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COMPARISON CROSSWALK '215-2010 Texas Board of Nursing (TBON) Verification Review Process and Evidence of Compliance with Chapter 215. Professional Nurse Education and the Commission on Collegiate Nursing Education (CCNE) Verification Review Process and Evidence of Compliance with Applicable CCNE Standards for Accreditation of Baccalaureate and Graduate Nursing Programs TBON Chapter 215. Professional Nurse Education PERTINENT STANDARD/CRITERIA TBON Compliance Verification Review Process and Suggested Evidence Applicable CCNE Standards for Accreditation of Baccalaureate and Graduate Nursing Programs (with Comments) PERTINENT STANDARD/CRITERIA CCNE Compliance Verification Review Process and Suggested Evidence '215.1 General Requirements* (a) The dean/director and faculty are accountable for complying with the Board's rules and regulations and the Nursing Practice Act. *Programs not exempt from Rule 215.1 -Review program=s orientation policies -Completion of BON online course -Interviews during survey visits to ensure dean/director maintain currency of knowledge of changes in Texas NPA and Board rules and comply with same. -Minutes of curriculum committee or other relevant faculty meetings where decisions about the program of study and curriculum are made. -Faculty Handbook -Clinical & Course Syllabi/course outlines -Clinical Evaluation Tools -Student Handbook or other publications for students -Total program evaluation plan -Program files (Comment: No true match. This is specific to the Texas BON requirement for dean/director and faculty to demonstrate currency of knowledge and compliance with Texas NPA and Board rules. It is unrealistic and impractical for CCNE site visitors from other states to be familiar with Texas law and rules.) '215.4 Approval (a)... Approval status is based upon each program's performance and demonstrated compliance to the Board's requirements and -Review biennial Compliance Audits -Review previous survey visit reports, progress reports Accreditation Standard IV related to Program Effectiveness in fulfilling its mission, goals, and expected aggregate student and faculty outcomes. IV- CCNE program evaluators conduct regular accreditation visits every 10 years with a continuous improvement progress report in 5 1

response to the Board's recommendations. Change from one status to another is based on NCLEX-RN examination pass rates, compliance audits, survey visits, and other factors listed under subsection (b) of this section.. -Review accreditation letters and reports -Review BON correspondence -Review documentation of program=s response to previously issued recommendations and requirements and/or responses to accreditation requirements -Compliance Audits and Data Reports -Previous survey visit reports, progress reports -accreditation letters and reports -BON correspondence -Documentation of program=s response to previously issued recommendations and requirements from CCNE or TBON A includes a review of NCLEX-RN pass rates and aggregate outcome data related to other aspects of their mission, goals, and expected student outcomes. Irrespective of required annual reports, continuous improvement progress reports, or other reports, the program is required to notify CCNE of any substantive change affecting the nursing program. Substantive changes include, but are not limited to changes in status with the State Board of Nursing, NCLEX examination pass rates, and other factors listed in CCNE s Substantive Change Notification. (Comment: How can the BON and CCNE collaborate to ensure that programs notify CCNE of substantive changes?) years following the visit. A Self Study is prepared by the program prior to the visit which provides information to the survey team, the Accreditation Review Committee, and the Board of Commissioners. Accreditation decisions are based upon compliance with the Standards evaluating the program quality and effectiveness. (b) Factors Jeopardizing Program Approval Status--Approval may be changed or withdrawn for any of the following reasons: (1) deficiencies in compliance with the rule; (2) utilization of students to meet staffing needs in health care facilities; (3) noncompliance with school's stated philosophy/mission, program design, objectives/outcomes, and/or policies; (4) continual failure to submit records and reports to the Board office within designated time frames; (5) failure to provide sufficient variety and number of clinical learning opportunities for students to achieve stated objectives/outcomes; (6) failure to comply with Board requirements or respond to Board recommendations -Review Compliance Audits -Review previous survey visit reports, progress reports -accreditation letters indicating weaknesses or concerns -Review BON correspondence -Review documentation of program=s response to previously issued recommendations and requirements -Compliance Audits -Previous survey visit reports, progress reports -BON correspondence -Documentation of program=s response to previously issued recommendations and requirements Accreditation is withdrawn by the CCNE Board when a baccalaureate or graduate nursing program pursuing reaccreditation fails to demonstrate its ability to meet the accreditation standards or when it fails to submit reports or payment of fees as requested by CCNE (Procedures, p. 13). (Comment: The BON recognizes the difficulties encountered by CCNE in monitoring unreported substantive changes in nursing programs. A gap arises when accredited programs do not notify CCNE of substantive changes and BON may assume this has occurred. Because of proximity to programs, more frequent contact with program representatives, and current knowledge of the status of nursing education in the state, it 2

within the specified time; (7) student enrollments without sufficient faculty, facilities and/or patient census; (8) failure to maintain a 80% passing rate on the licensing examination by first-time candidates; (9) failure of the program dean or director to document annually the currency of faculty licenses; or (10) other activities or situations that demonstrate to the Board that a program is not meeting legal requirements and standards. seems appropriate for BON to communicate with CCNE when questions arise about important program changes.) (c)(2)(a) Eighty percent (80%) of first-time candidates who complete the program of study are required to achieve a passing score on the NCLEX-RN examination. -Review of BON NCLEX-RN pass rate reports -NCSBN pass rates for the two previous BON examination years IV-A (Aggregate Student and Faculty Outcomes): Surveys and other data sources are used to collect information about student, alumni, and employer satisfaction and demonstrated achievements of graduates. Collected data include, but are not limited to, graduation rates, NCLEX-RN pass rates, certification examination pass rates, and employment rates, as appropriate. Among supporting documentation: NCLEX- RN pass rates. A program submits a substantive change report if the annual NCLEX- RN pass rates for all test-takers (first time and repeat) over a 3-year period are less than 80%. (Comment: The Texas BON determines the annual NCLEX-RN pass rate based upon first-time test takers. The BON requires that programs attain an 80% or higher pass rate for the examination year. The approval status will be changed tp full with warning after a program experiences a pass rate of lower than 80% for two consecutive years.) (c)(3) Survey visit. Each professional nursing educational program shall be visited at least every six years after full approval has been granted, unless accredited by a Board-recognized national nursing accrediting agency. -Survey visit -Review of reports from national nursing accrediting agencies See BON Education Guideline 3.2.3.a., Criteria for Conducting Survey Visits See IV-A above. Initial CCNE accreditation may be granted for a time period extending up to 5 years. Accreditation may be reaffirmed for a time period extending up to 10 years based upon demonstrated substantial compliance with the standards for accreditation and the -Self-Study document based upon CCNE guidelines -Comprehensive on-site evaluation by a team of peers 3

-Previous Board reports/letters -Reports/letters from national nursing accrediting agencies. continuing advancement of the program. A comprehensive on-site reevaluation serves as the basis for determining reaffirmation of accreditation. (Comment: The 10-year period between CCNE site visits is an extensive length of time, however, programs are required to submit a Continuous Improvement Progress Report in year 5. This report is reviewed by the Report Review Committee and feedback is provided to the program.) -For initial accreditation: evidence that the nursing program is approved by the state board of nursing, if applicable (Procedures, p. 6). 4

TBON Chapter 215. Professional Nurse Education PERTINENT STANDARD/CRITERIA TBON Compliance Verification Review Process and Suggested Evidence Applicable CCNE Standards for Accreditation of Baccalaureate and Graduate Nursing Programs (with Comments) PERTINENT STANDARD/CRITERIA CCNE Compliance Verification Review Process and Suggested Evidence '215.5 Philosophy/Mission and Objectives/Outcomes (a) The philosophy/mission and objectives/outcomes of the professional nursing educational program shall be consistent with the philosophy/mission of the governing institution. They shall reflect the diversity of the community served and shall be consistent with professional, educational, and ethical standards of nursing. -Compliance Audit review -Survey visit -Evaluation of curriculum -Philosophy/mission of the governing institution -Philosophy/mission of the nursing program -Any documents prepared for other accrediting agencies that make comparisons -Community advisory committee minutes I (Mission and Governance): 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. -Program s mission statement, goals, and expected student outcomes -Program goals -Expected student outcomes -Professional nursing standards and guidelines -Evidence of compliance with required and program-selected professional nursing standards and guidelines -Catalog, student handbook I-A (Mission and Governance): 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. The program identifies the professional nursing standards and guidelines it uses (b) Program objectives/outcomes derived from the philosophy/mission shall reflect the Differentiated Essential -Comparison of outcomes/objectives to DEC I-A (above) (Comment: BON requirement relates to program objectives/outcomes reflecting Texas competencies for 5

Competencies (DEC) of Graduates of Texas Nursing Program Evidenced by Knowledge, Clinical Judgment, and Behaviors: Vocational (VN), Diploma/Associate Degree (Dip/ADN), Baccalaureate (BSN), 2010. -Minutes of curriculum committee or other relevant faculty meetings where decisions about the program of study and curriculum are made -Course syllabi/course outlines -Total program evaluation plan -Student Handbook or other publications for students graduates of prelicensure nursing programs. Since this same requirement is stated in Rule 215.9, this difference is addressed in that section.) (c) Clinical objective/outcomes shall be stated in behavioral terms and shall serve as a mechanism for evaluating student progression. -Review of Clinical Evaluation Tools See BON Education Guideline 3.7.3.a., Student Evaluation Methods and Tools -Minutes of curriculum committee or other relevant faculty meetings where decisions about the program of study and curriculum are made -Faculty Handbook -Clinical & Course Syllabi/course outlines -Clinical Evaluation Tools -Student Handbook or other publications for students III-F (Curriculum and Teaching-Learning Practices): Individual student performance is evaluated by the faculty and reflects achievement of expected individual student learning outcomes. Evaluation policies and procedures for individual student performance are defined and consistently applied. IV-B (Aggregate Student and Faculty Outcomes): Aggregate student outcome data are analyzed and compared with expected student outcomes. IV-C (Aggregate Student and Faculty Outcomes): Aggregate student outcome data provide evidence of the program s effectiveness in achieving its mission, goals, and expected outcomes. -Course syllabi -Example of student work -Student performance evaluations -Documents that reflect decisionmaking (minutes, memoranda, reports) -Aggregate data (d) The conceptual framework shall provide the organization of major concepts from the philosophy/mission of the program that provides the underlying structure or theme of the curriculum and facilitates the achievement of the program objectives/outcomes. -Review curriculum -Minutes of curriculum committee or other relevant faculty meetings where decisions about the program of study and curriculum are made -Conceptual framework, if applicable -Faculty Handbook -Course Syllabi/course outlines -Student Handbook or other publications for students III-A (Curriculum and Teaching-Learning Practices: The curriculum is developed, implemented, and revised to reflect clear statements of expected individual student learning outcomes that are congruent with the program s mission, goals, and expected aggregate student outcomes. -Course syllabi -Curricular objectives -Expected aggregate student outcomes 6

(e) The faculty shall periodically review the philosophy/mission and objectives/outcomes and shall make appropriate revisions to maintain currency. -Review Total Program Evaluation Plan with data and supporting documentation -Review program/committee minutes -Total Program Evaluation Plan with data and supporting documentation -Minutes of relevant committees I-B (Mission and Governance): 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. -Documents that reflect decisionmaking (e.g., minutes, memoranda, reports). 7

TBON Chapter 215. Professional Nurse Education PERTINENT STANDARD/CRITERIA TBON Compliance Verification Review Process and Suggested Evidence Applicable CCNE Standards for Accreditation of Baccalaureate and Graduate Nursing Programs (with Comments) PERTINENT STANDARD/CRITERIA CCNE Compliance Verification Review Process and Suggested Evidence '215.6 Administration and Organization* (a) The controlling agency/ governing institution of a professional nursing school/educational program, not including a diploma program, must be accredited by an agency recognized by the Texas Higher Education Coordinating Board (THECB) or hold a certificate of authority from the THECB under provisions leading to accreditation of the institution in due course. (b) There shall be an organizational chart which demonstrates the relationship of the professional prelicensure nursing educational program to the controlling agency/governing institution, and indicates lines of responsibility and authority. -Validate recognition of accreditation status by THECB -Review organizational charts -Catalog statements -Documents confirming accreditation by an agency recognized by THECB -Organizational chart of governing institution -Organizational chart of nursing program -Minutes of meetings Procedures p. 1: CCNE is designed to evaluate and make judgments about the quality of baccalaureate and graduate degree programs in nursing located in colleges and universities that are accredited by an institutional (regional or national) accrediting agency recognized by the U.S. Secretary of Education. For new applicants, the written application must include evidence that the parent institution is accredited by an institutional accrediting agency recognized by the U.S. Secretary of Education (Procedures, p. 5). -Evidence of accreditation per statements -Reports submitted to and official correspondence received from applicable accrediting and regulatory agencies (c) In colleges and universities, the nursing educational program shall have comparable status with other academic units within the controlling agency/governing institution in such areas as budgetary authority, rank, promotion, tenure, leave, benefits and professional development. -Compare budgets and faculty policies of other institutional units with nursing program -Interviews during survey visit -College or university policies for: faculty appointment, academic rank, promotion & tenure, if applicable, leave and benefits, and professional II-F (Institutional Commitment and Resources): The parent institution and program provide and support an environment that encourages faculty teaching, scholarship, service, and practice in keeping with the mission, goals, and expected faculty outcomes. I-C (Mission and Governance): Expected faculty outcomes in teaching, scholarship, service, and practice are -Nursing unit budget for the current and previous 2 fiscal years -Policies regarding workload for teaching assignments -Mission, goals, and expected student and faculty outcomes -Appointment, promotion, and tenure 8

development. -Governing Institution=s Faculty Handbook -Budget -Comparison of nursing faculty FTE to other college faculty -Teaching Assignments congruent with the mission, goals, and expected student outcomes. Expected faculty outcomes are congruent with those of the parent institution. policies or other documents defining faculty expectations -Major institutional and nursing unit reports and records for past 3 years, such as strategic planning documents -Catalogs, faculty handbooks, personnel manuals (d) Salaries shall be adequate to recruit, employ, and retain sufficient qualified faculty members with graduate preparation and expertise necessary for students to meet program goals. -Review budgets -Verify number and length of unfilled positions and faculty turnover rates. -Faculty Salary Schedule/Scales -Faculty Personnel files -Teaching Assignments II-A (Institutional Commitment and Resources): Fiscal and physical resources are sufficient to enable the program to fulfill its mission, goals, and expected outcomes. Adequacy of resources is reviewed periodically and resources are modified as needed. Compensation of nursing unit personnel supports recruitment and retention of qualified faculty and staff. -Nursing unit budget for the current and previous 2 fiscal years (e) The controlling agency/governing institution shall provide financial support and resources needed to operate a nursing educational program which meets the legal and educational requirements of the Board and fosters achievement of program goals. The financial resources shall support adequate educational facilities, equipment and qualified administrative and instructional personnel. -Compare institutional policies with nursing policies -Review budget -Interviews during survey visit -Teaching observations -Tour of facility during survey visit -Institutional/nursing unit strategic plans or equivalent -Budgets -Description and observation of resources -Blueprints/capital planning if changes planned -Grants II-A and II F (Institutional Commitment and Resources) above II-A: Fiscal and physical resources are sufficient to enable the program to fulfill its mission, goals, and expected outcomes. Adequacy of resources is reviewed periodically and resources are modified as needed II-F: The parent institution and program provide and support an environment that encourages faculty teaching, scholarship, service, and practice in keeping with the mission, goals, and expected faculty outcomes. II-B. Academic support services are sufficient to ensure quality and are evaluated on a regular basis to meet program and student needs. -Nursing unit budget for the current and previous 2 fiscal years -Physical space -Equipment and supplies -Salaries -Support services: library, technology, distance education support, research support, admission, advising services (f) Each professional nursing educational program shall be administered by a qualified -Review of director file in BON program records II-C (Institutional Commitment and Resources): The chief nurse administrator: is a registered nurse, 9

individual who is accountable for the planning, implementation and evaluation of the professional nursing educational program. The dean or director shall: (1) hold a current license or privilege to practice as a registered nurse in the State of Texas; (2) hold a master=s degree or a doctorate in nursing; (3) hold a doctoral degree, if administering a baccalaureate or master=s degree program; (4) have a minimum of three years teaching experience in a professional nursing educational program; and (5) have demonstrated knowledge, skills and abilities in administration within a professional nursing educational program. (6) not carry a teaching load of more than three clock hours per week if required to teach. -Review director=s job/position description -Review director=s FTE dedicated to the program that the director is administratively responsible for and is indicated in the job description -Review director=s teaching load -Review director=s portfolio See BON Education Guidelines 3.4.1.a., Approval Process for Appointment of a New Dean, Director or Coordinator of a Nursing Educational Program, and 3.4.1.b., Dean, Director, and Coordinator Role and Responsibilities -Faculty Personnel files -Official transcripts -Documentation of verification of licensure -Approval letter from BON (if appointed after 9/1999) -Director=s job/position description -Director=s FTE dedicated to the program that the director is administratively responsible for and is indicated in the job description -Director=s teaching load -Director=s portfolio holds a graduate degree in nursing; is academically and experientially qualified to accomplish the mission, goals, and expected student and faculty outcomes; is vested with the administrative authority to accomplish the mission, goals, and expected student and faculty outcomes; and provides effective leadership to the nurse unit in achieving its mission, goals, and expected student and faculty outcomes. The program provides a rationale if the chief nurse administrator does not hold a graduate degree in nursing. (Comment: In addition, the BON rules require that the program director have a minimum of three years teaching experience in a professional nursing educational program. There is a rapid turnover rate among program directors in Texas and the importance of a level of experience for new directors has been validated in practice. The differences in qualifications between the BON and CCNE, the importance of updating program contact information promptly, and the difficulty of monitoring changes in directors at a national level provide the rationale for the Texas BON to retain purview over this section of Rule 215.) -Name, title, educational degrees with area of specialization, certification, relevant work experience, and teaching responsibilities of administrative officer associated with the nursing unit -Curricula vitae of the chief nurse administrator (g)(4) In a fully approved professional nursing educational program, if the individual to be appointed as dean/director or interim dean/director does not meet the requirements for dean/director as specified in subsection (f) of this section, the administration is permitted to petition for a waiver of the Board's requirements, -Review of dean/director information in BON program records -Review BON correspondence See BON Education Guideline 3.4.1.c., Approval Process for Waiver of a New Dean, Director or Coordinator Required Qualifications II-C (Institutional Commitment and Resources): The program provides a rationale if the chief nurse administrator does not hold a graduate degree in nursing. (Comment: BON rules allow for programs to petition for a waiver of qualifications, though this is 10

according to Board guidelines, prior to the appointment of said individual. *Programs not exempt from Rule 215.6 -Faculty Personnel files -Official transcripts -Documentation of verification of licensure -Approval letter from BON (if appointed after 9/1999) -Job/position description -Portfolio discouraged. The most common requests are to waive the doctorate for the director of a BSN program or to waive the 3 years of teaching experience. These requests are handled on an individual basis and must be presented to the Board.) 11

TBON Chapter 215. Professional Nurse Education PERTINENT STANDARD/CRITERIA TBON Compliance Verification Review Process and Suggested Evidence Applicable CCNE Standards for Accreditation of Baccalaureate and Graduate Nursing Programs (with Comments) PERTINENT STANDARD/CRITERIA CCNE Compliance Verification Review Process and Suggested Evidence '215.7 Faculty (a) There shall be written personnel policies for nursing faculty that are in keeping with accepted educational standards and are consistent with those of the controlling agency/governing institution. (1) Nursing policies which differ from those of the controlling agency/governing institution shall be consistent with nursing unit mission and goals (philosophy and outcomes). (2) Written policies concerning workload for the dean or director shall allow for sufficient time for administrative responsibilities consistent with 215.6 of this chapter (relating to Administration and Organization). (3) Faculty policies shall include, but not be limited to: qualifications, responsibilities, performance evaluation criteria, and terms of employment. (4) Written policies for nursing faculty workload shall allow sufficient time for faculty to accomplish those activities related to the teaching-learning process. (5) Position descriptions for the dean/director and nursing faculty outlining their responsibilities -Review faculty handbook, by-laws and policies -Review teaching assignments and workload of faculty and director -Review utilization of faculty extenders -Review faculty personnel files, including evaluations -Review budgets See BON Education Guideline 3.5.2.a., Faculty Policies -College and/or nursing faculty handbook -Workload policies of faculty and director -By-laws -Job /position descriptions -Records of workload assignments, teaching assignments, or the equivalent for current and past two years -Minutes relevant and other written records -Faculty personnel files, including evaluations -Summaries of evaluations -Performance appraisals -Assessment of faculty development needs and faculty development plan Budget/funding allocation for faculty I-F (Mission and Governance): Academic policies of the parent institution and the nursing program are congruent. These policies support achievement of the mission, goals, and expected student outcomes. The policies are fair, equitable, and published and are reviewed and revised as necessary to foster recruitment, admission, retention, and progression. II-F (Institutional Commitment and Resources): The parent institution and program provide and support an environment that encourages faculty teaching, scholarship, service, and practice in keeping with the mission, goals, and expected faculty outcomes. Institutional support is available to promote faculty outcomes congruent with defined expectations of the faculty role and in support of the mission, goals, and expected student outcomes. Faculty have opportunities for ongoing development in pedagogy. -Mission, goals, and expected student and faculty outcomes. -Appointment, promotion, and tenure policies or other documents defining faculty expectations. -Catalogs, faculty handbooks, personnel manuals, or equivalent information.. -Evidence of opportunity for faculty scholarship, research, practice 12

directed related to the nursing program shall be included in the nursing faculty handbook. (6) Written policies for nursing faculty members shall include: (A) Orientation of new nursing faculty members shall be initiated at the onset of employment. (B) A plan for nursing faculty development shall be offered to encourage and assist faculty members to meet the nursing program s needs as well as individual faculty members professional development needs. (C) A variety of means shall be used to evaluate faculty performance such as self, student, peer and administrative evaluation. development & policies for allocation of funds -Faculty policies, including college/university policies related to orientation, development, evaluation, promotion, and tenure as applicable -Orientation plans/schedules -Faculty handbook/manual (b) A professional nursing educational program shall employ sufficient faculty members with graduate preparation and expertise necessary to enable the students to meet the program goals. The number of faculty members shall be determined by such factors as: (1) The number and level of students enrolled; (2) The curriculum plan; (3) Activities and responsibilities required of faculty; (4) The number and geographic locations of affiliating agencies and clinical practice settings; and (5) The level of care and acuity of clients. -Review current faculty list and credentials BReview faculty personnel files during survey visit -Review clinical rotation schedules and rosters -Current BON Faculty Profile -Current assignments for usage of clinical teaching assistants and preceptors -Current enrollment statistics -Current affiliate agency list -Class rosters -Clinical rotation schedules and rosters -Advisor assignments II (Institutional Commitment and Resources): The faculty, as a resource of the program, enables the achievement of the mission, goals, and expected aggregate student outcomes. II-D (Institutional Commitment and Resources): Faculty members are: Sufficient in number to accomplish the mission, goals, and expected student and faculty outcomes; Academically prepared for the areas in which they teach; and Experientially prepared for the areas in which they teach. The mix of full-time and part-time faculty is appropriate to achieve the mission, goals, and expected student and faculty outcomes. Faculty-to-student ratios ensure adequate supervision and evaluation and meet or exceed the 13

requirements of regulatory agencies and professional nursing standards and guidelines. (c) Faculty Qualifications and Responsibilities (1) Documentation of faculty qualifications shall be included in the official files of the programs. (2) Each nurse faculty member shall: (A) Hold a current license or privilege to practice as a registered nurse in the State of Texas; (B) Show evidence of teaching abilities and maintaining current knowledge, clinical expertise, and safety in subject area of teaching responsibility; (C) Hold a master=s degree or doctorate degree, preferably in nursing. (D) A nurse faculty member holding a master=s degree or a doctorate degree in a discipline other than nursing shall hold a bachelor=s degree in nursing from an approved or accredited baccalaureate program in nursing; and (I) if teaching in a diploma or associate degree nursing program, shall have at least six graduate semester hours in nursing appropriate to assigned teaching responsibilities, or (ii) if teaching in a baccalaureate level program, shall have at least 12 graduate semester hours in nursing appropriate to assigned teaching responsibilities. -Review faculty information in BON program records -Review faculty personnel records during survey visit -For each faculty member: Transcripts, Curriculum Vitae, Job Description, Licensure verification, performance evaluation, continuing education records. -Personnel Files II-D (Institutional Commitment and Resources): Faculty are academically prepared for the areas in which they teach. Academic preparation of faculty includes degree specialization, specialty coursework, or other preparation sufficient to address the major concepts included in courses they teach. Faculty teaching in the nursing program have a graduate degree. The program provides a rationale for the use of any faculty who do not have a graduate degree. Faculty who are nurses hold current RN licensure. Faculty teaching in clinical/practicum courses are experienced in the clinical area of the course and maintain clinical expertise. -Name, title, educational degrees with area of specialization, certification, relevant work experience, and teaching responsibilities of each faculty member -Curricula vitae of the faculty -Policies regarding workload or teaching assignments (d) Faculty Waivers. (Comment: The Texas BON has a 14

(1) In fully approved programs, if an individual to be appointed as faculty member does not meet the requirements for faculty as specified in subsection (c) of this section, the dean or director is permitted to waive the Board's requirements, if the program and prospective faculty member meet the following criteria and after notification to the Board of the intent to waive the Board's faculty requirements for a temporary time period not to exceed one year: -Review faculty information in BON program records -Review faculty personnel records during survey visit -Review BON correspondence See BON Education Guideline 3.5.1.a., Approval Process for Faculty Waivers and Extension of Faculty Waivers -Copies of notification forms/letter to Board regarding faculty waivers -Records of workload assignments, teaching assignments, or the equivalent for current and past two years -Faculty Personnel Files -BON correspondence process whereby faculty who meet certain criteria may be waived by the director. In emergency situations, the petition for waiver may be submitted for Board action.) CCNE permits a program to provide a rationale for the use of any faculty who does not have a graduate degree. (e) Non-nursing faculty are exempt from meeting the faculty qualifications as long as the teaching assignments are not nursing content or clinical nursing courses. -Review faculty information in BON program records -Review faculty personnel records during survey visit -Records of workload assignments, teaching assignments, or the equivalent for current and past two years -Faculty Personnel Files CCNE requires an RN license for faculty who are nurses (II-D). (f) All nursing faculty, as well as non-nursing faculty, who teach nonclinical nursing courses that are part of the nursing curriculum, e.g., biological, physical, social, behavioral and nursing sciences, including pathophysiology, pharmacology, research, nutrition, human growth and development, management, and statistics, shall have sufficient graduate level educational preparation verified by -Review faculty information in BON program records -Review faculty personnel records during survey visit -Review teaching/course assignments -Transcripts -Job descriptions -Continuing education records See above. (Comment: Texas BON rules allow the program director to decide whether non-nursing faculty meet the intent of the rules for faculty qualifications.) 15

the program dean or director as appropriate to these areas of responsibility. (g) Non-nursing faculty assigned to teach didactic nursing content shall be required to co-teach with nursing faculty in order to meet nursing course objectives. -Review faculty information in BON program records -Review faculty personnel records during survey visit -Review teaching/course assignments (Comment: Texas BON rules require that only faculty who are nurses teach nursing content and/or nursing objectives.) -Records of workload assignments, teaching assignments or equivalent for current and past two years. -Faculty assignment which reflects evidence of co-teachers/instructors (h) Teaching assignments shall be commensurate with the faculty member=s education and experience in nursing. -Review faculty information in BON program records -Review faculty personnel records during survey visit -Review teaching/course assignments -Faculty Profile -Records of workload assignments, teaching assignments, or the equivalent for current and past two years II-D (Institutional Commitment and Resources): Faculty members are academically and experientially prepared for the areas in which they teach. Academic preparation of faculty includes degree specialization, specialty coursework, or other preparation sufficient to address the major concepts included in courses they teach. Faculty teaching in clinical/practicum courses are experienced in the clinical area of the course and maintain clinical expertise. -Curriculum vitae for faculty. (i) Faculty shall be responsible for: (1) supervision of students in clinical learning experiences; (2) all initial nursing procedures in the clinical area and ascertain that the student is competent before allowing the student to perform an actual nursing procedure independently; (3) developing, implementing, and -Review faculty policies & procedures/bylaws -Review Faculty Handbook Interviews with faculty -Faculty policies & procedures/bylaws -Faculty Handbook III-F (Curriculum and Teaching-Learning Practices): Individual student performance is evaluated by the faculty and reflects achievement of expected individual student learning outcomes. Evaluation policies and procedures for individual student performance are defined and consistently applied. ultimately faculty are responsible for evaluation of individual student learning -Course syllabi -Examples of student work -Student performance evaluations -Course/faculty evaluations 16

evaluating curriculum; and (4) participating in the development, implementation, and enforcement of standards/policies for admission, progression, probation, and dismissal of students, and participation in academic guidance and counseling. outcomes. (j) Teaching activities shall be coordinated among full-time faculty, part-time faculty, clinical preceptors and clinical teaching assistants. -Review course schedules -Review faculty workload -Minutes of faculty meetings -Teaching assignments II-D (Institutional Commitment and Resources): The mix of full-time and part-time faculty is appropriate to achieve the mission, goals, and expected student and faculty outcomes. (n) Faculty Organization: (1) the faculty shall be organized with written policies and procedures and/or bylaws to guide the faculty and program=s activities, including processes for enforcement of written student policies. (2) The faculty shall meet regularly and function in such a manner that all members participate in planning, implementing and evaluating the nursing program. Such participation includes, but is not limited to the initiation and/or change in program policies, personnel policies, curriculum, utilization of affiliating agencies, and program evaluation. (A) Committees necessary to carry out the functions of the program shall be established with duties and membership of each committee clearly defined in writing. (B) Minutes of faculty organization and meetings shall document the reasons for actions and the decisions of the faculty and shall be -Review faculty policies & procedures/bylaws -Review Faculty Handbook -Review program/committee minutes -Review Total Program Evaluation Plan with data and supporting documentation See BON Education Guideline 3.5.2.a., Faculty Policies -Faculty policies and bylaws -Minutes and other written records -Total Program Evaluation with data and indicating decision-making based upon data I-D (Mission and Governance): Faculty and students participate in program governance. I-F: Nursing faculty are involved in the development, review, and revision of academic program policies. I-G: There are established policies by which the nursing unit defines and reviews formal complaints. -Appointment, promotion, and tenure policies or other documents defining faculty expectations. -Documents that reflect decisionmaking (e.g., minutes, memoranda, reports). -Academic policies, faculty handbooks, personnel manuals 17

available for reference. (C) Part-time faculty may participate in all aspects of the program. Clear lines of communication of program policies, objectives and evaluative criteria shall be included in policies for parttime faculty. 18

TBON Chapter 215. Professional Nurse Education PERTINENT STANDARD/CRITERIA TBON Compliance Verification Review Process and Suggested Evidence Applicable CCNE Standards for Accreditation of Baccalaureate and Graduate Nursing Programs (with Comments) PERTINENT STANDARD/CRITERIA CCNE Compliance Verification Review Process and Suggested Evidence '215.8 Students* (a) ) The number of students admitted to the program shall be determined by the number of qualified faculty, adequate educational facilities and resources, and the availability of appropriate clinical learning experiences for students -Review admission/selection process -Review clinical rotation schedules with student placements included -Review class rosters -Review faculty assignments -Review list of faculty extenders -Review preceptor and clinical teaching assistants policies See BON Education Guideline 3.6.1.a., Criteria for Determining Student Enrollment II-B (Institutional Commitment and Resources): Academic support services are sufficient to ensure quality and are evaluated on a regular basis to meet program and student needs. Academic support services (e.g., library, technology, distance education support, research support, admission, and advising services) are adequate for students and faculty to meet program requirements and to achieve the mission, goals, and expected student and faculty outcomes. -Documents that reflect decision-making (e.g., minutes, memoranda, reports). -Faculty Profile -Faculty personnel files -Enrollment data -Class rosters -Clinical group assignments -Evaluations of clinical learning sites -List of preceptors and clinical teaching assistants -Preceptor and clinical teaching assistant policies (b) Individuals enrolled in approved professional nursing educational programs preparing students for initial licensure shall be provided verbal and written information regarding conditions that may disqualify graduates from licensure -Review Student Handbook -Review student records -Review Receipt of BON Eligibility Information form -Interviews during survey visits (Comment: -Requirements are essential to ensure students are knowledgeable about eligibility to qualify to take the licensing examination for a nursing license in Texas. Specific regulations related to licensure, good professional 19

and of their rights to petition the Board for a Declaratory Order of Eligibility. Required eligibility information includes: (1) Texas Occupations Code 301.252, 301.257 and 301.452 301.469; and (2) Sections 213.27 213.30 of this title (relating to Good Professional Character, Licensure of Persons with Criminal Offenses, Criteria and Procedure Regarding Intemperate Use and Lack of Fitness in Eligibility and Disciplinary Matters, Declaratory Order of Eligibility for Licensure). (c) The professional nursing educational program shall maintain written receipt of eligibility notification for up to six months after the enrolled individual completes the nursing educational program or permanently withdraws from the nursing educational program. See Texas Occupations Code 301.252, 301.257 and 301.452-301.469 (NPA) See Rule '213.27-'213.30, Practice and Procedure -Student Handbook -Student records -Receipt of BON Eligibility Information form -Review faculty policies, by-laws -Review Faculty Handbook -Review Student Handbook character, and the Texas Nursing Practice Act are included. Programs must provide evidence that students receive this information. -Accreditation standards do not include, nor are they expected to include, these requirements. -Texas Statute which requires NCLEX applicants to pass a jurisprudence examination based upon Texas law before they are licensed is also specific to Texas.) (d) The program shall have welldefined written nursing student policies based upon statutory and Board requirements, including nursing student admission, dismissal, progression and graduation policies that shall be developed, implemented and enforced. (1) Student policies shall be in accordance with the requirements of applicable federal and state agencies. (2) Nursing student policies which differ from those of the governing institution shall be in writing and shall be made available to faculty -Review Student Handbook -Review program/committee minutes -Interviews during survey visits -Review student records -Review Student Grievance Process and policies -Review articulation agreements -Review official publications describing mobility options -Review catalog -Review Total Program Evaluation Plan with data and supporting documentation Refer to BON Rule Section 213.27-213.30, Practice and Procedure I-F (Mission and Governance): 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. -Mission, goals, and expected student outcomes. -Catalogs, student handbooks, or equivalent information, including academic calendar, recruitment and admission policies, grading policies, and degree completion requirements. -A copy of the institution s policies on transfer of credit, including the criteria used to determine whether credit will be awarded and evidence that the policies are publicly disclosed. -Documents that reflect decision-making (e.g., minutes, memoranda, reports). 20

and students. (e) Reasons for dismissal shall be clearly stated in written nursing student policies (f) Policies shall facilitate mobility/articulation, be consistent with acceptable educational standards, and be available to students and faculty. (g) Student policies shall be furnished manually or electronically to all students at the beginning of the students enrollment in the nursing educational program. (1) The program shall maintain a signed receipt of student policies in all students records. (2) It is the responsibility of the program and the nursing faculty to define and enforce nursing student policies. -Written policies in student/faculty handbooks, catalogs or other publications for: 1. Selection and admission 2. Academic progression 3. Transfer of credit 4. Advanced Placement 5. Retention 6. Graduation 7. Withdrawal/dismissal 8. Readmission to the program -Examples of implementation of policies such as minutes of admission and progression decisions, student retention/attrition rates, records of student appeals. -There are written policies for repetition of a course, clinical safety, dismissal, and due process. -Student records -Student Grievance Process and policies -Formal articulation agreements -Informal articulation agreements -Official publications describing mobility options -Tracking and trending of enrollment, retention, and graduation data for LVNs or RNs -Total Program Evaluation Plan with data and supporting documentation (i) Students shall have mechanisms for input into the development of academic policies and procedures, curriculum planning, and evaluation of teaching effectiveness. -Review Faculty Handbook -Review Student Handbook -Review program/committee minutes -Interviews during survey visits -Review course evaluations and end of course reports -Bylaws -Student Handbook -Minutes that show evidence of student I-D (Mission and Governance): Faculty and students participate in program governance. III-G (Curriculum and Teaching-Learning Practices): Curriculum and teachinglearning practices are evaluated at regularly scheduled intervals to foster ongoing improvement. Data from the evaluation of curriculum and teachinglearning practices are used to foster -Student handbooks, catalogs. -Documents that reflect decision-making (e.g., minutes, memoranda, reports). 21

participation on committees -Faculty Handbook program improvement. (j) Students shall have the opportunity to evaluate faculty, courses, and learning resources and these evaluations shall be documented. -Review faculty policies, by-laws -Review Faculty Handbook -Review Student Handbook -Review program/committee minutes -Interviews during survey visits -Review program/committee minutes -Review student course, faculty, clinical facility evaluations -Review Total Program Evaluation Plan with data and supporting documentation III-G above -Course/faculty evaluations. -Documents that reflect decision-making (e.g., minutes, memoranda, reports). -Evaluation policies to include student ratings of the perceived quality of the following components of instruction: 1. Teaching effectiveness of individual faculty members 2. Individual courses 3. Clinical experiences 4. Learning resources -Evaluation tools -Evaluation databaggregated, tracked, and trended as appropriate -Minutes reflecting discussion and actions based upon student evaluations -Total Program Evaluation Plan with data and supporting documentation *Programs not exempt from Rule 215.8 22

TBON Chapter 215. Professional Nurse Education PERTINENT STANDARD/CRITERIA TBON Compliance Verification Review Process and Suggested Evidence Applicable CCNE Standards for Accreditation of Baccalaureate and Graduate Nursing Programs (with Comments) PERTINENT STANDARD/CRITERIA CCNE Compliance Verification Review Process and Suggested Evidence '215.9 Program of Study* (a) The program of study shall include both didactic and clinical learning experiences and shall be: (1) at least the equivalent of two academic years and shall not exceed four calendar years; (2) planned, implemented, and evaluated by the faculty; (3) based on the philosophy/mission objectives/outcomes; (4) organized logically, sequenced appropriately; (5) based on sound educational principles; (6) designed to prepare graduates to practice according to the Standards of Nursing Practice as set forth in the Board=s Rules and Regulations; (7) designed and implemented to prepare students to demonstrate the Differentiated Essential Competencies (DEC) of Graduates of Texas Nursing Programs Evidenced by Knowledge, Clinical Judgment, and Behaviors: Vocational (VN), Diploma/Associate Degree (Dip/ADN), Baccalaureate (BSN), 2010; and (8) designed to teach students to use a systematic approach to -Review of curriculum, including syllabi -Review of faculty policies, by-laws - Review of Faculty Handbook -Review of Student Handbook -Review of program/committee minutes -Interviews during survey visit -Review of Total Program Evaluation Plan with data and supporting documentation -Review catalog -Review degree plans See Texas Nursing Practice Act See Rule '217.11, Standards of Nursing Practice; Rule '217.12, Unprofessional Conduct. See Rule '224, Rule '225 (Delegation Rules) See ADifferentiated Essential Competencies (DEC) of Graduates of Texas Nursing Programs Evidenced by Knowledge, Clinical Judgment, and Behaviors: Vocational (VN), Diploma/Associate Degree (Dip/ADN), Baccalaureate (BSN), 2010@. -Catalog -Sample degree plans -Policies & procedures III-A (Curriculum and Teaching-Learning Practices): The curriculum is developed, implemented, and revised to reflect clear statements of expected individual student learning outcomes that are congruent with the program s mission, goals, and expected aggregate student outcomes. Curricular objectives (course, unit, and/or level objectives or competencies as identified by the program) provide clear statements of expected individual student learning outcomes. Expected individual student learning outcomes contribute to achievement of the mission, goals, and expected aggregate student outcomes. Teaching-learning practices are congruent with expected individual student learning outcomes and expected aggregate student outcomes. The environment for teaching-learning fosters achievement of expected individual student learning outcomes. III-B (Curriculum and Teaching-Learning Practices): Expected individual student learning outcomes are consistent with the roles for which the program is preparing its graduates. Curricula are developed, implemented, and revised to reflect relevant professional nursing standards and guidelines, which are -Course syllabi -Examples of student work -Student performance evaluations -Documents that reflect decisionmaking (e.g., minutes, memoranda, reports). 23