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For-profit nursing schools often market their programs to people working in low-level jobs, people looking to improve their life circumstances. Many promise a flexible, expedited education and a supportive environment, in which anyone who works hard can succeed.

But too often the schools fail to deliver on those promises. When that happens, students stand to lose tens of thousands of dollars in federal loans, the chance to sit for their nursing licensure exam, and a career many say they felt called to since childhood.

This is the fourth story in our series on for-profit nursing programs. As part of our investigation, MedPage Today spoke with more than a dozen current and former nursing students, as well as academics, nursing professors, and regulators.

"I've never wanted to do anything else in my life other than to be a mother and be a nurse," said Ali McNeill, BSN.

In June 2018, McNeill was living in Phoenix. She had just finished her shift working at a bar and was driving to pick up pet food when she heard an ad on the radio for Aspen University's pre-licensure BSN program.

Tuition was around $45,000, "start to finish," she said -- half the price of nearby Arizona College -- and that was what sold her. McNeill scheduled a tour of the campus for the following day and met with an enrollment advisor.

McNeill, now a nurse at St. Michael's Medical Center in Silver Dale, Washington, took the admissions test -- the Health Education Systems Inc. (HESI) exam -- and failed one section, but passed it on the second try. Applicants could retake the exam a number of times.

She joined the program's first cohort in July 2018, and the first 6 months of weekly seminars and papers were "bliss." But soon everything changed. Faculty became preoccupied with pass rates on the National Council Licensure Examination for Registered Nurses (NCLEX-RN) -- which is required to become a registered nurse in the U.S. and Canada -- and began threatening to dismiss students if they didn't bring up their grades, McNeill said. For nursing programs, low passage rates can lead to disciplinary action, loss of approval, or loss of accreditation. (See For-Profit Virginia Nursing School Shuts Doors Abruptly.)

The school was new and everyone was still "learning the ropes," but McNeill remembered thinking, "I'm paying to learn, not teach myself." Program directors and program rules changed three times in McNeill's 2 years, but she kept her head down. "I just rode it out ... to get that seat for the NCLEX," she said.

McNeill graduated in July 2020 and passed her NCLEX on the first try, but she is one of the more fortunate students.

Problems Surface Early

In November 2017, Aspen received from the Arizona State Board of Nursing to open a nursing program. But not long after the program launched, problems began to surface. Anonymous trickled into the board, presumably from faculty and students.

One complaint characterized the program as devoid of "lecture or guidance," and the program culture as "toxic and punitive," according to a notice from the board.

Another complaint alleged that students had not had any in-person clinical lab experience and weren't expected to have any before April 2021, if at all. suggested the program was shifting from hybrid to fully online without student input.

Since launching Aspen's nursing program in 2018, it "has never achieved the full direct care hours promised in its curriculum plan for any of its cohorts," .

Critically, Aspen's first-time pass rates on the NCLEX plummeted from 80% in 2020 to 58% in 2021, which the board described as "outside of normal program ranges, even for programs experiencing challenges." A in Arizona to maintain program approval.

The Board Investigates

An Arizona State Board of Nursing investigation found that until the summer of 2021, Aspen and discussion questions to assess student learning in most courses. Having five program administrators in less than 4 years also set off alarm bells. Such frequent turnover is believed to be harmful to students, .

The investigation concluded that from 2021 through March 2022, Aspen's "learning opportunities," faculty, resources, "quality of instruction," and infrastructure were "inadequate to support student learning or successful outcomes" under Arizona law, according to a signed by Aspen and the board on March 30, 2022.

Program Placed on Probation, Enrollment Halted

On March 31, 2022, the board revoked the program's provisional approval, driven largely by Aspen's markedly low pass rates -- the lowest of any BSN program in the state.

Importantly, the board stayed its decision, allowing the program to remain open provided that Aspen achieve a minimum first-time NCLEX pass rate of 80% for 2022, among other stipulations. In addition, the board suspended new student enrollments until pass rates improved. Aspen agreed to the terms of its probation -- along with a $4,000 civil penalty -- and signed a .

In September 2022, sensing that it would not meet the 80% requirement, Aspen requested to voluntarily surrender approval of its nursing program, according to , but only after its remaining students had a chance to complete their coursework through a "teach-out." The board accepted Aspen's request and agreed to delay its closure for 2 years, or until all currently enrolled students had completed or left the program, whichever happened first.

But the board included in its agreement an emergency "pull cord" of sorts: a provision stating that if the program failed to provide "minimum instruction and learning opportunities, including clinical opportunities," it or a designee -- after 10 days' notice -- had the right to immediately close the school.

Board Raises New Concerns

In February 2023, the unexpected happened. The board yanked hard on that emergency cord, pointing to a lack of improvement and a number of new complaints it received. Among them was a complaint from a student tasked with washing dishes and wiping down tables at a clinical rotation, who never interacted with an RN preceptor but did interact with a practical nurse.

Another complainant described similar menial work and for the board stating, "I don't feel like I'm safe to practice" and "the only saving grace is that I know that I have no intention to work in a hospital setting." Students also alleged that the program director Norma Gano, MSN, RN, tried to intimidate students from communicating with the board and told them, "

On Feb. 23, 2023 -- during a special meeting the board had called with representatives of Aspen -- Jenny Erkfitz, EdD, MSN, RN, Aspen's BSN program director, and Cheri St. Arnauld, EdD, Aspen University president, defended the program. Erkfitz explained that many Aspen students are the first in their family to attend college, and a number of students suffer from serious test anxiety. She described changes the program had implemented, from improving faculty training to ensuring a broad range of clinical experiences and offering one-on-one NCLEX coaching.

Erkfitz also claimed predictive data from practice exams for the remaining cohorts suggested that students could potentially achieve first-time pass rates "well above" the required 80% threshold for Arizona. Of the 359 licensed Aspen graduates, none had ever had a disciplinary action on their license, Erkfitz and St. Arnauld said. Erkfitz also pointed to the "acute nursing shortage" in the state as one more reason students should be allowed to graduate. "Our remaining 400 students are desperately needed in our profession," Erkfitz said.

At one point in the meeting, Patricia McMullen, JD, CRNP, RN, an independent consultant tasked with reviewing the program, testified that Aspen "has and continues to provide minimum instruction and learning opportunities."

Erkfitz testified to the board that Aspen's NCLEX pass rate "overall for all graduates" was 83% from 2020 to the current day. However, the program's NCLEX pass rate for test-takers on first attempt, as of Feb. 23, 2023, was 52.3%, a board investigator noted. (First-attempt pass rates, which exclude repeat test-takers, are the measure used by most nursing boards.)

Board president Carolyn McCormies, RN, FNP-BC, also pointed out that Aspen's scores "have not improved, and in fact they've consistently decreased as time has gone forward."

The average first-attempt NCLEX score for all 3 years of the program combined -- from Jan. 1, 2020 to Dec. 31, 2022 -- was 63%, one board member noted. Asked about the continued decline, Erkfitz said, "The group who just graduated -- they didn't get the benefit of the full curricular changes."

Board members expressed concerns for both the fate of the students and the safety of the public.

"If the students were unable to pass their NCLEX despite graduating from the program, they could never become licensed, and then would be left with possible student loan debts, but not be able to work as a nurse," a representative for the board told MedPage Today in an email.

During public discussions at the February meeting, board representatives also expressed concern that Aspen University was not properly testing students or providing the minimum required clinical education required of all Arizona nursing programs.

As the meeting drew to a close, the board , with two abstentions, signaling its intent to "potentially lift the stay on the voluntary surrender," which would effectively close the program. The board agreed to meet again after a minimum of 10 days to make a final determination.

When Is a Teach-Out 'Harm Reduction'?

Rachel Burns, PhD, a senior policy analyst for the State Higher Education Executive Officers Association, likens the teach-out process to "harm reduction."

After a closure, fewer than half of students re-enroll, Burns said, citing her research on the . And of those who do re-enroll, only about 30% earn a credential.

For students, it's much easier to have a credential than to have to transfer to another program where their credits may not be accepted, she said.

But encouraging students to complete a program that has "questionable practices" might not be a great option either, if that institution is "just going through the motions and rubber-stamping things."

Eileen Connor, JD, president and director of the Project on Predatory Student Lending, argued that programs in teach-out mode have an already tarnished reputation in their community.

"They're not going to be spending money on equipment...They're not going to retain qualified instructors," Connor said.

"It's almost like the worst of both worlds, because people will be locked into the debt that they had from that program," unlike with a closed program where students can have their loans "wiped out," she said.

With a teach-out, "they're almost guaranteed to be getting an even more substandard program than before," Connor said.

Students Fight Closure

Sarah Adler, an Aspen student, licensed massage therapist, and mother of three, is one of the roughly 400 students who fought to keep the program open. Adler and several other students set up a calling for Aspen's teach-out to continue. It received over 3,500 signatures.

She disagreed with the complaints about clinical experiences she'd read in an affidavit online. Her own clinical rotations included working in a skilled nursing facility, a short-term rehabilitation site, a lock-down unit, and "an actual hospital."

The NCLEX is considered the "gold standard" for determining which graduates are safe to practice as nurses, said Adler. "Why not allow us the opportunity to take the test?"

When Adler spoke with MedPage Today in March 2023, the last cohort was expected to graduate in December 2023. "We just want to finish our path," Adler said.

Meta Mitchell, BSN -- a veteran, mother, and Aspen graduate who now works as an operating room nurse and a circulating charge nurse at Banner University Phoenix Trauma Center -- said Aspen accepted her after she was "devastatingly dropped" from another nursing program only one semester before graduation.

"I had nothing but positive experiences with the program," she said.

An Aspen professor who spoke with MedPage Today on the condition of anonymity said students' lack of interaction with faculty was a problem. The didactic portion of the course was delivered " according to Aspen's own representatives.

As a result, the professor spent much of her time during clinicals and simulations essentially lecturing -- providing the education the students weren't getting online. "You have to be able to critically think and know if somebody's 'circling the drain' in front of you ... You can't learn that from a book," the professor said.

Another former faculty member said they "actually facilitated things that I shouldn't have done" such as pediatric simulations, given they did not have a background in that specialty.

According to Tammy Drewett, RN, MSN-Ed, Aspen's director of clinical simulation from May 2018 to May 2023, staffing "holes" forced faculty to teach some courses they weren't qualified to teach.

Every 2 months there seemed to be 30 more students coming in, but the number of faculty stayed the same, Drewett said. Asked why Aspen never invested in growing its faculty, Drewett said she thinks "they got greedy ... They wanted the money from the students, but they didn't invest the money in making sure that we could provide what they were paying for."

"The students deserved better," she said.

Fighting a 'Hostile' Board

J. Charles "Chuck" Coughlin, a lobbyist with strong government ties, was hired by Aspen CEO Michael Matthews in February 2022, to ensure that Aspen's views were heard by the board.

The nursing program had "deficiencies," he told MedPage Today. But the board appeared "hostile" to Aspen and hadn't given the program "sufficient time" for its changes to take hold. Instead, he said, "they went from 'teach-out' to wanting to close ...wanting to send the 400 students that were still in the program out on the street."

Five days after the Feb. 23, 2023 special meeting, Aspen's lawyers to the board's executive director Joey Ridenour, RN, MN, according to 12News, a local NBC affiliate. The letter argued that terminating the teach-out would "violate" the board's previous agreement and would "cause unnecessary and irreparable harm" to approximately 400 students.

The lawyers cc'd Arizona Gov. Katie Hobbs (D) and several current and former Republican members of the Arizona legislature on the email. A handful of those legislators also sent letters to the board. (Read their letters ).

On March 20, 2023, Aspen filed a complaint against the board and an application for a temporary restraining order with the Superior Court of Maricopa County. Judge John Rea granted Aspen's request the next day in essence, blocking the board from terminating the teach-out immediately.

On March 22, 2023, Gov. Hobbs to Ridenour and the board, urging the board to find "common ground" with the university and reconsider its plans to end the teach-out. According to Coughlin, the pressure from the governor and legislators ultimately caused the board to relent and conclude its teach-out.

The next day, the board and Aspen reached a settlement. According to an , Aspen agreed to dismiss its lawsuit and to retain an education consultant who can confirm that the program's clinical courses meet "minimum standards" and "involve appropriate activities" including "proctored examinations for the remaining courses in the teach-out."

Adler, the now former Aspen student who pushed back against the board, graduated in October 2023, and passed the NCLEX on her first attempt. She was accepted into a new graduate program at Banner Baywood Medical Center in Mesa, Arizona.

Aspen's teach-out was slated to end this month. However, 37 pre-licensure students remain in Florida, Tennessee, and Texas -- states where Aspen also has programs that are in teach-out mode.

On Friday, during another special meeting called by Arizona's board, Aspen representatives said that if the planned surrender of program approval were to occur immediately, an unusual quirk that ties the university's accreditation to Arizona's provisional approval would mean that the institution would lose its accreditation, and its pre-licensure programs in those three other states would not be allowed to operate.

The board ultimately voted 4-3 to postpone the voluntary surrender of approval to Sept. 20, 2024, to allow the remaining students a window for completion.

The university has "no plans to re-enter the pre-licensure business," Matthews said in an email.

Not a Source of Pride

When McNeill began her first job, she requested a month of orientation because she felt so unprepared -- she was given 2 months.

Despite the extra orientation time, she reached out "many times" to friends who graduated from what she considers more reputable nursing schools to ask about lab values or whether two intravenous lines can be run together.

McNeill posted a photo of herself on Facebook wearing her cap and gown, but she blurred out the word "Aspen" on her diploma.

She doesn't want her work colleagues to know she went to school there, she said. "If they're watching the news, they're going to think that I'm not credible."

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