I would ask that regulation 18VAC90-27-60 regarding faculty qualifications for BSN programs be considered for revision. Each member of the faculty must hold a graduate degree, yet there is no consideration for the specific requirements for clinical faculty.

Given the shortage of nursing faculty and nurses in the Commonwealth, it is difficult to find potential nursing faculty who either have or are willing to pursue a graduate degree. The regulations currently allow preceptors to hold a BSN. However, they do not allow for nurses to become clinical faculty who hold a BSN and have multiple years' experience in the specialty. These highly skilled BSN-prepared nurses would make ideal candidates for clinical faculty positions to educate nursing students in the clinical setting and can be provided training through an onboarding process with the university. 

There is a clear deficit in availability of clinical sites, clinical faculty, and preceptors for clinical instruction.  When at clinical, the sites are short staffed and it is difficult for the sites to offer a great experience to the students with their staffing issues: including high turnover, high ratio of inexperienced nursing staff, and inexperienced nurses serving in charge and leadership roles.

The evidence states that up to 50% of clinical hours is appropriate for use in nursing education.  There have been several studies that indicate the positive benefits of simulation and improved critical thinking and judgment when using clinical simulation.  Please consider increasing the hours allowed for simulation in clinical instruction in order to not only address the shortage of clinical sites, but also improve student and patient outcomes. 

https://www.wolterskluwer.com/en/expert-insights/up-to-50-of-clinical-hours-can-be-replaced-by-simulations

Clarity and allowance of preceptors (who may not have masters degrees) for community health experiences is critically needed. Wonderful clinical experiences in the community are not able to accommodate normal sized clinical groups of 6 - 8. With proposed future practice delivery changes supported by the National Academies, it is critical that we prepare our graduates to be competent and confident to practice in community settings. Rural areas and specifically my region of SWVA are designated HPSA areas where nurses can make a real positive impact. Both our BSN and MSN programs have a special emphasis on rural practice.

I would like to ask that regulation 18VAC90-27-60 regarding faculty qualifications for BSN programs be considered for revision specific to clinical faculty. 

With the current state of nursing, it is extremely difficult to find Master's prepared nurses who can function as clinical faculty. Those who do have a Master's degree are typically in a nurse practitioner role and either do not have the time to do a clinical rotation (due to working Monday-Friday at their NP job) or can only do a clinical rotation on a Saturday or Sunday (which is still not appealing to them due to most already working 5 days a week at their NP job). 

By current standards, it is allowed for a Preceptor to be BSN prepared. There are extraordinary nurses who have worked multiple years in the acute care setting and are BSN prepared. These nurses would make great candidates as clinical instructors as they are actively working in acute care settings and have a schedule that would allow the flexibility to work a day as a clinical instructor. We know there is a nursing shortage AND a nursing faculty shortage. We need to be innovative in our approach for nursing clinicals - but a large barrier to that is requiring the clinical instructors to be MSN prepared. Let's work towards a solution that can move Virginia forward in regards to nursing education!

Revision of 18VAC90-17-60 faculty qualification for BSN programs. To allow clinical faculty to hold a BSN degree and not a MSN. 

I work with numerous bedside nurses who hold a BSN degree who would make excellent clinical faculty. These nurses hold both the experience and expertise to supervise and teach in the clinical setting and can be overseen by the course faculty who holds the MSN degree. A BSN prepared nurse is allowed in the preceptor role, so can this be revised to allow a BSN prepared nurse to be clinical faculty. This revision would help with the nursing faculty shortage we are currently seeing.

With the difficulty in placing students in quality clinical rotations, and based upon research showing the value of positive simulation experiences, I would like there to be consideration of increasing the hours allowed for simulation as clinical instruction. Even an increase from 25% to 33% would be helpful and has the potential to increase the quality of clinical experiences for students. 

Rural community colleges are struggling with clinical placements in general and especially in specialty units.  We are land locked and what clinical placements we can find are struggling with low census, staffing issues, high turnover rates, inexperienced nurses, and poor learning environments for students.  We are also struggling with the continued problem of finding qualified clinical faculty as many schools across the state are.  With the known benefits of simulation and the ability to provide students with robust controlled learning opportunities, please reconsider the 50% cap on simulation hours.  Especially the piece that that states "if the courses are integrated, simulation shall not be used for more than 50% of the total hours in different clinical specialties and population groups across the life span".  As many of us rural colleges are desperately struggling to find specialty placements and it would be very helpful if we could supplement more than 50% of the hours with simulation in these specialty areas. 

Students can be given more learning opportunities and the ability to utilize critical thinking skills in a safe environment that they cannot do in a live patient situation.  It allows students to learn through making mistakes and interacting with peers through collaboration. 

Thanks for your time and consideration.

Please consider using second time NCLEX PN pass rates as part of program viability.

We are hearing from students that they are using the "first" attempt just to see what NCLEX PN looks like. Every student is given and the websites reviewed for NCLEX testing but we are still hearing this statement.

Often, test anxiety is lessened on the second attempt.

Students who go on to pass on second attempt are licensed. and working. Why would a second attempt not be considered for the program?

Lena Whisenhunt

In SW VA, the access to healthcare facilities outside VA is vital. Students are actually closer to TN or KY hospitals/facilities than Virginia facilities in certain counties such as Lee, Dickenson, Buchanan.

It is getting harder to find clinical placements and with the limited resources in our area - TN or KY placements just make sense.

Please consider modifying the current 50 mile rule and the percentage in VA clinical locations.

The members of the Virginia Association of Colleges of Nursing (VACN) request that the Virginia Board of Nursing clarify the Regulations for Nursing Education Programs, Section 18VAC90-27-110 to promote best practices for public health nursing clinical education.

The recently rescinded Guidance Document #90-21 (February 2017), in particular sections 2 and 3 of the Exceptions to Direct, On-Site Supervision in Nursing Education Programs (heretofore called “Exceptions”) aligned with the National Academies of Sciences, Engineering, and Medicine Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (NASEM, 2020) and the World Health Organization Framework for Community Health Nursing Education (WHO, 2010). Without these exceptions, the regulations overly restrict education in a greatly needed area of healthcare and will discourage students from pursuing careers in public health nursing.

The NASEM Future of Nursing report highlights the nursing role in promoting health equity through recognition and action against systemic inequities and structural racism in society that impact public health. To achieve this, nursing education must provide students with a broad range of substantive experiences such as in schools, homes, workplaces, homeless shelters, and public health clinics. Further, students must engage in an equally broad range of exposures to community health systems such as identification of community health resources, assessment of community conditions and risks to health, design and implementation of public health interventions, and evaluation of local policies and laws on community health (WHO, 2010). Congruently, the 2021 AACN Essentials emphasize diversity, equity, and inclusion and are centered on four spheres of care, one of which is disease prevention and health promotion (AACN, 2021). The Essentials state that “the workforce of the future needs to attract and retain registered nurses who choose to practice in diverse settings, including community settings to sustain the nation’s health (AACN, 2021, p. 8). Rethinking the role of nurses in public health and promoting primary care as a career choice for new graduates will require creativity, community engagement, and a plan for broad, interesting, and impactful experiences for students.

Currently, BON regulation 18VAC90-27-110: Clinical practice of students restricts best (and needed) practices for public health nursing education in two ways. First, as defined in 18VAC90-27-10 (p.4), the current definition of direct client care is incongruent with the American Nurse Association Scope and Standards of Practice for Public Health Nursing (2013). Systematic needs assessments are in line with the Scope and Standards of public health nursing practice, are promoted by the Council of Public Health Nursing Organizations (CPHNO) as a core competency and are important clinical learning experiences to develop the skillset as a critical first step to identify health disparities and promote health equity. Realignment of the BON regulations with standards of practice for public health nursing is urgently needed.

Second, section F.1 states “The faculty member shall be on site in the clinical setting solely to supervise students.” This generates confusion for community/public health nursing where “clinical settings” include public school systems, public housing developments, and workplaces. Faculty members are “on site” in that they are present within the clinical setting but, given that students are distributed in different areas of the clinical setting, faculty members are not directly supervising the actions of all students during the clinical day. Clarification of these issues as they apply to community/public health nursing education is necessary so that exposures to a broad array of diverse and substantive community health issues are possible and standards of practice can be achieved.

We urge the BON to support public health nursing education by providing freedom to teach students in a way that engages their intellect and desire to address health equity. This is a very exciting time for public health nursing—long awaited and greatly needed. Thank you for considering clarification of the regulations so that they promote clinical exposures for students that highlight the full scope of public health nursing practice now and well into the future.

AACN Essentials (2021). The Essentials: Core Competencies for Professional Nursing Education. Retrieved April 15, 2022 from https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf.

American Nurses Association (2013). Public Health Nursing: Scope and Standards of Practice, 2^nd ed. Silver Spring, Maryland. https://www.nursingworld.org/nurses-books/public-health-nursing--scope--standards-of-practice-2nd-edition/.

National Academies of Sciences, Engineering, and Medicine 2021. The Future of

Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC:

The National Academies Press. https://doi.org/10.17226/25982.

World Health Organization (2010). A framework for community health nursing education. Retrieved November 10, 2022. https://apps.who.int/iris/bitstream/handle/10665/204726/B4816.pdf

There are many bedside staff with good qualifications that do not have a graduate degree. In order to offer the best experience to our students it would be helpful to have an expansion of this regulation. BSN-educated staff are more than capable of providing excellent training under the guidance of the course faculty. 

Please consider incorporating language similar to a previous VBON Guidance Document into general regulations: (Schools need flexibility with community placements and opportunities for student in order to provide the most beneficial learning experiences in preparation for community and population health care).

The exceptions to direct, on-site supervision, are in the following areas:

The clinical experience is a community health experience meeting the following criteria:

• 1. The nursing students have successfully completed foundational nursing concepts, as identified above, and basic medical-surgical nursing concepts prior to being assigned to a community based clinical experience.
  2. There are established clinical objectives and an appropriate orientation to the setting.
  3. The nursing care provided by the nursing student is limited to basic screening and data collection, health teaching, and assisting with low-risk, non-invasive nursing care (height/weight; vital signs, assessments, basic activities of daily living (ADLs).
  4. The nursing faculty member verifies the student???s competency in the care and/or other skills required for the clinical setting prior to the rotation.
  5. The supervising nursing faculty member meets with the nursing students regularly to evaluate their progress toward meeting the objectives.
  6. The supervising nursing faculty member is readily available by telephone to provide direct assistance, supervision, and evaluation as needed during the rotation.

Examples of community health experiences may include, but not limited to: Boys and Girls Club, Home Health, Health Department, Community Services Board, Child Care Centers, and Adult Day Care Centers.These experiences can be counted toward the required supervised direct care clinical hours as defined in 18VAC90-27-100.A.

Randolph-Macon College’s Department of Nursing faculty request revisions to BON regulation 18VAC90-27-110: Clinical practice of students as it relates to public and population health nursing clinical learning experiences. The requirement of direct supervision by faculty severely limits our BSN program’s clinical placement of students in public health and population health clinical experiences.

For example, VDH Chickahominy district is a collaborative clinical agency partner, yet we cannot currently use VDH experiences for direct clinical learning hours due to faculty and space constraints. There are opportunities for small student groups of 2-4 students to provide community-based clinics (BP, foot, refugee) or home visits within their student scope with a faculty available as needed but not directly at each site. These clinical experience opportunities, supporting our local VDH district’s needs and aligning with public health nursing standards, cannot be implemented. These experiences are not feasible financially from a faculty resource perspective or clinically necessary to have a faculty member onsite for this type of community-based clinical placements. This prevents us from using this clinical site and supporting student experiences in public health.

Serving their community is relevant and necessary to building a cadre of BSN-prepared public health nurses in the future and there are numerous opportunities available for which we cannot plan as clinical experiences. It drives our program to an acute care focus for clinical learning which does not best align with our curriculum or the Commonwealth’s nursing professional current and future needs. We request that the regulations be revised to allow flexibility for what counts as direct care hours specifically for community, public, and population health clinical practice to align with the best practices outlined in VACN’s public comment.

Please consider increasing the allowed program simulation for direct client contact hours to 50% of total clinical hours.  The NCSBN's National Simulation Study (Hayden, Smiley, Alexander, Kardong-Edgren & Jeffries, 2014) found no significant differences regarding knowledge acquisition and clinical performance when traditional clinical experiences were substituted with up to 50% simulation.  Clinical site availability and preceptorship opportunities have become more restrictive.  Increasing the use of simulation, delivered by qualified nursing faculty with meaningful debriefing can provide control of the content of clinical experiences and enhance student clinical judgment skills.  Currently, 27 of the 50 states permit 50% or greater of total nursing program clinical hours to be delivered through simulation.  The NCLEX results of the vast majority of these 27 states support the delivery of this level of simulation in lieu of a traditional clinical experience.  

Clinical instruction for the baccalaureate degree nursing programs is best delivered by faculty who are clinically current and either recently or actively working in a direct care setting.  The exclusion of BSN prepared nurses to serve in this role severely limits the quantity and often quality of available clinical faculty.  The number of graduate degree prepared faculty to deliver bed-side clinical instruction is low as these individuals are often not in direct care roles.  The restrictive nature of excluding outstanding nurses holding a BSN from delivering clinical instruction is hindering nursing education.  The need to incorporate well-qualified BSN nurses in clinical instruction is critical to providing rich clinical experiences and ensuring an adequate number of graduates to address the nursing shortage.

Exceptions to direct, on-site supervision in nursing education programs-community, public & population health.

Please consider incorporating language similar to a previous Virginia BON guidance document into general regulations. Flexibility with community, public, and population health placements allow programs to seek beneficial learning opportunities for students. We request that the regulation be revised to allow for what counts as direct clinical hours specifically for community, public and population health clinical practice to align with the best practices as noted by other commenters.

We would request that regulation 18VAC90-27-60 regarding faculty qualifications are considered specifically for clinical faculty. There is still a critical shortage across the country and the Commonwealth. This shortage as well as the impact of the COVID-19 pandemic, has directly affected many nurses who have taught as clinical instructors in our programs in the past. It is difficult to find potential clinical faculty who have  graduate degrees and can teach part-time in the clinical setting. There are highly experienced and skilled BSN-prepared nurses who would be excellent clinical faculty while they are also actively practicing in the acute care settings.

With my background in Mental health nursing and teaching psychiatric nursing and community health nursing, I can attest that having staff at those outpatient sites usually did not have a graduate degree. This placed additional stress on finding students varied clinical experiences.  I believe that in today’s health care needs focusing on outpatient rehabilitation, for psychiatric needs and community health needs,  it will be critical for us to consider how to maximize the best clinical rotations in mental and community health nursing when the facilities does not always have graduate nurses to precept the BSN students. 

I agree with others who have commented on the value in augmenting that clinical faculty can hold a BSN degree since some of them have been working in their specialty or clinical area  for a period of time. 

Simulation experiences have been cited as a means to improve students’ abilities to think critically, make appropriate clinical decisions, and communicate effectively with patients, peers, and interprofessional colleagues within a complex healthcare system (Pagano, O’Shea, & McIlowie, 2021). Each academic year the number of available clinical sites is decreasing. We are finding that OB/Peds clinical sites are at a premium. To that end, I would like to request consideration be given to increase the minimum allowable simulation for direct client clinical hours to 50%.