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3 Shelley Conroy, EdD, MS, RN, CNE, is Associate Dean for Graduate Programs and Department Chair, Adult Health and Nursing Systems, School of Nursing, Virginia Commonwealth University.
Conflicts of Interest: None.The views expressed in this article are those of the authors and do not necessarily reflect the official policy or positions of the American Association of Colleges of Nursing
DOI: 10.1016/S2155-8256(22)00009-6 Also available on ScienceDirect Copyright: © 2022 National Council of State Boards of Nursing. Download Full Issue Download started OkIn April 2021, member deans of the American Association of Colleges of Nursing approved new standards for nursing education, with competency-based education as its foundation. The revised Essentials framework includes competencies organized within 10 domains at two levels of nursing education: entry level and advanced level. An advantage of this approach is greater clarity and confirmation regarding the knowledge and skills of nursing school graduates. Implementation of the new Essentials will occur over the next several years, and substantial changes to the curriculum, learning activities, and learner assessment is expected. The revision of the Essentials presents a significant opportunity for regulators to collaborate with schools and practice partners. To that end, this article provides an overview of the newly revised Essentials, discusses considerations and implications for nursing regulation, and puts forth recommendations for boards of nursing.
Healthcare in the 21st century is currently experiencing a major transformation. Numerous trends—including advances in research, informatics, and technology; shifting population demographics; changes in healthcare economics and health policy; addressing healthcare inequities and shifts in healthcare delivery—are contributing to what might be called a healthcare revolution (AACN, 2019). As the largest profession within the healthcare workforce, nurses have an exciting opportunity to lead within this healthcare revolution.
The dramatic changes in healthcare require an expedited response and partnership among nurse educators, regulators, and practitioners to ensure that the nursing workforce is well-prepared for this evolving future. As part of that preparation, academic nursing has an obligation to transform nursing education in alignment with the current and future needs for healthcare. Nursing graduates, armed with a wide range of skills and competencies, are needed now and for the coming years (AACN, 2019).
The educational framework for the preparation of nurses sanctioned by the American Association of Colleges of Nursing (AACN) has been outlined in a series of documents known as the Essentials. First introduced in 1986, the Essentials documents have provided specific guidance to AACN-member schools for the development and revision of nursing curricula at each degree level. Three past versions of the Essentials included The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008), The Essentials of Master’s Education in Nursing (AACN, 2011), and The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006). Given the aforementioned dramatic changes in higher education, learner expectations, and the rapidly evolving healthcare system as outlined in AACN’s Vision for Academic Nursing (2019), new thinking and different approaches to nursing education are needed to prepare the nursing workforce of the future.
In 2018, the AACN formed the Essentials Revision Taskforce and encouraged taskforce members to be bold and to re-envision the Essentials in alignment with the future workforce needs of nurses entering the profession and for those entering advanced nursing practice. The work of the Essentials Taskforce was largely influenced by the AACN’s Vision for Academic Nursing (2019), which recommended, among many things, a shift to competency-based education and a clarification of educational pathways. The Essentials Taskforce, composed of 35 nursing leaders from academia and practice, represented a unique and powerful collaboration. The voice and insights from the practice partners proved to be beneficial and resulted in a robust framing of educational standards. In addition, the task force intentionally sought input from the National Council of State Boards of Nursing (NCSBN) regarding the Next Generation NCLEX to ensure that the planned revisions to the Essentials would align with that work. After a draft of the Essentials was created, AACN sought input from a variety of stakeholders (including NCSBN) through a series of stakeholder meetings.
Approved by AACN member deans on April 6, 2021, The Essentials: Core Competencies for Professional Nursing Education (AACN, 2021) represents not only new educational standards for AACN member schools, but also nursing education transformation. For this reason, an extended transition period (at least 3 years) is planned by AACN to ensure all schools have ample time to adapt and implement the new Essentials into their academic programs. Additional details regarding the timeline for transition are currently being worked out. An Essentials Tool Kit is being developed to provide information, learning resources, and assessment exemplars for programs to facilitate successful implementation.
The purpose of this article is to provide an overview of the newly revised Essentials, to discuss considerations and implications for nursing regulation, and to put forth recommendations for boards of nursing (BONs).
The Essentials: Core Competencies for Professional Nursing Education provides a framework for preparing individuals as members of the nursing discipline, reflecting expectations across the trajectory of nursing education and applied experience (AACN, 2021). As the title of the revised document suggests, one of the major changes to the Essentials is the adoption of a competency-based approach to education. Other major changes include a new framework, a new model, and changes in expectations associated with clinical learning experiences.
Competencies are broad statements that incorporate the essential knowledge, skills, behaviors, and attitudes expected of learners. Competency statements are clearly defined, and students are held accountable for competency achievement. Competency-based education builds competence by providing intentional learning activities involving defined competencies. Frank et al. (2010, p. 641) defined competency-based medical education as “An outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programs, using an organizing framework of competencies.” Similarly, Levine and Patrick (2019, p. 3) described competency-based education as a process whereby students are empowered to make “decisions about their learning experiences, how they will create and apply knowledge, and how they will demonstrate their learning.” In other words, the benefit to a competency-based approach to the revised Essentials is that faculty, students, and employers will have a clear and consistent understanding of what a graduate can do (AACN, 2021).
Competency-based education has become increasingly visible throughout higher education and has been recommended by Lucey (2018) as the desired approach for health professions education. Teaching and learning strategies are aligned with performance expectations that are observable and measurable. This requires the application of student-centered learning, guided practice, and ongoing assessment with feedback, allowing the learner to progress toward competency achievement in a number of situations and contexts (Frank et al., 2010; Iobst et al., 2010; Moreau, 2021). Thus, a key component of the competency-based approach is a robust assessment process whereby learners demonstrate competence in multiple situations and contexts.
Competencies have also been developed by several organizations with specific focuses, including the Quality and Safety Education for Nurses competencies, Interprofessional Education Collaborative Competencies, and nursing informatics competencies, published by the American Nurses Association (ANA; 2014). Competencies are also used to outline the expectations within each of the 18 national standards of practice in the newly revised Nursing: Scope and Standards of Practice (ANA, 2021) and for validation of professional practice skill mastery in nursing professional development (Association for Nursing Professional Development, 2021).
The Essentials framework is comprised of 10 domains and eight core concepts (Table 1) that exemplify nursing as a profession and are understood by other healthcare professionals, employers, learners, faculty, and the public. Competencies are organized within the domains, which are applicable across all areas of healthcare and across diverse patient populations. Concepts core to professional nursing practice are evident across the domains and competencies, reflecting broad application. Integration of concepts ensures their application throughout the educational experience and ultimately in nursing practice.
The domains, concepts, and competencies are identical for both entry and advanced levels of education. However, each competency statement is developmentally based to reflect different expectations for entry- and advanced-level learners through two specific levels of sub-competencies. Collectively, the sub-competencies at each level describe what is needed to attain the parent competency (Figure 2).
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The first-level sub-competencies set the foundation for nurses entering professional practice and are used within curricula for prelicensure preparation leading to the baccalaureate nursing degree (traditional, second-degree) or a master’s entry nursing degree. These entry-level competencies are also used within curricula for upper division degree completion pathways for nurses with initial preparation in associate degree programs. Entry-level professional nursing programs prepare graduates as generalists for practice across the lifespan, with diverse populations, and across practice settings.
All programs offering advanced nursing education will include the advanced sub-competencies within the curricula for programs leading to an advanced role (nurse practitioner, nurse midwife, clinical nurse specialist, or nurse anesthetist) or advanced specialty (nursing administration/practice leadership, informatics, public health/population health, health policy). Regardless of the role or specialty emphasis, the Essentials advanced level sub-competencies represent the foundation for advanced nursing practice. These advanced-level sub-competencies complement and provide a foundation for the additional competencies required for achieving advanced role or advanced specialty practice. In the future it is believed that graduates will communicate their preparation to employers through an electronic portfolio that includes their license, academic degree, competencies achieved, and other stackable credentials (Green et al., 2014). The benefit to employers is greater clarity and confirmation regarding the skills an applicant has when seeking employment.
Clinical learning experiences represent another significant area of change within the revised Essentials. Entry-level nursing education programs will include direct and indirect clinical experiences within four distinct practice areas—referred to as four spheres of care (AACN, 2019; Lipstein, et al., 2016)—which include (a) wellness, disease prevention; (b) regenerative, restorative care; (c) chronic disease management; and (d) hospice and palliative care. Furthermore, all entry-level programs will include a clinical immersion experience that provides an opportunity for concentrated clinical synthesis at some point in the program. No specific hour requirement is set for entry-level programs; however, the clinical experiences must be sufficient so that students can provide clear evidence of competency achievement.
Advanced-level nursing education programs will also have direct and indirect clinical experiences and now incorporate level 2 sub-competencies from the Essentials and advanced role or specialty competencies. Furthermore, it is clear that the time needed to satisfy advanced role or specialty competencies may vary. For this reason, the revised Essentials requires a minimum of 500 practice hours (post–entry-level sub-competency achievement) for demonstration of level 2 sub-competencies. Students will complete additional practice hours, as dictated by certification and/or regulatory bodies. Dictating a specific number of hours is not consistent with competency-based education delivered in a pure sense. However, a time-based requirement is needed until further evidence exists to support reliable assessment and time-variable competency-based education.
The revised Essentials advocates for the use of simulation as a reliable and valid component of clinical education, serving as an augmentation to direct clinical care within healthcare settings. It is recommended that any simulated learning experiences align with standards of best practice for simulation, such as those offered through the International Nursing Association for Clinical Simulation and Learning (2016) to attain quality and measurable learning outcomes. Examples of these standards include simulation design, pre-briefing, debriefing, facilitation, and outcomes, to name a few. The use of simulation as a component of clinical education is determined further by regulatory and certification requirements.
Clearly the new Essentials represent considerable future changes for nursing programs. It would benefit regulators to gain an understanding of the changes and to think about some of the regulatory considerations that may result from these changes, along with the potential for regulatory innovations.
One of the first considerations is alignment between standards and degrees. As described previously, the revised Essentials represents standards for baccalaureate prelicensure education through advanced nursing education at the doctoral level. In contrast, boards use one set of general criteria to regulate prelicensure registered nurse programs that range from diploma, associate degree, baccalaureate degree, and master’s degree (and even some DNP entry options). Some BONs also regulate advanced practice registered nurse (APRN) programs, and statutes for scope of APRN practice vary from state to state. Thus, considerations of a typical BON are broader for prelicensure education (because multiple education paths are represented), and there is variability among the states regarding the agency charged with regulation of APRN education. For this reason, the majority of regulatory considerations address prelicensure nursing programs.
Whereas the nursing education programs belong to the AACN and are guided by the Essentials, the individual state BONs belong to the NCSBN and are guided by NCSBN’s Model Rules (2021). Specific to the regulation of nursing programs, the Model Rules outlines general criteria for prelicensure registered nurse education curriculum. For example, the criterion in section 6.1.2.a. states:
Curriculum shall include experiences that promote clinical judgment; skill in clinical management, supervision and delegation; interprofessional collaboration; quality and safety; and navigation and understanding of health care systems (NCSBN, 2021, p. 14).
Another example, criterion 6.1.2.a.2.iii, relative to coursework, states:Didactic content including prevention of illness and the promotion, restoration and maintenance of health in patients across the lifespan and from diverse cultural, ethnic, social and economic backgrounds (NCSBN, 2021, p. 14).
As can be seen, there is a close alignment of the domains and concepts from the Essentials with the examples provided. However, the Model Rules also states that the purpose and outcomes of the nursing education program must be consistent with the rules, regulations, and statutes for each state. Thus, there is variability regarding the prescriptive nature of BONs in regards to curriculum content and delivery method. As one example, many states have a regulation that specifies the number of hours required in specialty and population-focused areas (pediatrics, adult, psychiatric/mental health). In many states, modifications to and updates for such educational rules and regulations is a complex and time-consuming process determined by each state’s statutes. Thus, the process for modifying statutes, rules, and regulations related to nursing education curricula and delivery may become a stumbling block to adopting contemporary education models such as the Essentials.
Similar variations between state regulations exist regarding clinical education. The Essentials has framed clinical education around the concepts of Spheres of Care and Lifespan, with direct and indirect care experiences. Specifically, the Essentials requires that students engage in direct care learning activities in all four spheres of care and across the lifespan. The number of hours is not dictated in the Essentials; rather, students must demonstrate evidence of consistent competency achievement over time. Another requirement specifically mentioned in the Essentials is an immersion experience at some point in the program (typically at the end of the program), where competency attainment can be observed in practice.
As a comparison, the NCSBN Model Rules (2021) specify the inclusion of lifespan (not spheres of care) in didactic and clinical experiences and specify medical/surgical, obstetrics, pediatrics, psychiatric/mental health, and community health content and clinical experiences (6.1.2.a.2.iii). Some individual BONs specify the number of clinical hours, how hours are counted, and what students are doing (direct and indirect patient care experiences) during the documented clinical hours. Also, some BONs mandate a specific minimum number of direct patient care clinical hours in designated population groups (pediatrics, as an example). In such cases, nursing programs will have to navigate the BON requirement (a specific number of direct clinical hours for each population group) and the Essentials requirement (clinical experiences in each sphere of care, across the lifespan). This can become especially challenging in an era in which clinical placements have become increasingly competitive. Even if the AACN sets minimum clinical hour requirements for prelicensure education, educators and regulators may still be required to base the hours on regulations within the state.
The incorporation of simulation is another component of clinical education that has important regulatory considerations. The Essentials does not specify a recommended number or percent of clinical hours for simulation, but it acknowledges the NCSBN study that concluded that substituting up to half of traditional clinical hours with simulation experiences produces comparable end-of-program educational outcomes (Haydon, et al., 2014). The use of simulation to validate competency attainment is a sound assessment methodology. Debriefing has been found to facilitate individual learner clinical judgment and competency development (Wallace & Moughrabi, 2016; Johnston, et al., 2018). The AACN recommends that additional evaluation or research is needed on the appropriate uses of simulation for learning and assessment. Despite the findings presented in the NCSBN study, some BONs have specific regulations related to the total number of clinical hours within simulation learning environments that can be substituted for traditional clinical hours. Considering the expectations noted in the Essentials to incorporate clinical education within spheres of care and across the lifespan, limiting the number of clinical hours that can be gained through simulation experiences may make achieving these requirements more challenging for some programs. Again, the process for modifying statutes, rules, and regulations may delay or prevent some nursing education programs from adopting the Essentials clinical recommendations.
One of the most notable changes to the Essentials, as noted above, is the move toward competency-based education. The hallmark of competency-based education is an emphasis on the attainment of competencies—and that competency attainment is the focal point of outcome assessment, irrespective of the time needed to achieve the competency (Lucey, 2018; Oandasan et al., 2020). However, a time-variable approach associated with competency-based education does not align well with the long-standing paradigm in higher education as it relates to how academic credits are determined. A competency-based approach also does not align with long-standing regulatory requirements by BONs regarding the number of direct clinical hours required for graduates of prelicensure and APRN programs (AACN, 2019). The Essentials does not recommend transitioning to or implementing time-variable education at this time. The next steps include validating the competencies and developing valid and reliable assessment methods to ensure competency attainment.
The new model for nursing education described in the revised Essentials (Level 1 for entry into professional practice and Level 2 for advanced nursing education) addresses inconsistencies that currently exist regarding a degree earned and the actual experience of graduate-prepared nurses. With this new model, future nursing faculty, at a minimum, will be prepared in a specialty area or advanced practice clinical focus area associated with advanced nursing education (Level 2). It is recommended that all nurses in an academic role obtain additional education (through professional development or certificate programs, as examples) to obtain the skills needed to teach. Regulators will continue to confirm that faculty have the appropriate clinical and educational background to teach in the areas they have been assigned. The change for determining qualifications for future faculty will be documenting the attainment of a graduate nursing degree, which requires attainment of Level 2 competencies within a specialty practice area.
Existing faculty (particularly those involved in clinical education) will need extensive faculty development in competency-based assessment. It is recommended that faculty development activities consider a longitudinal and multimodal approach for optimal outcomes (Sirianni et al., 2020). Nursing schools will also need to develop or acquire evaluation tools that are valid and reliable for observational assessment.
AACN member schools are on the cusp of introducing widespread reform of academic nursing through the implementation of the Essentials. The Essentials represents the future of nursing education—and it incorporates many features associated with contemporary health professions education. There is an opportunity for nursing regulation to partner with education and practice to transform nursing education.
Each BON should conduct a critical review and assessment of regulations for nursing programs to ensure relevancy to the current and future delivery of nursing education. They should also explore opportunities to promote less prescriptive paradigms along with ways to modify regulation to ensure program innovation and flexibility while maintaining quality and public protection measures. In addition, NCSBN should consider incorporating the four spheres of healthcare within the practice analysis to reflect a balanced representation of nursing practice, which would enable BONS to incorporate the four spheres of healthcare and increase flexibility in regulatory language related to older educational models. Furthermore, nursing programs should be given the authority to provide attestation of clinical and subject-specific hours met (as opposed to a dependence on transcript review). Programs will still need to be accountable to demonstrate how hours are met, but, more importantly, a shift to competency-attainment should be considered for future regulatory language. The partnerships between nursing programs and BONs will be essential, but these are not the only two parties with vested interests.
When considering changes to laws and regulations for the purpose of better alignment with the Essentials, BONs’ processes for change should be well informed by stakeholder involvement. Stakeholders include representatives of faculty and leadership from a variety of models of nursing education programs, practice partners from various settings, and leaders from the related accrediting bodies. Intentional education and involvement of professional associations and legislators is also necessary throughout the process to build a strong coalition and to avoid obstacles to adoption of new requirements that will modernize curricula. Consideration should also be given to the economic impact of any proposed changes as well as to the potential for disadvantaging a certain group or population. Whether a regulatory or statutory change is necessary, BONS will need to be prepared to address these factors as they relate to programs, individual students, and the community at large.
By design, the plan of study in most prelicensure nursing programs follows a predictable sequence, with most students progressing in a cohort model. As a result, BONs tend to use students’ success in a course as an indicator of successful academic progression and student outcomes. The new Essentials, however, will require schools to adopt strategies to measure student outcomes (through competencies), and these will be subsequently tied to program outcomes. It would be very helpful for BONs to gain an understanding of new assessment models that will be developed to measure competency achievement. Documentation of students’ achievement of program outcomes through a robust competency assessment platform will be linked to domains, concepts, and competencies within and across courses and settings (spheres of care). Thus, the program assessment plan and student progression indicators used by schools will look different than in the past. In other words, competency attainment is not assessed by checking off specific course and hour completion. There is an opportunity for regulators to consider alternative ways to evaluate and verify program compliance and also to adopt a wider view, recognizing the ability to gain competency achievement in other ways than direct patient care in a patient setting.
All nursing regulators will need to become familiar with the revised Essentials and the AACN Toolkit (accessible at https://www.aacnnursing.org/AACN-Essentials) because these guidelines will reshape nursing education in AACN member schools. A thorough understanding of these documents will assist BONs in modifying their site visits and records review once the Essentials is implemented. Furthermore, it is recommended that BONs adopt a “joint visit” process to coincide with the school’s nursing accreditation visit (if the BON requires an onsite visit). Of course, nursing program faculty need to articulate where they are with adoption of the Essentials and point to the evidence to support their process. Templates for the survey visit, tools, and processes used by regulators to assess course objectives, outcomes attainment, and tracking of student completion may need to be modified to be congruent with the new Essentials and competency-based education.
One important concern among faculty, administrators, and students with any major changes to program curricula is the effect it will have on the program’s NCLEX-RN pass rates. This concern will likely be amplified in the upcoming years as the Next Generation NCLEX is rolled out. Although it is still in the research and development phase and a specific implementation date has not yet been announced, it could be implemented as early as 2023 (NCSBN, n.d.). From a regulatory standpoint, the revised Essentials seems to better align with the Next Generation NCLEX because of its focus on competencies as opposed to content. Furthermore, competency attainment requires clinical judgment, and the NCSBN Clinical Judgment Measurement Model is the foundational basis for the Next Generation NCLEX. These changes will help bring nursing education’s use of the new Essentials and nursing regulation into closer alignment.
AACN’s new Essentials provides nursing education programs with the competency-based benchmarks needed to ensure consistency and high standards across nursing education programs at the bachelor’s, master’s, and doctoral levels. As this paper outlines, competency-based learning and assessment are gaining traction in higher education, particularly healthcare education, and within professional organizations because this framework requires students to demonstrate their knowledge, clinical judgement, and skills to advance. Therefore, the changes to the AACN Essentials have implications for BONs.
AACN’s new Essentials dovetail nicely with the Next Generation NCLEX. As these parts come together, there is an opportunity for greater engagement between nursing schools, practice, and BONs. These three entities are like a three-legged stool; each depends on the others to support the nursing profession. Nursing education must respond to the rapid changes in healthcare and changing population demographics, and it will be critical for BONs to find the right balance of regulation to protect the public without inhibiting needed changes in education. The concept of right-touch regulation—where the level of regulation is proportionate to the level of risk to the public—certainly applies here. Right-touch regulation also includes agility so that regulation can be agile and responsive to needed change (Professional Standards Authority, 2015).
The adoption of competency-based assessment will dramatically change the way nursing education programs assess achievement of student outcomes. BONs will need to understand how programs have incorporated the Essentials into the curriculum and how programs demonstrate and track student progression and program outcomes. Specifically, schools will need to create a process to document students’ competency attainment over time as well as showing a link to progression within the program. A shared understanding among schools and BONs will be helpful when preparing for and conducting site visits.
Nursing regulators have a vested interest in remaining current and relevant to the changes occurring in education and practice, and they too should be included in partnerships with education and practice. BONs have an opportunity, if not an obligation, to become more engaged in the transformation or our profession—the future of our profession depends on it.
