Peer Reviewed Nursing and Health Care Journal

Research Article

Self Quality Audit Report of Nursing Department College of Health Science, Mizan-Tepi University

Sisay Shewasinad*, Melak Menberu, Kebadnew Mulatu, Habtamu Acho, Wendesen Niguse and Alemayehu Sayih

Mizan-Tepi University, Ethiopia

Submission: October 05, 2017; Published: November 30, 2017

*Corresponding author: Sisay Shewasinad, Lecturer, Mizan-Tepi University, Ethiopia, Email: sisyehu@gmail.com

How to cite this article: Sisay S, Melak M, Kebadnew M, Habtamu A, Wendesen N ,et al. Self Quality Audit Report of Nursing Department College of Health Science, Mizan-Tepi University. JOJ Nurse Health Care. 2017; 5(4): 555668.DOI:10.19080/JOJNHC.2017.05.555668

Abstract

To obtain quality assurance, an institution should conduct self evaluation for continuing improvement purposes. The purpose of this study is to investigate the implementation of Self Evaluation in quality assurance at a higher education institution. This paper looks at the effectiveness of self evaluation implementation at Mizan Tepi University College of health science, department of nursing as an example for the investigation. The paper, therefore, explores the process and the role of self evaluation in quality assurance at the university.

Data is collected through evaluating quality management documents, observation, and inquiries. Through research, the paper reveals the following contributions on the self evaluation in quality assurance:

1. Supporting university management and promoting quality assurance,

2. Strengthening the idea that "quality assurance is the "king” of a university

3. Improving the process and the role of self evaluation in quality assurance

4. Building campus culture to help people at the university be more involved in conducting self evaluation.

Keywords: Quality assurance; Self evaluation; Internal auditing; Higher education

Introduction

Quality assurance in higher education institution has become an issue of major concern among universities all over the world. Due to the rapid changes in education environment, improvement on the quality retains its high priority the principles program of institution. In Ethiopia, quality assurance has now recently placed on the main agenda as well. In Ethiopia some legal regulations concerning structural and organizational aspects of higher education systems were introduced, The Ethiopian Higher Education Relevance and Quality Agency (HERQA) was established under the higher education proclamation of 351/2003 Ethiopia calendar, and the subsequent 650/2009 Ethiopia calendar amendment, to guide the regulation of quality and relevance of higher education offered by both public and private institutions in Ethiopia. In accordance with its mandate, HERQA has accredited 91 higher education institutions, 43 of which are engaged in providing health programs. HERQA has also conducted spot checks or unannounced supervision visits to ensure that the accredited institutions have maintained the basic quality standards and also support the quality improvement endeavors in each institution.

There are some environment forces imposing the need for quality assurance. These include:

A. The increase of nationally and internationally competition in higher education industry.

B. The rise in public accountability and demand for transparency in the way in which higher education institutions are managed.

C. An increase diverse students population as a result of international program

D. Greater expectation of students as customers.

E. An increase in collaborative provision between institutions.

Some ofthese forces demand that higher education institutions have quality assurance procedures that are transparent to the stakeholders. One of the key elements in implementing quality assurance is self evaluation program. Self evaluation should be conducted systematically, independently and documented to assure that the quality management system comply with the standard that has been established. This report focuses on the experience of Mizan-Tepi University on quality assurance, especially in the implementation of self evaluation at unit and overall organization levels.

For the quality assurance purpose, an organization or institution should implement quality management systems. The quality management system is required when an organizations (a) needs to demonstrate its ability to consistently provide product that meets customer and applicable regulatory requirements, and (b) aims to enhance customer satisfaction through the effective application of the system, including processes for continual improvement of the system.

If an organization claims to have a system for the quality management, the organization should conduct self evaluation process through monitoring, measuring and improving activities. Organization should improve the effectiveness of its quality management system continually. Organization should plan and implement the monitoring, measuring, analyzing and improving activities needed to show product conformity, ensure the compliance of quality management system and continuous improvement on the quality management system. This process should be done in all levels of organization, unit as levels as well organization as a whole.

Self evaluation should be initialized with reporting of any activities in all level of organization. The self evaluation to the process by which an institution review the effectiveness of its quality management system for assuring, developing, and monitoring the quality of organization performance against the established criteria [1]. Self assessment is useful for encouraging fundamental review of objectives, practices and outcomes [2]. In self assessment process, the unit collects and analyzes data on where it is and what it wants to be. The analysis covers the strengths, weaknesses, and the development programs which are prepared to indicate how the unit is going to reach the objectives [3].

The self evaluation has two objectives. Firstly, it should be used as documentation for the final report and its recommendations. Secondly, it should be seen as an inspiration for the evaluated unit or for quality improvement [4] stresses that self assessment in higher education implies two aims: to contribute to higher education quality improvement and provide reliable information about existing higher education quality including studies and research.

Self evaluation process is conducted through monitoring, evaluating and improving activities. Organization should plan and implement monitoring, measuring, analyzing and improving processes needed to show the compliance of quality management system, and to ensure continual improvement. The function of this process occurs in all levels of organization, unit level as well as organization as a whole.

Self evaluation within an organization involves an audit process called as internal quality auditing. Internal quality auditing is required to be a part of management. Purposes that internal auditing is an independent appraisal function established within an organization to examine and evaluate activities as a service to the organization [5].

The objective of internal auditing is to assist organization member at all levels to implement their tasks effectively and efficiently [6]. The objective internal auditing is to assist member of organization in effective discharge of their responsibilities. Internal auditing furnishes them with the analysis, appraisal recommendation, counsel and information concerning the review of the activities.

The role of internal audit fall into two primary categories: assurance service and consulting service. Assurance services involve the internal auditor's objective assessment of evidence to provide an independent opinion or conclusions regarding a process, or system. Consulting services are advisory in nature, and are generally performed at the specific request of the client [7].

In higher education, internal audit aims to provide a mechanism for the identification and transmission of good quality management practice and to assists organization in identifying its strength and weaknesses in their operations. The internal audit process covers the testing and evaluation of internal control in the organization. Internal audit plays an important role in organization for three reasons:

A. To increase efficiency and effectiveness of organization performance.

B. To provide reliable information,

C. To ensure that the organization obeys legal requirement and law.

The actualization of professionalism in audit is shown in professionalism standard of internal audit, which includes: independency, professionalism capability, scope of the job, audit implementation and internal audit management. As every organization is unique, they should have an internal audit report that suits the management needs.

The Quality Assurance at Mizan-Tepi University

Mizan-Tepi University has consistently committed in implementing quality management system. The vision of Mizan- Tepi University is to be widely recognized as a university with high capability of producing professional human resources in their fields, yet always proactively adjust to the fast on-going development of knowledge, technology and arts in international environment.

The missions of Mizan-Tepi University are:

A. Presenting programs, leading to the development and implementation of knowledge, technology and arts.

B. Creating conducive atmosphere to improve the efficacy of teaching-learning process, and research to produce creative and innovative graduates.

C. Promoting relevance and interrelations among all academic activities and ensuring that the school's graduates turn out to be professional with positive attitude.

D. Building partnership with national and international institutions so that the teaching-learning process and its materials are constantly updated.

The Implementation of Self Evaluation at Mizan-Tepi University

Existing internal quality assurance system at Mizan-Tepi University has been functioning according to the implementation and being constantly developed quality management model to integrate the system of quality management of Ethiopia. The functioning is cyclic and its implementation is actualized through self evaluation. Self evaluation process at Mizan-Tepi University is systematic, occurring in a particular cycle: all units, departments assess the previous annual activities according to the forms prepared by Quality assurance directorate of the university. Each area of activity in the form of self analysis is defined according to the certain criteria and indicators that have been established. Study program is the most important and widely analyzed. In this process continual pursuing for quality improvement is considered to be inseparable from the principle of accountability. Every semester the heads of departments present their self analysis must report to their deans and the deans to the university. This process indicates that the study program and the faculty should manage their activities complied with the established objectives and procedures.

At Mizan-Tepi University, self evaluation reports provide a good basis for a review and assessment content characteristics of faculties and for defining activities aimed at achieving improvement. Managers of Mizan-Tepi University are responsible to establish a new approach to management that will enable the organization to maintain and improve its performance in a changing environment. Each member of the organization contributes something different; but should be in line to the University goals.

As self evaluation is conducted at every level, students as the main customers of the university, their opinions concerning teaching and learning process, teaching staff, facilities, department, faculty and overall activity quality are very important. Students' surveys are carried out annually. After the self analysis of activities has been conducted, advantages and weaknesses are revealed, a very important component of internal quality assurance is public presentation through a report of internal audit findings.

Self evaluation at Mizan-Tepi University as a component of internal audit process is based on valid and reliable data collection and analysis. Due to this reason issue of objectivity, openness and analytical approach of self analysis occurred at all levels. The process of continual monitoring and assessment has succeeded in improving a high level of quality assurance awareness at Mizan- Tepi University. Systematic and regular monitoring has facilitated the creation of a quality culture although there are some denials, or resistance from the organization members. According to Sallis (2002), development of quality culture is a long running process and a very difficult task [8].

Internal Quality Audit Process

Internal Quality Audit conducted as a part of self evaluation. The audit process consists of monitoring whether there has been compliance with regards to the core process and quality document. The audit process also examines whether the quality objectives has been achieved and measures taken to ensure continual improvement. "Thorough and independent checking aimed at finding out whether activities and results regarding quality are in accordance with the planned measures and whether these measures are implemented correctly”. The main parties involved in internal quality audit are:

A. Audit team leader/lead auditor- the person responsible for planning and managing audit activity.

B. Auditors- the persons carrying out the audit.

C. Audi tee- the persons, usually managers, responsible for the area or process being audited.

The internal audit process usually consists of 3 stages:

Self evaluation

The first stage of internal audit is self assessment process of the units and the preparation self assessment report. The objectives of self assessment report are: (1) to provide a framework to stimulate internal discussion on the strengths and weaknesses related to the unit. This will provide the basis for further improvement and development of quality assurance system in Mizan-Tepi University (2) to provide the necessary documentation for the work process of the audit.

Site visit

An internal auditor conducts two-days site visit in which the auditor seeks confirmation of the unit performance report, asks for explanation. Based on this visit, the auditor compiles a report with recommendations.

Reporting

The analysis, conclusion and recommendation of the audit are documented in the audit report.

Independence and Competence of Internal Auditor

The audits are performed by Senior academic staff who has taken one day training on self quality auditing. Most of them are lecturers, but quite few come from the management (deans, head of departments). In the present there are 6 internal auditors participated. They have been trained in internal quality audit base on Ethiopia higher education relevance and quality agency standards.

Self-Assessment

Self-assessment also called self-evaluation serves as a tool for improvement and accountability. It is an exercise that Department/institutions should engage in periodically. As it is fairly resource- intensive, it is recommended that it is undertaken biennially. At the opportune time the findings of an immediate exercise of this nature can be used to prepare an institutional portfolio for the purposes of an external quality audit.

Nowadays, it is common practice worldwide to monitor the quality of higher education by two well-known processes, namely quality audit (also known as academic audit) and quality assessment, although different countries have adapted them to suit their specific needs [1].

Quality Audit and Quality Assessment

A quality audit is concerned with the evaluation of the effectiveness of quality assurance system within a department/ institution with a view to establishing:

A. The Department/ institution uses its resources appropriately to uphold its mission and meet its stated objectives and that it will continue to do so in the foreseeable future; and

B. The Department/ institution's ability and effectiveness of providing quality educational experience to its students.

On the other hand, a quality assessment is concerned with assessment of how quality and standards are maintained and enhanced at a programme level. The focus is on curriculum development and teaching and learning. Part of the exercise involves assessment of teaching to determine how well a particular subject is being taught. Hence, it is also known as subject assessment [2]. This set of guidelines is proposed to facilitate Nursing departments to undertake their self- assessments in preparation for a quality audit.

Quality Assurance

For our purposes, quality assurance may be described as a process of systematically and continuously evaluating the provision of education or delivery of a service (teaching and learning, research and Community support services) with the objective of maintaining its specified standard and improving on it. It should be the responsibility of each and every educational institution to see to it that an effective quality assurance system is in place and that planned and regular quality assurance exercises are carried out by competent and responsible people and that all staffs are fully informed and are involved in it. The main processes employed for assuring quality are quality audit, otherwise called academic audit, and quality assessment. It include [3]

A. An outline of the quality assurance system, policy and responsibility

B. Quality assurance in the provision and design of programmes of study

C. Review of established courses and programmes

D. Quality assurance in teaching, learning, research and communications

E. Quality assurance in relation to academic staff-staff appointment procedures, staff development and training, staff appraisal, promotion, evaluation of teaching quality, etc.

F. Quality assurance in relation to assessments

G. Mechanisms for quality assurance in the validation of courses, internal and external to the institution

H. Verification, feedback and enhancement-external examiners, appointment of external examiners, student evaluation of courses and programmes, staff/student liaison committees and views of professional and external bodies

I. Problems identified, actions taken and outcomes

J. Future developments

Quality Assessment

Quality assessment is a process by which an external body independently assesses the quality of teaching/learning and research in a department/ institution. Such an evaluation is judgmental and at the end of the exercise, a department/ institution is deemed to have attained a certain criteria referenced score, which is indicative of its performance. 'Review' and ‘evaluation’ are sometimes used instead of assessment. Quality assessments are usually undertaken on a programme basis and for this reason the alternative term programmatic accreditation is sometimes used [4].

Quality Control

This is a concept which has its origin in industry, but is also used in education although its application is rather limited. In the industrial sector, as a result of mass production, formal procedures had to be set up to ensure that goods met specifications and passed the quality control checks. Those that failed the checks were rejected. Such a system of control is not readily applicable to education. The nearest application of quality control in education and training would be the failing/rejection of students who do not succeed in examinations/assessments. Even here, failure means that the student did not attain the minimum pass marks or did not satisfy the learning outcomes. This brings in the concept of minimum/threshold standard which implies that students who meet the minimum standards are eligible for promotion. Such a notion is contrary to the concept of quality as it usually refers to excellence. However, in reality, the adoption of the "fitness for purpose” means that the minimum standard approach is acceptable. Of course this does not mean that students should be content with satisfying minimum standards only. Again, in practice, the majority of students score average grades, with a minority finding themselves on the lower scale [5].

Quality control is more applicable to design, validation and approval of programmes of study, including assessment schemes. The external examiner system which seeks to establish fairness in the assessments and comparability with other institutions could be considered as a quality control system. Now a days, even in industry, total quality management has replaced quality control [6].

Quality Audit

It is the process by which an independent body assures itself and the stakeholders that an educational institution has adequate and appropriate mechanisms set up to ensure quality of educational provisions. It is not an exercise to determine quality per se. It is therefore concerned with an evaluation of the way in which quality is assured by an institution. Institutional Accreditation is another term used to denote more or less the same thing as an academic audit or quality audit (7).

Purpose of a Quality Audit

Quality assurance agencies and educational authorities in different countries have adopted a more or less common approach to carrying out academic audits. However, they may differ to varying extents on their rationale. In some countries emphasis is on accountability and the audit's outcome has a bearing on funding of the institution concerned. In others, improvement is given prominence. Thus, in our context, an academic audit is undertaken for the following purposes [8]:

A. Assessing the strength of the quality culture;

B. Determining the commitment to continuous improvement;

C. Appraising the systems in place to determine academic standards;

D. Evaluating the systems in place to ensure that measures taken to maintain and enhance quality are appropriate and effective; and

E. Establishing whether the Department is embracing the concept of fitness for purpose as well as fitness of purpose through fulfilling its mission and achieving its objectives in an efficient and effective manner and demonstrating relevance of its undertakings.

Quality of Nursing Education

Introduction

Human resources for health or the health workforce play an important role in the health-care system to achieve health outcomes and health-related GTP. Since the nursing workforce is a major health workforce in many parts Ethiopia, with proper training it could make a significant difference to the health of individuals, families and the community. Nursing educational institutions are in a critical position to produce qualified nurses who acquire the knowledge; skills and attitudes set by the professions and are able to perform their roles as expected by society [9]. A "nurse” is a person who has completed a nursing education programme and is qualified and authorized in her country to practice as a nurse.

At the end of the programme, it is expected that the students should:

A. Acquire knowledge, skills and positive attitudes for the practice of basic nursing

B. Be eligible to sit in the national examination to become a certified nurse/certified;

C. Be able to work as a member of an intra- or interprofessional health team;

D. Be able to provide knowledge-based care for all patients and pregnant women during the antenatal, childbirth and postnatal periods, and for the woman and her newborn, including conducting normal deliveries;

E. Be able to identify illnesses and conditions detrimental to the health of the people/women and/or newborns, carry out first-line management in emergency situations, and arrange for timely referral as needed; and

F. Acquire an attitude of lifelong learning through continuing education and other means.

Nursing Programme/Curriculum

The nursing programme prepares graduates to enter the health-care delivery system at the beginning or practitioner level in structured health-care settings. Nursing is a health-care profession with the goal of assisting clients to achieve a level of wellness through a holistic approach. The development of nursing programmes is based on a body of knowledge where the arts and sciences are integrated.

Nursing programmes seeking accreditation should be designed to incorporate areas of professional activity, core knowledge and professional values underpinning the National Professional Standards Framework from which the accreditation criteria are developed and aligned. The number of staff responsible for delivering the nursing programme and number of support staff involved with the programme, their responsibilities, and brief details of qualifications, experience, research interests and relevant publications must be indicated [10].

Programmes/curricula submitted for accreditation should:

A. Have a clear philosophy, mission, goals and expected outcomes.

B. Be nationally or internationally approved and meet standards.

C. Have appropriate resources.

D. Have a quality assurance system.

Programmes should be designed to cover the six areas of the professional standards framework:

A. Designing and planning of learning activities and/or programmes of study.

B. Teaching and/or supporting student learning.

C. Assessing and giving feedback to learners.

D. Developing effective learning environments and student support and guidance.

E. Integrating scholarship, research and professional activities with teaching and supporting learning.

F. Evaluating practice and continuing professional development.

Standards and Criteria of Nursing Programmes

Standards and criteria are a set of specifications defined by the national nursing organization/council. Such standards and criteria should be adopted by nursing institutions in order to shape the programme, and are required for accreditation, which is based specifically on the ability to meet national standards and criteria. For accreditation, should have the following seven components to ensure that they are able to meet the accreditation requirements [11]:

A. Mission/governance

B. Academic staff or teachers

C. Students

D. Curriculum and instruction

E. Resources

F. Quality assurance system

G. Administration

Quality Assurance System

By and large, a quality assurance system (QAS) refers to a formal managing system used to strengthen the management of routine work in an organization and ensure that everything is done systematically. In the context of nursing and midwifery education, QAS refers to systems management of the daily practices in the nursing and midwifery institution in order to ensure that the institution runs the nursing and midwifery programme according to the standards defined by the national nursing and midwifery organization. The quality of the programme must develop and improve continuously in order to ensure that clients being cared for by nurses/midwives who have graduated from accredited institutions are safe.

The department should establish their own QAS and develop effective teaching processes so that they produce qualified nursing graduates who are able to effectively provide care of the best quality [12].

Standards and Criteria for Nursing

Nursing education within and among countries of the Ethiopia is varied. These variations are seen in the institutions' goals and objectives, curriculum, student admission criteria, faculty qualification, teaching and learning activities, infrastructure and management system. This is due to countries being at different stages of educational development and a lack of implementation national and regional standards for nursing education. Each country is, therefore, encouraged to set its own standards for nursing education or programmes as a basis for its establishment, monitoring, evaluation and improvement.

Five areas specific to the development of global standards for initial nursing education are programme admission criteria, programme development requirements, components of programme content, faculty qualifications and programme graduate characteristics.

The parameters of these standards depend on the country's decision on the key quality components in nursing education. Each standard consists of a statement of a standard and criteria. Evidence to support the criteria has to be clearly identified in order to guide data collection, monitoring and evaluation. To be consistent with quality assurance and accreditation, Nursing department should have standards and criteria for at least seven components as given below [13]:

A. Vision/mission/goal and objectives

B. Organization/administration

C. Academic staff

D. Students

E. Curriculum

F. Resources, and

G. QAS (Quality Assurance System)

Findings of Self Quality of Nursing Department

Standard

There is a clear and publicly stated vision, mission, goal and objectives appropriate to nursing education

Criteria for quality management

Criterion 1: The vision of the Nursing is clearly stated.

Criterion 2: The mission of the Nursing is congruent with the University / institution's regulations or rationale for its establishment.

Criterion 3: The goals and objectives of the Nursing are achieved through activities identified in the University / institutional plan.

Criterion 4: The administrative, academic and support staff understand the vision, mission, goal and objectives of the Nursing.

Examples of Evidence Checked

A. Clearly stated vision, mission, goal and objectives of the Nursing, which are aligned with those of the parent University / institution and institutional regulation.

B. The context in which the programme is offered is explained, including analysis of the demographic and institutional characteristics that influence the mission, vision, goal and expected outcomes of the programme.

C. Strategic plan of the Nursing department.

D. Interviews of administrators and staff on the vision, mission, goal and objectives of the Nursing department.

Gabs Identified During Quality Audit

A. Most Academic and supportive staff did not understand the department mission, vision, goal and objective

B. There is no well organized strategic plan that is based on BSC level up to individual

Organization/administration

Basic standard

There is an administrative structure which has the responsibility for carrying out the policies of the organization in accordance with the vision, mission, goal and objectives of the organization/department.

Criteria for Quality Management

1. Criterion 1: The organo gram, responsibilities and functions of the Nursing unit are clearly written and displayed in an organizational chart.

2. Criterion 2: The Nursing administrator should have a basic educational background in nursing.

3. Criterion3: The Nursing administrator has leadership capability.

4. Criterion 4: The management of the Nursing department is implemented, monitored and evaluated by committees.

5. Criterion 5: The administration of academic work, personnel, budget and finances is in compliance with rules and regulations, announcements, and guidelines issued by the Nursing department.

6. Criterion 6: The administrative staff is adequate and competent in their work.

7. Criterion 7: The general administrative body holds regular meetings, takes minutes, and communicates pertinent information to staff.

Examples of Evidence Checked

A. The department/organizational chart displaying the organizational structure and their relationships.

B. Educational qualifications of the Nursing administrator.

C. Description of the leadership of administrators.

D. Appointment of committees and their functions.

E. Related rules, regulations, announcements and guidelines on administration.

F. Profile of administrative staff and their performance evaluation.

G. Minutes of administrative meetings.

Gabs Identified During Quality Audit

A. There is no organo gram, that indicate the responsibilities and functions of the Nursing unit are clearly written and displayed in an organizational chart

B. The Nursing administrator has no leadership capability building training

C. Rule and regulation not announced to the concerned body

D. Lack of educational qualifications of the Nursing administrator

E. Appointment of committee were without no duty and responsibility

Academic Staff

Basic standard

There is qualified academic staff with credentials that are appropriate for the Nursing and who can strengthen its educational effectiveness [14].

Criteria for quality management

A. Criterion 1: The academic staff has adequate hours of teaching in the classroom and/or clinical settings (suggested time 12 hours/week for lectures or 10 hours/week for practice).

B. Criterion 2: The academic staff develops the syllabus of the course she/he is the chairperson of and a teaching plan for every class.

C. Criterion 3: The academic staff who teaches nursing core courses has an educational background in nursing.

D. Criterion 4: The academic staff conducts research, publishes or gives presentations on their scientific work periodically.

E. Criterion 5: The academic staff updates their knowledge and clinical competence in the area they teach through continuing education.

F. Criterion 6: The ratio of academic staff/preceptors to students is appropriate for classroom, laboratory and clinical teaching (suggested ratio is 1:5 in the clinical setting).

G. Criterion 7: The academic staff is evaluated on their performance every year.

H. Criterion 8: The academic staff receives awards, grants and other forms of recognition.

Examples of Evidence Checked

A. Table/graph of academic staff indicating their educational backgrounds, academic qualifications, teaching responsibilities, number of research projects undertaken/ grants received and continuing education courses attended.

B. The teaching programme for the academic year with hours, names of responsible persons and course syllabus.

C. Teaching plan for each class.

D. Faculty/preceptor-to-student ratio.

E. Research studies, papers published or presentations by academic staff.

F. Rewards and scholarships granted to academic staff.

G. Academic staff's performance assessment forms.

H. Awards, grants or recognition received.

Gabs Identified During Quality Audit

A. The ratio of academic staff/preceptors to students is not appropriate for classroom; laboratory and clinical teaching (suggested ratio is 1:5 in the clinical setting).

B. The teaching staff establishment is not sufficient to deliver the curricula.

C. The teaching staff complement is not suitable for the curricula, in terms of the mix of qualifications and skills, experience, aptitudes, age, status etc.

D. All staff, academic and non-academic, are not given induction, in- service training, consultancy, research and other scholarly activities.

E. The academic staff not receives awards, grants and other forms of recognition.

F. Some academic staff did not develop the syllabus of the course she/he is the chairperson of and a teaching plan for every class.

G. The academic staff has no adequate hours of teaching in the classroom and/or clinical settings (suggested time 12 hours/week for lectures or 10 hours/week for practice).

H. The academic environment, physical and social, is generally not conducive to learning.

I. The physical environment is not adequately maintained in terms of safety, cleanliness, repairs and decor.

Students

Basics standard

The teaching and learning environment is conducive to academic achievement by students [15].

Criteria for quality management

A. Criterion 1: Students are recruited based on a written test.

B. Criterion 2: Student policies of the Nursing are congruent with those of the governing organization and take into account the socio-cultural diversity of the students.

C. Criterion 3: Students have access to support services administered by qualified individuals, which include but are not limited to health, counseling, advice on academics, career placement and financial aid.

D. Criterion 4: Students are supported to develop a student club and engage in extracurricular activities.

E. Criterion 5: The academic adviser arranges time for students to meet her/him and advise them at least once a term.

F. Criterion 6: There are plans for student development.

Examples of Evidence Checked

A. Admission criteria and results of student recruitment.

B. Availability of internal, external rewards/scholarships for excellent students and Dean's list of excellence.

C. Availability of internal and external financial support/ scholarships.

D. Students' alumni and students' organizations.

E. Documentation of graduation rates, licensing pass rates, job placement rates, and other measures of student success, as deemed appropriate by the programme.

Gabs Identified During Quality Audit

1. Some Students have no access to support services (Student advisee) administered by qualified individuals, which include but are not limited to health, counseling, advice on academics, career placement and financial aid.

2. Students are not supported to develop a student club and not engage in extracurricular activities.

Curriculum

Basic standard

The curriculum should accomplish its educational and related purposes.

Criteria for quality management

Criterion 1: The curriculum developed for nursing flows from the vision/philosophy, mission, goal and objectives of the Nursing standards through an organizational framework in a logical progression of course outcomes and learning activities to achieve the desired programme objectives/ outcomes.

Criterion 2: The programme designed provides opportunities for students to achieve programme objectives, competencies and values necessary for nursing practice.

Criterion 3: Practice environments are selected and monitored by the Nursing and provide opportunities for a variety of learning options appropriate for the practice of contemporary nursing.

Examples of Evidence Checked

A. Documentation of curriculum management structure and the sequence used for curriculum formulation.

B. Teaching and learning plans for the entire programme.

C. Documentation of course syllabi and student work.

D. Explanation of how professional nursing standards and guidelines for practice are incorporated into the curriculum.

E. Documentation of ongoing and systematic programme evaluation, survey response and summary of the data.

F. Explanation of how the Nursing staff and students are involved in the evaluation of their individual performance, and how performance evaluation is communicated to the students and used to foster improvement.

G. Documentation of nursing graduates achieving the competencies congruent with professional nursing standards.

H. Documentation of policies regarding the review and maintenance of records of student (dis)satisfaction and complaints.

I. Description/documentation of how the results of comprehensive student performance are analysed and how they are used to change or improve the curriculum.

J. A summary of Nursing education outcomes for the past three years and analysis of the data in relation to expected programme outcomes, and examples of how aggregate data are used for improvement.

K. Examples of how inputs from the community of interest is used in curriculum development and revision.

L. Availability of lesson plans.

Gabs Identified During Quality Audit

A. There is no documentation of ongoing and systematic programme evaluation, survey response and summary of the data.

B. There is no explanation of how the Nursing staff and students are involved in the evaluation of their individual performance, and how performance evaluation is communicated to the students and used to foster improvement.

C. There is no documentation of policies regarding the review and maintenance of records of student (dis)satisfaction and complaints.

D. No examples/evidence of how inputs from the community of interest are used in curriculum development and revision.

E. Most courses have no availability of lesson plans.

F. Curricula aims and objectives are not explicit and known to staff and students.

Resources

Basic standard

Resources are sufficient to fulfill the purposes of the Nursing education standard.

Criteria for quality management

Criterion 1: Fiscal resources are sufficient to support the purposes of the Nursing education and are commensurate with the resources of the governing organization.

Criterion 2: Programme support services and staff are sufficient for the operation of the nursing education unit or institution.

Criterion 3: Teaching/learning resources and staff are comprehensive, current, developed with nursing education input, and accessible to the Nursing department and students.

Criterion 4: Physical facilities including information technology (IT) and the environment are safe, clean and appropriate to support the purposes of the Nursing education standard.

Criterion 5: Clinical resources including hospital and community role models, patient-student ratio, and nursing equipment are appropriate to support the purposes of the Nursing education standard.

Criterion 6: Students are provided opportunities to practice in essential areas.

Examples of Evidence Checked

A. Documentation of the Department/ institutional policies and practices for resource allocation to enable the nursing programme to achieve its mission, goal and expected outcomes.

B. Documentation of how academic support services facilitate the achievement of its mission, vision, goal and expected outcomes.

C. Documentation of how the programme and parent institutions provide resources for the professional growth and development of the Nursing education standard.

D. Programme budget documents for the previous two fiscal and current years.

E. Rationale for the adequacy of the number and qualifications of Nursing staff to accomplish the mission, vision, goal and expected outcomes.

F. Policies and practices regarding teaching assignments and the number and size of classes to support the achievement of the mission, goal and expected outcomes.

G. The contract and policy regarding teaching assignments.

H. Demonstration of IT, computer and programme software, library including textbooks and journals, learning resource centre (LRC) including nursing skills laboratory, audiovisual aids provided for teaching and learning in the Nursing education standard.

I. Demonstration of classrooms, clinical placement both in hospitals and the community, laboratory room, instructors' offices, dormitory, cafeteria provided for teaching and learning in the Nursing education standard.

J. Checklist of students’ clinical performance.

Gabs Identified During Quality Audit

A. Fiscal resources are not sufficient to support the purposes of the Nursing education

B. Programme support services and staff are not sufficient for the operation of the nursing education unit or institution.

C. Physical facilities including information technology (IT) and the environment are not safe, not clean and not appropriate to support the purposes of the Nursing education standard.

D. Classrooms, clinical placement both in hospitals and the community, laboratory room, instructors' offices, dormitory, cafeteria provided for teaching and learning is not in the Nursing education standard.

E. No checklist of students’ clinical performance.

F. No adequate number and qualifications of Nursing staff to accomplish the mission, vision, goal and expected outcomes.

Quality Assurance System

Basic standard

There is an identified plan for systemic quality assurance (QA) and its evaluation.

Criteria for quality management

Criterion 1: There is a written plan for a systematic QA programme for nursing education, which is used for continuous programme evaluation and improvement.

Criterion 2: There is a written plan for systematic evaluation of the programme's purposes and product outcomes.

Criterion 3: A QA committee is appointed, and there is a personnel unit and internal auditing and monitoring control.

Criterion 4: There is documentation of the implementation plan of the QAS.

Examples of Evidence Checked

A. Documentation of the QA policy and its revision.

B. Current self-assessment documents/reports relevant to the programme.

C. Methods used for monitoring, reviewing and evaluating the programme.

D. A brief description of the institution’s staff development policies

E. Documentation of how the policies are currently implemented and how this is reflected in the programme.

F. Documentation of the institution's teaching-learning strategy and guideline or operational plan both in the classroom and for clinical practice.

G. Annual programme reports.

H. Names and positions of external examiners/reviewers, a current external examiner’s/adviser’s report and the response from the programme team.

I. Documentation of arrangements for the pruning of outdated material from the programme and inclusion of future needs.

J. Documentation of the views of any committee(s) which oversees the programme.

Gabs Identified During Quality Audit

A. There is no teaching-learning strategy and guideline or operational plan both in the classroom and for clinical practice.

B. No any committee(s) which oversees the programme.

Guidelines for Action

Self-assessment is a valuable means of identifying whether a department/ institution is adhering to its mission and achieving its objectives. In undertaking this task the team must consider the following [16]:

A. Planning-this must be carried out within the framework of the Department/ institution's principles of self-assessment.

B. Scope of the assessment-who and what are to be assessed.

C. Persons involved in the assessment must be knowledgeable, dedicated and have a thorough understanding of the plan.

D. The assessment should be deductive and not inductive

Auditors

Introduction

In undertaking the task assigned to it, a quality audit panel collectively shoulders a very high responsibility as it has to make a judgments on the department being audited. Such a decision can have an enormous impact, positive or otherwise, on the department as well to the institution. Thus, it is crucial to ensure that the members making up the panel have the right profile, ability and experience to assume such a responsibility. The panel leader plays a critical role in ensuring that the team works as a cohesive unit. Hence, it is equally vital to ensure that the leader is adequately versed in this exercise. The success of a quality audit is dependent to a large extent on the members of the quality audit and the participants during quality audit [16,17]. It is members serving on an audit panel and they are as follows:

1. Sisay Shewasinad: Chairperson quality assurance coordinator at college. Melak Menberu: secretary of quality audit team and who has experience in teaching, research and consultancy;

2. Kebadnew Mulatu: logisticof quality audit team and who has experience in teaching, research and consultancy;

3. Habtamu Acho: members of quality audit team and who has experience in teaching, research and consultancy;

4. Wondowosen Niguse: members of quality audit team and who has experience in teaching, research and consultancy; (Head of nursing department).

5. Alemayehu Sayih: members of quality audit team and who has experience in teaching, research and consultancy

Selection of Auditors

Selection was made from college by taking into consideration seniority and experience, and also bearing in mind that there should be no conflict of interest with the department audit as well the institution to be audited. For the purposes of forward planning, for each interview to be held at least 2/3 of quality audit team should be available [18].

Approval of the Panel Members

This was take place at three levels. In the first instance the college was approved on the basis of recommendation of the department head. Upon the college’s approval, the selected was sent to the quality assurance and relevance directorate, asking them to approve the team of quality audit and finally approved by the university. Once the panel is finalized, the co-ordinator communicates with the institution's QA representative to sort out preliminary arrangements.

Following the audit process: a wealth of information is generated which needs to be sorted out and presented in an appropriate format which is acceptable to the stakeholders within and outside the institution audited. The audit report is the official document describing the outcome of the audit process. It is carefully prepared after thorough checks and cross checks with the auditors to ensure that the statements made in the report accurately reflect the areas that were explored in the audit, the nature of the discussions that ensued and the findings of the audit panel, including possible recommendations [19,20].

Audit process overview

A. Prepare for the audit

B. Perform the audit

C. Report the results

D. Corrective action

Prepare for an Audit

A. Define audit objectives

B. Define audit scope

C. Define audit resources

D. Define audit criteria

E. Prepare and distribute an audit notification to audited

F. Gather and understand relevant documents

G. Prepare work plan i.e. audit plan

Submission of the Audit Report

This document becomes the property of the department as well the institute and is as such intended for the institution audited. However, prior to it submission, it is approved by the college. Thereafter, three copies sent to quality assurance and relevance directorate, one copy is sent to the department audited and at the same time, a copy is sent to each of the panel members. The university has the right to respond to the report. The sector- wide Quality Assurance Committee is apprised of the outcome of the audit.

Appeal

If the team addressed in the audit report feels that the audit report does not accurately reflect the state of affairs in the department, it has the right to appeal. Such an appeal should be made directly to the college and quality assurance and relevance directorate.

Acknowledgement

It is great full to thank the Department of Nursing, College of Health Sciences, Mizan Tepi University Quality assurance and relevance Directorate for allowing us to prepare this self educational quality audit of nursing department. We would like to thank nursing students at different level, academic and supportive staffs of Mizan-Tepi University as well any participant who participate directly or indirectly by giving us necessary data for program level quality audit of nursing department.

Recommendations

Invariably an audit results in recommendations for the purposes of improvements in the services provided by the department as well the institution. The quality assurance unit of the department should see to it that the recommendations have been acted upon appropriately within the time frame. When they have been achieved, a short report describing the outcome of the recommendations is submitted to the college and quality assurance and relevance directorate for its approval following which it is transmitted to the university. The latter will communicate with the university’s quality assurance and relevance directorate to confirm the attainment of the objectives set in the recommendations.

Terms of reference for auditors

A. To make a commitment to act as a quality auditor for the institution identified as per the schedule worked out, participate in the pre-audit workshop and the audit.

B. To act within the scope identified in the Quality Audit Handbook.

C. To be objective at all times, ensuring that they are non- judgmental in their approach; that they are aware of possible personal bias.

D. To observe confidentiality.

E. To give full support to the Chairperson.

F. To work as a team, ensuring that members are working in harmony with a view to accomplishing a fact finding mission grounded on the self-assessment document.

G. To identify good practice as well as unhealthy practice and make necessary recommendations.

H. To ensure that there is agreement among the members on the conclusions of the panel.

I. To fully co-operate in getting the audit report ready within two months of the audit by writing the specific observations made and checking with the Tertiary Education Commission’s Secretariat to see that the report is a true reflection of the panel's findings (Annex 1-3) [21].