November 14, 2014
I’ve had the great pleasure of working with Nancy Spector over the past few years as the National Council of State Boards of Nursing works on the issue of prelicensure Nursing requirements across the states. They have made significant progress in developing a “home state” model that will eventually require that only the state which the institution considers its home will be responsible for approving its prelicensure distance education programs. Thank you to Nancy for this guest blog post updating us on their work. — Russ Poulin
The National Council of State Boards of Nursing (NCSBN) has been working to promote consistency, among the boards of nursing (BONs), with the state approval of prelicensure distance education programs. Before we talk about this initiative, a little background on why BONs are involved in nursing education is important for you to understand.
In the U.S., prelicensure nursing programs are approved by their BONs before the students can take nursing’s licensure exam (the NCLEX). Nurse licensure in the U.S. is based on a 2-pronged model. First the faculty from a BON approved program must sign off that their student is clinically competent and able to take the NCLEX. Then the board of nursing will make the student eligible to take the NCLEX, which is a computer adapted exam. When the student passes the NCLEX, he/she can be licensed to practice nursing. As part of the approval process, BONs evaluate and approve all nursing programs, including those that offer both traditional and distance education programs.
Issues in the Oversight of Distance Education Nursing Programs
Two national reports in nursing have recommended that nurses advance their education (Benner, Sutphen, Leonard & Day, 2010; IOM, 2011). Distance education programs provide tremendous opportunities for nurses to further their education, particularly by offering quality programs in small communities or rural areas where nursing programs don’t exist or by allowing flexibility for those students who otherwise couldn’t attend a program. However BONs have reported issues with distance education programs and some educators have complained about the varying BON regulations of the “host” states (where the student is located) with which they must comply. Therefore, NCSBN’s Board of Directors convened a committee of our membership which met from 2012-2014 to identify the issues that boards of nursing and prelicensure nursing education programs face because of distance education and to develop some recommendations.
Some of the issues the committee identified included:
- Core education requirements for approving distance education programs are needed so that states/jurisdictions are consistent when approving programs for having students in host states.
- There is a need for licensure clarification, particularly with faculty who only teach didactic courses, though there was consensus that preceptors or clinical faculty who work with patients be licensed in the host state where the patients are located.
- BONs in certain states want to know when students from out-of-state programs take clinical experiences in their state.
- Host states want assurance that students participating in clinical experiences in their states are being supervised by qualified faculty or preceptors.
- BONs report that the quality of online programs is more varied than with traditional programs and they have requested information on specifics on how to evaluate the quality of distance education programs.
- Educators are worried about complying with all the different regulations from Boards of Higher Education as well as BONs.
To answer these concerns, the committee members took several steps. First, we developed relevant definitions:
- Distance education – Instruction offered by any means where the student and faculty are in separate physical locations. Teaching methods may be synchronous or asynchronous and shall facilitate and evaluate learning in compliance with BON approval status/regulations.
- Home state – Where the program has legal domicile.
- Host state – State/jurisdiction outside the home state where students participate in clinical experiences or didactic courses.
Changing the Need for Approval in Every Host State
Then, after conducting interviews, conference calls and surveys with our BONs, educators, and with representatives of the new National Council of State Authorization Reciprocity Agreement (NC-SARA) organization, we developed guidelines for BONs that were translated into model administrative Rule/Act language and adopted at NCSBN’s 2014 annual meeting. The summarized guidelines are:
- Distance education programs must meet the same approval guidelines as any other program.
- Only the home state approves distance education programs.
- Home state ensures faculty supervision over clinical students in the host states.
- (a) Clinical faculty or preceptors are licensed where the patients/students are located. (b) Faculty who only teach didactic content are licensed in the home state. Model licensure exemption language was developed to allow for this.
- BONs will include a question on their annual reports on whether students are engaging in clinical experiences in host states.
The committee encouraged the BONs to make these changes by 2020, which is in line with other national nursing education recommendations (IOM, 2011). We developed a model (Figure 1, below) that clearly depicts the role of the home and host state with these new guidelines. A major difference is that there will need to be more collaboration among the home and host states for program approval and for allowing programs to enroll students in host states. Please see Lowery & Spector (2014) for a more comprehensive discussion of this committee work.
Website and Virtual Conference for Further Information
To support these efforts, NCSBN has developed a Distance Education web page with resources for BONs and educators. This web page has a link for host states distance education requirements that educators have found valuable: https://www.ncsbn.org/6662.htm. NCSBN is also planning a virtual conference on April 28, 2015, for its BONs, which will feature Dr. Diane Skiba as a keynote presenter on the future of distance education and Dr. Diane Billings talking about quality indicators for distance education programs. There will be plenty of time for dialogue, as well as panel discussions on the issues. A special session will highlight the NC-SARA initiatives and Case Western Reserve’s new massive open online course (MOOC) on quality improvement.
For next steps, NCSBN’s Board of Directors has convened a second committee, the APRN Distance Education Committee, which will develop guidelines for graduate programs with distance education courses. With that new initiative, we will also develop a web page that will list all host state requirements for graduate nursing programs. That work should be completed by August 2015.
It is imperative for BONs and educators to work together to promote excellent learning outcomes with distance education, which in turn will improve the quality and safety of patients. Authentic conversations will be essential as we move forward together.
Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical reform. San Francisco: Jossey-Bass.
Institute of Medicine (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
Lowery, B. & Spector, N. (2014). Regulatory implications and recommendations for distance education in prelicensure nursing programs. Journal of Nursing Regulation, 5(3), 24-33.
Nancy Spector, PhD, RN
Director, Regulatory Innovations
National Council of State Boards of Nursing
 The National Council of Boards of Nursing (NCSBN) is composed of the 59 member boards, which include 50 states, the District of Columbia, and four territories (Virgin Islands, Guam, Northern Mariana Islands, and American Samoa). Three boards of nursing have RN and practical nurse boards and one board has an RN and advance practice registered nurse board. . The mission of NCSBN is to provide provides education, service, and research through collaborative leadership to promote evidence-based regulatory excellence for patient safety and public protection. The mission of our BONs is to protect the public.
 NCSBN’s model administrative Rule and Act language is developed by our members for the BONs to use as they write and revise their administrative Rules and Practice Act. The NCSBN Model Rules and Act can be found here: https://www.ncsbn.org/681.htm