Responding to the pandemic: Nursing education and the ACEN.

The purpose of this article is to provide an overview of some of the ways in which nursing education programs and the Accreditation Commission for Education in Nursing (ACEN) adapted to the challenges of the COVID-19 pandemic. Although the longer-term impacts of the pandemic cannot be known, it is clear that nurse educators rose to the challenge of educating nurses during a pandemic through rapid implementation of innovative teaching strategies and student support. The article also provides some guidance for ACEN-accredited nursing education programs regarding substantive changes that may be permanently implemented as a result of what programs learned during the pandemic.

Introduction

The last year has brought many changes and challenges to nursing education programs throughout the United States and other countries as programs responded to the COVID-19 pandemic. Consistent with professional nursing practice, nurse educators rapidly responded and adapted their teaching to ensure students were able to complete their programs of study and to graduate in a timely manner in order to join the nursing workforce on the frontlines. The article will discuss some of the program changes that occurred in response to the pandemic as well as an overview of some of the ways the pandemic affected the work and future direction of the Accreditation Commission for Education in Nursing (ACEN). The article will also provide an overview of what ACEN-accredited programs may need to report if the programs plan to retain any of the changes they implemented during the pandemic.

Nursing education program responses to the pandemic

Pivot to distance education for didactic components

In response to the COVID-19 pandemic, many ACEN-accredited nursing programs had to transition from a face-to-face delivery modality to using some form of distance education. Some programs utilized synchronous video conferencing while others used online courses or a combination of delivery modalities. Programs needed to make these transitions quickly to facilitate the students’ ability to complete the academic term and to continue to provide the nursing program throughout the pandemic. With the transition, some nursing faculty needed additional professional development to develop courses, teach in an online environment, and learn new software products. Institutions responded to the needs of the faculty by providing information technology (IT) support to implement the changes as well as providing professional development/inservices to faculty who needed additional assistance.

Typically, when a nursing program begins using distance education for nursing courses, the program may need to submit a substantive change report in accordance with Policy #14 Reporting Substantive Changes (ACEN Accreditation Manual, Section II Policies, online), which will be discussed later in this article. However, as a result of the emergency nature and temporary use of distance education, programs who began using distance education in response to COVID-19 were not required to submit a substantive change report. The ACEN was able to waive this requirement because the United States Department of Education (USDE) allowed accrediting agencies to waive mandatory reporting during the pandemic emergency.

As the pandemic appears to be waning and life is returning to a new state of normal, programs are beginning to transition back to the delivery modality/modalities previously used, which in many cases was face-to-face delivery. Now is the time for the faculty to consider the changes that were made and make some intentional decisions regarding which of these changes, if any, will be retained.

As the faculty begin making these decisions regarding the continued use of some form of distance education, there are several factors to consider. First, the faculty need to ensure that they know how the ACEN defines distance education, which may differ from their institutional definition. The ACEN defines distance education as “an educational method of delivery of nursing courses in which instruction occurs when a student and instructor are not physically in the same place. Instruction may be synchronous or asynchronous. Distance education uses one or more distance technology to support regular and substantive interactions between the instructor and students” (). The ACEN definition of hybrid education is “an educational method of delivery of nursing courses in which instruction occurs using both distance and traditional education methods of delivery. Hybrid education, regardless of the percentage of the traditional education time it replaces, is considered a form of distance education by the ACEN” ().

Faculty also need to ask themselves several questions regarding the use of distance education. Some examples are: What benefits are there for continuing to use distance education? How has the use of distance education affected student retention, student engagement, and student success? What opportunities are there to continue using some form of distance education in the didactic courses or didactic course components? Does the program need additional resources to continue using distance education within the nursing courses? Are these resources available within the institution or will additional resources need to be obtained? What additional professional development do faculty need if the program continues to use distance education?

As faculty are making the determination regarding the use of distance education, the faculty are also encouraged to review Policy #15 Distance Education ACEN (Accreditation Manual – Section II Policies, online). This policy requires that nursing programs using distance education ensure that the distance education critical elements are currently being met or can be met when the faculty make the decision to use distance education permanently. This policy also requires that the program/institution have a process in place to verify the students’ identification in the courses/course components using distance education. Additionally, faculty may need to consider the student support services offered by the institution and how moving to a distance delivery modality may affect access to these resources.

Finally, if the faculty determine that they will retain some form of distance education, then the ACEN may need to be formally notified in accordance with Policy #14. See additional information regarding substantive change later in the article.

Increased use of simulation

A common change reported by ACEN-accredited programs was the implementation of state waivers or adjustments to the amount of simulation that could be used in a program and/or substituted for actual clinical experiences. Some nursing education programs began to use their skills laboratories for the first time to simulate clinical experiences. Other programs increased the use of their current simulation experiences and/or substituted clinical hours with simulation. There was also the addition of or increased use of virtual simulation in some programs.

As the pandemic continued, faculty and students began to see the value of some of these changes, despite the loss of some clinical experiences. Because of these forced experiences and the potential benefits for some programs, it will be interesting to see how nursing programs respond once state waivers are revoked; the ACEN is already receiving many questions regarding potential permanent changes. It is also anticipated that some states may continue to support the use of additional amounts of simulation and/or the use of virtual simulation in nursing programs. This is not to suggest that clinical experiences can be replaced completely, only that considering the amounts of each relative to best practice is a worthy discussion.

The ACEN requires that all nursing education programs include clinical experiences to support students' achievement of the end-of-program student learning and program outcomes. Though changes regarding the use of simulation were intended to be a temporary response due to the clinical placement challenges during the pandemic, for some programs, the adjustments may be permanent. The intentional decision to retain simulation and/or the use of virtual simulation experiences as well as the amount of these experiences in a curriculum will undoubtedly be a topic of discussion during faculty meetings. As most states do not dictate the amount of clinical required, it is anticipated that faculty will work to intentionally identify the best balance of clinical and simulation time that will best support their curriculum and assist their students.

Clinical challenges and opportunities

During the pandemic, the shortage and uncertainty of clinical/practicum experiences posed challenges for many programs, which resulted in adoption of new clinical/practicum experiences. The abrupt suspension of clinical/practicum experiences compelled faculty to explore the components of their programs’ clinical/practicum experiences and search for new strategies for students to achieve student learning outcomes. For decades, the ACEN has required clinical/practicum experiences. ACEN's current definition emphasizes “direct, hands-on, planned learning activities with patients across the lifespan, interaction with the interprofessional team, and interaction with the patient's family and friends that are sufficient and appropriate to achieve the end-of-program student learning outcomes, program outcomes, and/or role-specific professional competencies, and are overseen by qualified faculty who provide feedback to students in support of their learning” ().

In many instances, as faculty searched for learning opportunities in practice settings, clinical/practicum experiences as defined by the ACEN were augmented with virtual, simulation and laboratory experiences due to clinical disruptions. Although the ACEN does not specify the number of hours that should be included in clinical/practicum experiences and the academic term in which clinical experiences should occur, faculty had to determine which students should attend clinical/practicum experiences and the academic term in which clinical experiences should be offered. The challenge was identifying how many clinical/practicum hours were necessary to achieve student learning outcomes given limited clinical capacity. Unfortunately, in some programs, students were unable to complete courses because clinical/practicum experiences were not available to achieve the student learning outcomes or insufficient in quantity to achieve the student learning outcomes.

Further, the pandemic placed most clinical experiences on hold for an undetermined timeframe. Inherent in this situation were two notable questions: 1. how do students “make up” missed clinical/practicum hours; and 2. given the uncertainty of returning to clinical/practicum settings, what strategies should faculty undertake to augment clinical/practicum hours? To be clear, nurse administrators and faculty have experience in managing clinical disruptions for reasons such as faculty and student illness and inclement weather. Identifying how to provide clinical/practicum experiences, during a pandemic, for one, two, or even three academic terms posed a new challenge. Adding to the challenge was some requirements by Boards of Nursing for clinical/practicum hours. Recognizing the lack of clinical access, some Boards of Nursing increased the percentage of simulation that could be used to replace clinical hours while other Boards of Nursing maintained their requirements for clinical hours even during the pandemic. The range of clinical flexibility varied among Boards of Nursing.

To address the first question, faculty acknowledged that “makeup” clinical/practicum experiences were unlikely. Therefore, the faculty implemented an increase in simulation, laboratory, and virtual simulation learning experiences for students based on the National Council of State Boards of Nursing (NCSBN) Simulation Study (Hayden et al., 2014). Yet, understanding that nursing is a discipline that requires “hands-on” clinical/practicum experiences, the faculty explored other clinical/practicum learning experiences (e.g., COVID-19 screening, testing, and administration of COVID-19 vaccinations), thus adopting new opportunities. Similarly, some students practiced in COVID-19 units and conducted leadership experiences that included mass community planning of COVID-19 management and implementation of COVID-19 vaccinations. Both of these examples highlight the faculty's foresight and understanding that caring for patients with COVID-19 and preparing for community disasters were learning opportunities that their students may not experience in the near future. During the pandemic, the NCSBN endorsed the practice-academic partnership model. In this model, hospitals hire nursing students as paid employees who work for the hospital while earning clinical hours to achieve student learning outcomes. The benefits of the practice-academic partnership are exposure to emergency management, public health, communication, and interdisciplinary teams.

Although faculty adapted rapidly to adopt practice learning experiences to augment clinical/practicum experiences, some strategies will likely be maintained since they resulted in positive student learning outcomes. For example, faculty who increased the hours of simulation and found that students performed better on their clinical evaluation tools and practiced with greater confidence may maintain additional simulation hours. Some of the creative clinical settings could be maintained such as community-based centers for vaccinations, mobile vaccination units, and disaster management. Practice-academic partnerships are another example of clinical/practicum learning experiences that could be maintained and beneficial to students, the program, and clinical sites. Although the pandemic created disruptions and uncertainties, the faculty have identified new opportunities that appear promising.

What the future holds

ACEN substantive-change

As noted previously, early in the pandemic, the ACEN notified programs that temporary flexibility regarding the use of distance education was allowed beginning in Spring 2020 and for 180 days following the date on which the COVID-19 national emergency declaration is rescinded. This temporary flexibility means that programs can use distance education methods of delivery, whether or not the program has been approved by the ACEN to use distance education, for delivery of the didactic portions of their curriculum. While many programs intend to return to a face-to-face method of delivery as soon as it is possible, other programs have determined that they want to continue the use of at least some distance education in their program of study. Programs that have not been previously approved to offer their program of study using some form of distance education but that now plan to continue using some form of distance education will need to determine if this needs to be submitted to the ACEN per Policy #14 Reporting Substantive Changes ACEN (Accreditation Manual – Section II Policies, online).

For example, if a nursing program has 40 credits in nursing courses and 25 credits were specifically allocated to didactic courses/course components that now will be using any form of distance education, then 62.5% of the nursing program would be offered using distance education. In this situation, the program would need to report this to the ACEN. However, if only 15 credits were offered using distance education or 37.5% of the nursing courses were offered using any form of distance education, this would not need to be reported to the ACEN.

As a reminder, for the ACEN, the central factor in determining if a program is using distance education is when the student and the instructor are not in the same place at the same time. Therefore, a program that uses synchronous remote teaching and a program using asynchronous module-based teaching are both using distance education. Because all nursing programs must have clinical/practicum learning experiences and some programs may implement a hybrid or a HyFlex method of delivery, programs are advised to review the ACEN FAQs (https://www.acenursing.org/faq/) related to distance education to determine if a substantive change report is required based on how the program plans to deliver the program of study.

An area of concern identified by some nursing programs is related to the potential impact of the pandemic on program outcomes such as the licensure examination pass rate, program completion rate, and/or job placement rate. The COVID-19 pandemic, in combination with unrest related to social justice and political concerns across the United States, as well as potential changes in local hiring practices or employment opportunities, and even natural disasters over the last year have the potential of negatively affecting program outcomes. Knowing that their program outcomes may not meet established benchmarks or expected levels of achievement (ELA), many programs are concerned about the impact a change in program outcomes may have on a program's accreditation status. Per ACEN Policy #14 Reporting Substantive Change, the following must be reported to the ACEN: when the program's aggregated 12-month licensure examination pass rate falls below 80%; when the program's aggregated completion rate is more than 25% below the program's ELA for two consecutive years or when a single year falls more than 40% below the program's ELA; or when the program's aggregated job placement rate is more than 30% below the program's ELA for two consecutive years or when a single year falls more than 45% below the program's ELA. It is important to note that the program must use a proportional calculation, based on the program's own ELA, to determine if the program completion rate or job placement rate must be reported to the ACEN.

If a program is required to submit a substantive change report for a decline in program outcomes, it is important for the program to provide sufficient context about the decline and identify external factors that may have had an adverse effect on the outcome reported. If the program identifies, through the analysis of their program data, that the pandemic or other societal factors appear to have contributed to the decline this should be described in the substantive change report. Whenever a substantive change report is submitted to the ACEN, the ACEN staff and the Board of Commissioner's do their due diligence to contextualize the information reported and to be consistent in any recommendations or decisions made. Substantive change decisions related to a decline in program outcomes are not based solely on one data point, which is why the substantive change report templates require the submission of three years of outcomes data as well as provision of information about the program's analysis of the data and the actions identified and taken to address the decline(s). Further, if it becomes clear that there are national trends related to declines in identified program outcomes that are linked to the pandemic, the ACEN Board of Commissioners will incorporate this information when they make any decision about a program's accreditation status.

ACEN changes

The ACEN has also undergone changes as a direct impact of the pandemic. Like many nursing faculty and staff, the ACEN staff worked remotely from March 2020 through May 2021. In addition, the ACEN as well as nursing education programs and peer evaluators adapted to the rapid implementation of virtual site visits for the Fall 2020 and Spring 2021 accreditation cycles. While the transition to virtual site visits was a challenge for everyone involved, the experience did provide an opportunity for the ACEN to implement new processes related to submission of supporting evidence for site visits. In addition, based on USDE requirements, the ACEN is implementing a verification visit process for programs that were reviewed virtually during Fall 2020 and Spring 2021.

In recent years, the ACEN has refined a process for paperless submission of written reports and supporting evidence. The pandemic expedited this process as the organization prepared to have programs host virtual site visits. In the Fall 2020, programs worked with their site visit teams to share their evidence through learning management system access, share drives, and flash drives. In Spring 2020 this continued, though the ACEN also piloted a new document repository to allow programs to upload their evidence, which was then accessible to the ACEN staff as well as the peer evaluators on the site visit team, the Evaluation Review Panel, and the Board of Commissioners. Beginning Fall 2021, all programs under review will share their reports and supporting evidence through the ACEN Document Repository. This change will not only reduce the need to print most site visit review materials but also provide an easy and consistent mechanism for programs to share information with their peers prior to the visit, which will allow peer evaluators to better prepare for the visit. The ACEN is excited about the new repository; more information regarding the repository is available on the ACEN website.

Verification visits are a direct result of hosting virtual site visits for Fall 2020 and Spring 2021. Though the USDE provided waivers for accreditors to allow programs to host virtual visits, it was with the caveat that there would eventually be future onsite verification visits once it was safe to do so. Therefore, all ACEN programs that hosted a virtual visit in Fall 2020 or Spring 2021 will eventually have a brief (half-day) onsite visit conducted by one peer evaluator. Please note that there are no fees associated with this visit as all fees were already paid by programs for the virtual site visit.

The focus of the verification visits will be on students and physical resources. For student verification, programs have the option of having the peer evaluator observe students in the classroom or clinical setting or having a brief student meeting. To verify physical resources, the peer evaluator will tour the program's physical facilities. The peer evaluator conducting the visit will write a short report of their findings during the visit. This report will be reviewed by the Board of Commissioners at their next meeting, and the report will be retained in the program's record, along with the previous virtual site visit report.

Programs have been asked to be patient as the ACEN collects information regarding when it is safe and appropriate to schedule the verification visits, including when students will be on campus. Programs that require a verification visit will be contacted directly by the ACEN for scheduling. It is anticipated that the verification visits will be conducted over the next two years. For any questions regarding an ACEN verification visit, please contact the ACEN office.

Conclusion

The impact of the pandemic on the profession and nursing education cannot be overstated. Several nursing education programs lost members of their faculty or leadership to COVD-19 and many more nurse educators and students experienced the challenges of personal illness or illness among family, friends, and colleagues. Through it all, nurses once again rose to the challenge to meet the needs of the communities they serve and nurse educators continued their stalwart service to students through creative and innovative educational practices as well as engagement in public and community health initiatives in support of the country's pandemic response. While it may take years for us to fully understand what we have learned as individuals, as a profession, or as nurse educators, it is clear that we continue to meet the challenges of our chosen profession and we will emerge stronger and better.

Declaration of Competing Interest

The authors have nothing to report.