as to integrate the college core values into the faculty role.

Faculty teaching assignments are based on the college’s needs, faculty requests, and academic and experiential qualifications of faculty. Each January the dean requests feedback, through the faculty planning request, which includes the following questions: How can your teaching assignment be designed to best assist you in meeting the professional goals you anticipate for 2013-14?; What aspects of your 2012-13 teaching assignment would you like to remain the same in 2013-14?; What change in your current teaching assignment would you like to request for 2013-14 provided that the needs of the college can be met? If you anticipate requesting a change in your faculty contract (e.g. request for sabbatical change in your status, full-time equivalent (FTE) or responsibilities; anticipated retirement, etc.) please describe this change. The dean and the program directors collaboratively determine assignments and needed resources, i.e. additional full-time or adjunct faculty. Faculty receive an individual teaching assignment in March/April of the current academic year. Faculty individual teaching assignments for the past three academic years will be available in the resource room (OSI-8). Faculty evaluations will be available in the office of the president.


I-D. Faculty and students participate in program governance.

Elaboration: Roles of the faculty and students in the governance of the program, including those involved in distance education, are clearly defined and promote participation.

Program Response:

The FGA is the formal body of faculty governance; its membership is specified in the RCN faculty by-laws (ERI-26). A faculty member elected by the body chairs the FGA. The FGA oversees the activities of the standing committees and is responsible for curriculum, degree requirements and standards, and all educational aspects of student welfare and faculty policies. Any member of the FGA may submit agenda items for FGA meetings. All full and part-time faculty and administrators with faculty appointments are voting members. The president and the dean are voting members of all standing committees unless otherwise specified. The FGA oversees nine standing committees, undergraduate curriculum; graduate curriculum; admission, progression and graduation; learning and technology; faculty affairs; scholarly activities, student affairs; human subjects; and evaluation.

FGA elections are held each year in April by written ballot. Faculty may self nominate or be nominated by colleagues. But any faculty member nominated by colleagues has the option to accept or decline the nomination. Descriptions of standing committees governed by the FGA are published in the faculty handbook. Students are represented on all FGA committees except the faculty affairs committee. The Student Government Association (SGA) requests participation of students for the selected committees. These student names are then forwarded to the director of student affairs who then contacts committee chairs to place students. Because students have historically had difficulty attending committee meetings, subsequently; some committees are utilizing electronic communication methods such as e-mail to increase student feedback, in particular from graduate students who, if enrolled in fully online tracks may have no presence on campus. In addition, the director of student affairs initiated a dean’s advisory group which is comprised of SGA and Research Student Nurses Association (RSNA) officers. This group meets at least annually to provide information related to college matters to the dean. The advisory group

provides another venue for communication and for problem solving related to such issues as financial aid access, timing of course exams across multiple courses and other non-course related issues.

Faculty and students at both RCN and RU share the governance of the undergraduate programs. To ensure integrated participation between the two institutions, the RU dean of arts and science appoints RU faculty members to RCN committees. Conversely, the president of RCN appoints faculty members to selected RU committees. Appendix I-D.1 illustrates RCN committee membership and Appendix I-D.2 illustrates shared membership between RCN and RU. Appendix I-D.3 is the organizational chart for RMC and RCN. Appendix I-D.4 illustrates the organizational relationship with RU, RCN and the nursing program. Participation occurs at the level of the senior administration where the RCN president is a


member of the RU president’s cabinet. The RCN dean will be a member of the RU deans’ council when the position is filled. The RU president is a member of the college governing Board. RCN faculty have participated on searches for key RU positions such as the associate dean for graduate and professional studies and the vice-president for academic affairs. Currently the RU vice-president for academic affairs serves on the search committee for the RCN dean.

I-E. Documents and publications are accurate. References to the program’s offerings, outcomes, accreditation/approval status, academic calendar, recruitment and admission policies, transfer of credit policies, grading policies, degree completion requirements, tuition, and fees are accurate.

Elaboration: A process is used to notify constituents about changes in documents and publications. Information regarding licensure and/or certification examinations for which graduates will be eligible is accurate.

Program Response:

Documents and publications are accurate and available to prospective and current students as well as other members of the college’s community of interest. The CAP Section I.C (ERI-27) outlines the process for review of college policies and major college publications. RCN committee chairs are responsible for submitting recommendations for changes in curriculum or policy to the FGA. All committee chairs complete an annual report which documents actions of the committee for that academic year. The FGA chair prepares an annual report which then documents the actions of all committees. The program directors, the dean, and the director of student affairs use these reports to update the college catalog, guide to student life, and the website and recruitment materials. For example, after the FGA approved the revised undergraduate student learning outcomes in May 2010, it forwarded this information to the admissions department at RU to include in the revision of the undergraduate nursing recruitment brochure (ERI-28). Similarly, approval of the addition of the adult-gerontology nurse practitioner (AGNP) track in November 2010 was submitted to the director of transfer and graduate recruitment to include in graduate program materials (ERI-29).

At minimum, the website ( is updated annually; however, materials that are time-sensitive are uploaded as soon as they are approved. The website is administered and maintained by the college’s director of technology with input provided by program directors, faculty, the dean and the directors of financial aid, student affairs and admissions. When, for example, the website was reviewed as part of the self study process; the mission statement was found to include a second paragraph which had been deleted as part of the revision process. The website has been corrected to reflect the accurate mission statement.

The RCN catalog and the guide to student life are reviewed and updated annually. Policy changes that occur between revisions are communicated to all students through Blackboard and RCN email.


Information about licensure is included in the RCN catalog (ERI-30). The dean meets with graduating seniors and accelerated students to review the process of application for the NCLEX-RN® examination. Graduate students receive information about the certification examination from the RCN catalog and from faculty in their final practicum courses NU 7451 Independent Primary Care Practicum for the Family Nurse Practitioner (FNP) and the NU 7452 Independent Primary Care Practicum for the AGNP.

The governing board sets and approves tuition and fees in March of each year. Undergraduate tuition is set at the same rate as our partner institution, RU. The dean, with input from the program directors and the director of the learning resource center/Seelos Center determines specific undergraduate nursing fees. Graduate tuition is set by the dean and the director of financial aid; it is reviewed annually and approved by the governing board (ERI-31).

I-F. Academic policies of the parent institution and the nursing program are congruent. These policies support achievement of the mission, goals, and expected student outcomes. These policies are fair, equitable, and published and are reviewed and revised as necessary to foster program improvement. These policies include, but are not limited to, those related to student recruitment, admission, retention, and progression.

Elaboration: Nursing faculty are involved in the development, review, and revision of academic program policies. Differences between the nursing program policies and those of the parent institution are identified and are in support of achievement of the program’s mission, goals, and expected student outcomes. Policies are written and communicated to relevant constituencies. Policies are implemented consistently. There is a defined process by which policies are regularly reviewed. Policy review occurs and revisions are made as needed.

Program Response:

Academic policies of the nursing program are congruent with RCN which is its parent institution. All policies and procedures outlined in the RCN catalog and the guide to student life policies support the achievement of the mission and expected student outcomes of the program. Although policies are reviewed based on the cycle defined by the CAP Section I.C (ERI-27), faculty or the student affairs director may initiate a review of policies at any time. Faculty participate in the development, review and revision of academic program policies through the committee structure and through the FGA.

The appropriate committees review admission, progression, grading and other relevant policies annually. As a result of such review the graduate admission policy was revised to describe requirements with more depth and clarity and to include an interview (ERI-32); the undergraduate grading scale (ERI-33) was revamped; the administrative and academic requirements for enrollment and progression policy were revised (ERI-34); the readmission following dismissal policy was revised (ERI-35).

The student affairs committee initiates development and review of student life policies by making recommendations for action to FGA. For example, the committee developed a statement on diversity in


order to more clearly state the nursing program’s position and to articulate its alignment with the college mission (ERI-36). In order to be responsive to the program’s clinical partners, revisions were made to the student cell phone policy (ERI-37) and to the dress code policy (ERI-38).

Academic policies are applied in a consistent and fair manner to all students in order to facilitate an environment conducive to learning and to the accomplishment of student learning outcomes. Faculty and staff believe that these policies provide the framework for support of student success and that ensure students meet the requisite requirements necessary to provide safe, quality patient care.

I-G. There are established policies by which the nursing unit defines and reviews formal complaints.

Elaboration: The program’s definition of a formal complaint and the procedure for filing a complaint are communicated to relevant constituencies. The program follows its established

policies/procedures for formal complaints. Program Response:

The college defines a formal complaint as “one which focuses on serious, trivial academic or non-academic matters, is made in writing and signed by the author, is submitted to an institutional officer with the responsibility to handle the complaint and is outside the scope of the academic appeal process” (ERI-39, ERI-40). The process is described fully in the RCN Guide to Student Life, 2012-13 (ERI-41). There have been no formal complaints filed against the college.


Standard I Summary Strengths:

Strong commitment from the community of interest

Shared support for the academic-practice enterprise between RCN and RMC Faculty and undergraduate student participation in governance

Systematic evaluation of the mission, student learning and program outcomes

Utilization of feedback from the community of interest to inform curricular and co-curricular decisions

Strong partnership with RU for the undergraduate program New faculty orientation process

Areas for improvement

Involvement of online graduate students in governance Assuring that the website is accurate and current

Enculturation into faculty role related to governance for new faculty and existing faculty

Facilitation of transition of late career faculty to part-time roles and retirement with consideration of impact on current faculty.

Action Plan:

Continue to seek involvement of graduate students in committees through direct contact by course faculty and use of technology such as Skype and WebEx

Consistently use the recently designed template to update the website

Implement focused discussion related to faculty roles of teaching, scholarship and service at FGA meetings

Utilize results from the 360 faculty assessment to develop annual goals/strategies for faculty and transition plans for career change