Welcome to our special issue on diversity, equity, and inclusion (DEI). The focus on DEI leads us to question some of our longstanding practices in nursing education and administration, why we do them, and the need for change. One specific practice that warrants consideration and review has to do with progression policies in our nursing programs. A significant number of prelicensure nursing students are known to repeat courses (Lewis et al., 2022).
As experienced educators, we have seen many nursing students, especially in the first semester, struggle to achieve expected course and program outcomes. Many of these students are first-generation college students or transfer students who may lack exposure to experiences and access to services. The transition from the prerequisite courses typical of the first two years of study to more rigorous nursing courses can come as a shock to many students. Nursing students who struggle are often affected by structures and systems that discourage or make academic progression difficult and unforgiving. What can educators do to facilitate the transition to professional education for students who struggle? What is our responsibility? What is just and fair?
Students have some control over their ability to develop the necessary skills for success. Development of study habits, time management, prioritization, readiness for professional course work, professionalism, honesty, and integrity are either inherent or can be developed. Some things, however, are decidedly not in a student's control: being a first-generation college student, racism, sexual orientation, gender identity, a history of family trauma, challenges with mental health, death of a loved one, financial hardship, food insecurity, and housing difficulties.
Administrators and educators have the power and influence to implement opportunities that are just and fair for students who struggle to demonstrate competencies. Academic progression policies are under our control. Traditionally, most schools follow the "two course failures you are out of the nursing program" policy. Some dismiss students after one failure (Lewis et al., 2022). There is literature that describes students' feelings and experiences about course failure and program dismissal (Lewis, 2018), but there is little data to quantify types of dismissal policies in academia. Lewis et al. (2022) reported that 64 percent of nursing programs surveyed allowed students to repeat a course once before being dismissed from the program. One course failure! Are we losing students who, with additional support and guidance, could be successful? Are we losing the students we are actively recruiting to better represent the profession and the people we care for? It appears that we are. So, what can be done?
MOVING FORWARD WITH PROGRESSIVE POLICIES
The typical nursing curriculum is sequenced to facilitate scaffolded student learning and the development of cumulative knowledge and clinical reasoning skills. Students must demonstrate competency before progressing in a nursing program. Instead of dismissing a student who has failed two or more courses in a semester, might the student (and the profession) be better served by offering the student the opportunity to repeat the semester in which the failures occurred? Adopting a policy where two failures of the same course or two semester failures result in dismissal from the nursing program would ensure the integrity of the program.
Understandably, this raises concerns about the potential financial, emotional, and psychological effects of such a policy. Repeating courses may put financial pressure on students and families. Financial aid may be impacted. University graduation metrics may be impacted. Students may be subject to stigma associated with failing a semester. These are obstacles that must be considered when developing progression policies.
We also must ask, what support services are in place to support students repeating a semester? It can be argued that dismissing a student from the program for course failure disproportionally affects students who have been traditionally underrepresented in nursing and who come to us with a lack of resources. We would be better served as a profession to intervene in ways that demonstrate compassion and justice. Recognizing that standards are in place to protect the public and ensure competent, safe, knowledgeable, and ethical practice, we could move forward with more progressive progression policies that allow for the development of competencies for professional practice. Part of those competencies would be to demonstrate proficiency of leveled courses. These are courses that are grouped together by their level of competency and typically offered together in a semester (or quarter). Failure of two or more courses within a single level would lead to failure of that level (semester or quarter) because the competencies are tied together.
A policy that would allow a student to continue after a course failure by repeating the semester in which the course failure occurred may better prepare the student for future success in the nursing program and offer an opportunity for progression. This option may be better than removing the student from the program. Of course, multiple opportunities to repeat semesters are not optimal nor should be encouraged. There is a need for gatekeeping in nursing programs. The unique responsibilities and safe practice required of nurses mean that we have a responsibility to identify students who do not meet program outcomes despite efforts to remediate. We encourage educators with an interest in progression polices to design studies that capture the effects of progression pathways in their nursing programs.
IMPLICATIONS OF MAINTAINING THE STATUS QUO
By diversifying nursing education and updating progression policies, health inequities may dissipate as cultural humility, inclusive language, and the how and why are taught to educators and students within health care majors. When educators embrace the understanding of differences that vary in people groups and teach differences as normal human variations within the Homo sapiens species, both health care students and the patients they care for will be less likely to experience racism and discrimination in health care (American Nurses Association, 2022). We're thinking, for example, of dietary and religious practices, body image norms, differences in hair and skin care, linguistics, and other differences.
In maintaining the status quo, persons with disabilities and persons who look and socially behave differently than what academic systems perceive as the norm will succumb to programmatic failure because of presumptions of academic and clinical professionals. Of course, students should not be allowed to progress academically when they are unable to demonstrate competency in the skills necessary for the provision of safe and quality health care or if they are unable to meet grade expectations. However, when students experience racism, discrimination, or bias surrounding faculty and administrative expectations of low-quality work and academic performance because of linguistics, race, racism, gender, socioeconomic status, sex, disability, and religious beliefs, there is no future for nursing. Seemingly, the profession has remained the same. Hence, health inequity is sustained because there is no equity in the academic training of future nurse professionals.
When educating our faculty, students, and administrators, it is important that we move to an upstream perspective that focuses on systems and structures, policy and politics, historical drivers of disparities, and structural racism as root causes of inequities. One step in improving equity and justice in nursing programs is updating our progression policies to consider the variations in students' lived experiences and the impact those experiences may have on progression.
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