Regulation of pre-licensure registered nurse (RN) education aims to protect the public and assure quality education. How and if such regulation occurs varies considerably around the globe (Benton, Fernández-Fernández, González-Jurado, & Beneit-Montesinos, 2015; McCarthy, 2012; McKimm et al., 2012). Published arguments report negative consequences associated with professional licensure and regulation; however, these arguments generally are supported using non-nursing examples (Kleiner, 2006; Young, 1987). Leaders in nursing regulation have indicated broad negative assumptions about licensure may not apply to nursing and have expressed a need to explore and adapt to emerging regulatory trends (Benton, 2017; National Council of State Boards of Nursing [NCSBN], 2018a]). To support or refute the value of regulation, inform policy decisions, and counter potential threats of deregulation, nurse regulators and other nurse leaders need published evidence summarizing reported outcomes of regulation of nursing education, which this review intended to provide. A scoping review was determined to be the appropriate methodology to generate a broad overview of this topic and unearth existing evidence.
Review Objective and Question
The objective of this scoping review was to examine and map existing information regarding outcomes of regulation of pre-licensure RN education, identify gaps, and inform opportunities for future research. This review intended to answer the question: What outcomes have been reported about the regulation of pre-licensure RN education?
Inclusion and Exclusion Criteria
This scoping review considered all studies and papers focused on pre-licensure education programs that prepare nursing students to become RNs, pre-licensure RN students, or pre-licensure graduates of RN programs in any country or countries. The concept examined was any reported outcome of regulations or regulatory activities concerning nursing education. Regulations and regulatory activities included government regulation, accreditation, and regulatory requirements for initial licensure that may relate to nursing education.
The following types of studies and papers were considered: quantitative designs, qualitative designs, economic evaluations, and textual evidence. Papers needed to be available to the reviewers and in the English language. Papers were excluded if the exclusive focus was education of midwives or if opinion literature expressed brief, unsubstantiated comments. Historical literature was excluded if outdated and contemporarily irrelevant. Technical reports, bulletins, news articles, and newsletters were not considered.
Methods
The Joanna Briggs Institute (JBI) methodology for scoping reviews was employed (Peters et al., 2017). Objectives, inclusion criteria, and methods were specified a priori and documented in a protocol. A three-step search strategy was undertaken to find published and unpublished papers. Step one was a limited search of CINAHL Complete and MEDLINE using keywords “Nurse,” “Education,” Licensure,” “Accreditation,” and “Regulation,” with text word analysis of titles and abstracts. Step two was a comprehensive search across all included databases. Step three was a search of reference lists of included papers. The first author did an initial review and excluded clearly irrelevant papers. All remaining papers were reviewed independently by two reviewers. Disagreements were resolved with discussion. Relevant data were extracted, mapped and detailed in a table, which included author(s), publication year, aim or purpose, methodology, reported outcomes, and synthesized recommendations.
Results
Ultimately, 20 papers met inclusion criteria (Al-Gasseer et al., 2003; Aluwihare-Samaranayake, Ogilve, Cummings, & Gellaty, 2017; Armstrong & Rispel, 2015; Blaauw, Ditlopo, & Rispel, 2014; Fealy et al., 2009; Fernandes et al., 2013; Foreman, 2017; Gao, Chan, & Cheng, 2012; Hudspeth, 2012; Kako & Rudge, 2008; McCarthy, 2012; McGillis Hall, Lalonde, & Kashin, 2016; Morgan, 2012; Morin, 2012; Morrison & Benton, 2010; Spector, Hooper, Silvestre, & Qian, 2018; Spitzer & Perrenoud, 2006a, 2006b; Taylor, Loftin, & Reyes, 2014; Xu, 2010). Included papers were published between 2003 and 2018: 19 in professional journals and one as a doctoral dissertation.
Papers addressed concepts around regulation and/or accreditation of pre-licensure RN education programs, regulation affecting pre-licensure graduates of RN education, and impact of regulation on pre-licensure graduates of RN education programs. Regulation of students was not addressed in any paper. Various geographical contexts were represented. In addition to papers with an international perspective, specific counties and regions discussed included several African nations, Western European countries, Australia, Bahrain, Brazil, Canada, the People’s Republic of China, the United States, and Sri Lanka. Methodological approaches included case studies, descriptive methods, discourse analysis, literature review, opinion, policy analysis, qualitative approaches, and thematic analyses.
Authors reported a variety of actual or expected outcomes resulting from regulation of nursing education. These outcomes fell into five broad categories: protection of the public, individuals, and the profession; professional status of nursing; meeting health needs; mobility; and standardized testing. Reported outcomes were tabulated and identified as positive, negative or neutral.
Discussion
Findings from this review highlighted considerable variation in how nursing education is regulated across the world. Significant socioeconomic and political differences in nursing education, practice, and regulation from country to country made synthesis of reported information challenging. Despite contextual differences, the majority of authors indicated regulating nursing education generates positive outcomes, specifically in promoting patient safety and protecting nursing students; however, objective evidence to support the view that regulating nursing education protects the public was absent, making the argument that regulating nursing education protects the public vulnerable to criticism.
Reports about other outcomes tended to be mixed. Perspectives about whether regulation of nursing education protects the nursing profession were split, revealing intra-professional discord. To counter this, nursing regulators and educators should work collaboratively to find mutually agreeable solutions aimed at achieving desired outcomes. Additionally, the value of partnering with stakeholders outside of nursing, namely policy makers and leaders in higher education, to advance nursing education is clear, as is the need for strong nursing leadership and political savvy. Opinions also were mixed about whether regulation of education advances the nursing’s professional status. Exemplars demonstrated that regulations can either advance or stifle a profession.
Nurse mobility was reported as either a positive or neutral outcome of educational regulation. The perception was positive when regulations enhanced international mobility of RN program graduates. Conversely, negative outcomes were reported when inequivalent nursing education and subsequent qualifications restricted mobility.
Several authors opined how accreditation and regulation of nursing curricula impacted program graduates’ abilities to meet population and local health needs: Some viewed such regulation as beneficial and others discussed both pros and cons. Measurement and reporting of tangible outcomes are needed to show how well nursing curricula prepare students to meet population health needs, inform how to shape and refine nursing education, and delineate which, if any, associated regulations are beneficial.
Reported outcomes related to standardized testing focused exclusively on the National Council Licensure Examination (NCLEX-RN). Concerns surfaced about using NCLEX-RN as a measure of program quality. Criticisms arose about the NCLEX-RN’s appropriateness to assess competency of Canadian graduate nurses. No reported outcomes associated with graduates who successfully pass the NCLEX-RN on the first attempt were found, casting doubt on the appropriateness of this measure in terms of assessing program quality and protecting the public. Sellman (2016) questioned whether a national licensing exam is necessary at all and argued that successful program completion should be sufficient to earn a nursing license.
Conclusions and Recommendations
This review answered the question: What outcomes have been reported about the regulation of pre-licensure RN education? When reported outcomes were categorized, the most common theme was the expectation that regulating nursing education protects the public, which aligns with statements from the International Council of Nurses (2007), NCSBN (2018b), and WHO (2009). Despite this, none of the included papers presented empirical evidence that regulation of nursing education protects the public. The majority of reported outcomes lacked objectivity, exposing the dearth of published quantifiable outcomes on this topic. The only metrics reported as outcomes of regulation were improved first time NCLEX-RN pass rates from accredited versus non-accredited nursing education programs, and this information was limited to the United States (Spector et al., 2018).
Although most authors postulated that regulating nursing education is beneficial, not all reported outcomes were positive. These mixed perspectives, coupled with identified gaps in the evidence, reinforce Benton et al.’s hypothesis (2017) that persons aiming to support, sustain, or advance regulation of nursing education must be cognizant of which outcomes have been reported and where gaps exist.
Further research and publication related to regulation of prelicensure RN education are needed. Specifically, research is necessary to identify which outcomes are appropriate to measure the impact of regulation of pre-licensure nursing education, clearly define those outcomes, and determine appropriate measurement methodologies. Economic evaluation is advised (Gao et al., 2011). Comparative research between countries also is recommended (Xu, 2010). This should be a call to action for the nursing profession.
Acknowledgements
The authors would like to acknowledge the expertise of David Benton, PhD, RGN, FRCN, FAAN; Robin Christian, DNP, FNP-C; and Dru Riddle, PhD, DNP, CRNA in critiquing this proposal; and Alysha Sapp, MLIS, BA for guiding the search strategy.
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