Title of Regulation: 18VAC90-27. Regulations for Nursing Education Programs (amending 18VAC90-27-10, 18VAC90-27-220, 18VAC90-27-230).

Statutory Authority: §§ 54.1-2400 and 54.1-3005 of the Code of Virginia.

Public Hearing Information:

September 19, 2017 - 10:15 a.m. - Perimeter Center, 9960 Mayland Drive, Suite 201, Richmond, VA 23233

Public Comment Deadline: September 22, 2017.

Agency Contact: Jay P. Douglas, R.N., Executive Director, Board of Nursing, 9960 Mayland Drive, Suite 300, Richmond, VA 23233, telephone (804) 367-4520, FAX (804) 527-4455, or email jay.douglas@dhp.virginia.gov.

Basis: Regulations are promulgated under the general authority of § 54.1-2400 of the Code of Virginia, which provides the Board of Nursing the authority to promulgate regulations to administer the regulatory system. In addition, § 54.1-3005 of the Code of Virginia provides authority for the board to approve nursing education programs.

Purpose: The purpose of the proposed regulatory action is to use national accreditation as a standard for demonstrated quality in nursing education, create more opportunities for financial aid for students, enhance employment opportunities, and facilitate academic progression for graduates to baccalaureate or master degrees.

Quality may be demonstrated by a higher percentage of graduates passing the national examination (NCLEX) from accredited nursing education programs. In 2014, 86% of graduates from accredited programs passed NCLEX, and 76% of graduates from nonaccredited programs passed. The board requires a passage rate of 80% over a three-year period to maintain approval of a nursing education program.

94% of employers in Virginia (predominantly hospitals) reported that accredited nursing programs have a large to moderate impact on clinical outcomes for registered nurses. Accreditation standards result in a quality education demonstrated in a number of ways, but most importantly, in the clinical care nurses provide to patients. Therefore, it is essential to protect the health and safety of citizens for the Board of Nursing to move toward accreditation of all registered nursing education programs.

The goal of this action is to align educational programs with recommendations of the National Council of State Boards of Nursing and the Institute of Medicines Future of Nursing report, which recommends increasing the proportion of nurses with a baccalaureate degree to 80% by 2020. Nurses from practical, associate, and diploma programs who graduate from nonaccredited programs will find it difficult, if not impossible, to obtain a baccalaureate degree. Graduates of nonaccredited programs will also find it increasingly difficult to find employment as employers, especially many hospitals, are hiring only baccalaureate degree nurses.

Substance: The proposed amendments require all prelicensure registered nursing education programs in Virginia to have accreditation or candidacy status with a national accrediting agency recognized by the U.S. Department of Education by the year 2020. The accrediting bodies currently recognized are the Commission on Collegiate Nursing Education (CCNE), the Accreditation Commission for Education in Nursing (ACEN), and the Commission for Nursing Education Accreditation. There will be no change for prelicensure programs preparing students for licensed practice nursing.

Issues: The primary advantage of the proposed amendments is greater assurance of quality in the didactic and clinical education for registered nurses. For graduates of such programs, there are advantages in employment opportunities and availability of graduate level education to further their careers. There are no disadvantages for nurses or the public.

There is an advantage to the board because accredited programs only have to be reevaluated every 10 years, whereas nonaccredited programs have to be reevaluated every five years, a process that consumes resources and personnel. There are no disadvantages to the Commonwealth.

Department of Planning and Budget's Economic Impact Analysis:

Summary of the Proposed Amendments to Regulation. The Board of Nursing (Board) proposes to require that each registered nursing (RN) education program be accredited or be a candidate for accreditation in order to maintain Board-approved status. Additionally, the Board proposes to expand the number of approved accrediting organizations for nursing education programs.

Result of Analysis. The benefits likely exceed the costs for all proposed changes.

Estimated Economic Impact. The Regulations Governing Nursing Education Programs set out the requirements for RN education programs and licensed practical nursing education programs in Virginia.

Required Accreditation for RN Programs: Under the current regulation RN education programs do not need to be accredited in order to maintain board-approved status. Nonaccredited RN education programs are reevaluated at least every five years by submission of a comprehensive self-evaluation report and a survey visit by representatives of the Board. Accredited RN education programs are reevaluated at least every 10 years by submission of a comprehensive self-evaluation report as provided by the Board. As evidence of compliance with specific requirements of this chapter, the Board may accept the most recent study report, site visit report, and final decision letter from the accrediting body. According to the Department of Health Professions, all 33 bachelors' degree RN education programs in the Commonwealth are accredited. Of the 45 associates' degree RN education programs in Virginia, 26 are currently accredited and 19 are currently unaccredited.

The Board proposes to require that all RN education programs be accredited or be in accreditation candidacy status in order to maintain board approval. For programs that are not currently accredited and did not plan to pursue accreditation without the Board's proposed requirement, this proposal will introduce several thousand dollars of fees in acquiring and maintaining accreditation. For information on those fees, please see the appendices at the end of this document for fee schedules from three Board-recognized accrediting organizations. For at least some of the currently nonaccredited programs, there would be further additional cost in changing the program to meet the accrediting organization's requirements.

On the other hand, there would be some savings to offset costs for accreditation in that an accredited program only has to be reevaluated by the board every 10 years by submission of a report, and an accredited program may use its reports from the accredited body as evidence of compliance with Board regulations. A nonaccredited program has to be reevaluated every 5 years and requires submission of a full report and a survey visit from a Board representative. Both the Board and the accredited programs would realize some savings by the longer period between reevaluation for continued approval by the Board. The cost for a survey visit by the Board is $2,200; an accredited program would realize that savings every 5 years.

There is some evidence that RNs from accredited nursing education programs perform better than RNs from unaccredited programs. Members of the Virginia Hospital & Healthcare Association were surveyed concerning the accreditation of nursing education programs. When asked whether they saw a difference in clinical practice between RNs from accredited nursing programs and nonaccredited nursing programs, 86% chose "Yes, RNs from accredited nursing school programs demonstrate a stronger and more in depth clinical practice than nurses from nonaccredited nursing school programs, versus 14% who chose "No, we do not see a difference in clinical practice between RNs from accredited and nonaccredited nursing school programs." When asked to evaluate the effect of nursing program accreditation on delivering quality clinical outcomes to patients within their institution, a) 74% chose "Accredited nursing school program RNs have a large impact on clinical outcomes," b) 20% chose "Accredited nursing school program RNs have a moderate impact on clinical outcomes," and c) 6% chose "Accredited nursing school program RNs do not have an impact on clinical outcomes." This implies, but does not establish,¹ that the health care provided by graduates of accredited nursing programs is superior to that provided by graduates of nonaccredited nursing programs and makes a positive difference in patient health outcomes. To the extent that this is accurate, the benefits of the proposed amendments likely exceed the costs.

Additional Accrediting Organizations: Under the current regulation "Accreditation" is defined as "having been accredited by the Accreditation Commission for Education in Nursing, the Commission on Collegiate Nursing Education, or a national nursing accrediting organization recognized by the board." The Board proposes to amend the definition to "having been accredited by an agency recognized by the U.S. Department of Education to include the Accreditation Commission for Education in Nursing, the Commission on Collegiate Nursing Education, the Commission for Nursing Education Accreditation, or a national nursing accrediting organization recognized by the board." The proposed new language is underlined. Additional options for accreditation can be beneficial for nursing education programs in that they may find options that are either more affordable or available, or match their mission better.

Businesses and Entities Affected. The proposed amendments potentially affect the 78 prelicensure RN education programs in the Commonwealth, as well as nursing students, employers of nurses such as hospitals, and patients. The 19 currently unaccredited RN education programs would be particularly affected.²

Localities Particularly Affected. The proposed amendments do not disproportionately affect particular localities.

Projected Impact on Employment. The proposal to require accreditation for RN education programs to maintain Board-approved status may lead to the closing of a few propriety programs. This would eliminate employment at those programs. Most of the students who would have enrolled in those programs would likely enroll in a different Virginia program instead. Given the increased demand, at least some of the potential reduction in employment at the closing programs may be counterbalanced by increased employment at the programs with the potential increased demand.

Effects on the Use and Value of Private Property. The proposal to require accreditation for RN education programs to maintain Board-approved status may lead to the closing of a few propriety programs. If this were to happen, the property currently used to house these closing RN education programs would likely be used for a different purpose going forward.

Real Estate Development Costs. The proposed amendments do not affect real estate development costs.

Small Businesses:

Definition. Pursuant to § 2.2-4007.04 of the Code of Virginia, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

Costs and Other Effects. Most of the RN education programs are either part of universities, community colleges, or national propriety college chains. There may be a few smaller proprietary programs. For these programs, if they are not already accredited or in candidacy status, the proposal to require accreditation for RN education programs to maintain Board-approved status would increase costs through accreditation fees and potentially in changing the program to meet the accrediting organization's requirements.

Alternative Method that Minimizes Adverse Impact. There is no clear alternative method that reduces adverse impact while still meeting the policy goal of increased minimum skills training for Board-approved RN education programs.

Adverse Impacts: 

Businesses. The proposal to require accreditation for RN education programs to maintain Board-approved status would increase costs for proprietary RN education programs that are not already accredited.

Localities. The proposed amendments do not adversely affect localities.

Other Entities. The proposed amendments do not adversely affect other entities.

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¹ Research that includes data on patients and their health outcomes linked with their nurses and their educational background, controlling for factors unrelated to the nurses' educational background that could affect health outcomes, would be needed to more firmly establish the actual impact.

² Data source: Department of Health Professions

Appendix A

Appendix B

Appendix C