2004 Edition Accreditation Manual with Interpretive Guidelines by Program Type for Post Secondary and Higher Degree Programs in Nursing

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2 2004 Edition Accreditation Manual with Interpretive Guidelines by Program Type for Post Secondary and Higher Degree Programs in Nursing A publication of the National League for Nursing Accrediting Commission, Inc. This publication is organized in two sections: the first section contains the accreditation processes and procedures and Commission Policies, and the second section provides guidelines and specific documentation needed to show compliance for each nursing program type. Information provided in this publication is accurate as of August Significant changes occurring between publications are reprinted in electronic media, print media, and on the NLNAC website. NLNAC 61 Broadway-33 rd Floor New York City, NY Phone: Ext.153 Fax: Web site: The trademarks NATIONAL LEAGUE FOR NURSING ACCREDITING COMMISSION and NLNAC are owned by the National League for Nursing, Inc., and are being used pursuant to license. i

3 TABLE OF CONTENTS SECTION I: ACCREDITATION MANUAL I. INTRODUCTION NLNAC Mission Purpose Goals Recognition 2 Benefits of Accreditation Philosophy of Accreditation. 4 History of Nursing Accreditation NLNAC Products and Services Persons Responsible for Accreditation II. THE COMMISSION Overall Structure of the Commission... 9 Board of Commissioners.. 9 Members of the Board of Commissioners 10 NLNAC Organizational Structure III. ACCREDITATION STANDARDS AND CRITERIA FOR ACADEMIC QUALITY OF POSTSECONDARY AND HIGHER DEGREE PROGRAMS IN NURSING NLNAC Definition of Quality.. 12 NLNAC Accreditation Standards. 13 Understanding standards and criteria in the evaluation of nursing education units. 13 Standards and Criteria Planning for Systematic Program Evaluation (SPE) Elements for SPE including Assessment of Student Academic Achievement. 17 IV. ACCREDITATION PROCESSES AND PROCEDURES Planning for Accreditation Initial Accreditation. 18 Continuing Accreditation Accreditation of Programs within Multi-Campus Institution Evaluation Process Staff Consultation Self Study Self Study Report Guidelines for Writing the Self Study Section One: Executive Summary.. 22 Section Two: Standards I - VI and Criteria Section Three: Standard VII and Criterion Educational Effectiveness. 23 Section Four: Appendix Submitting the Self Study Report Formatting the Self-Study Report 24 ii

4 The Site Visit Multiple Nursing Programs Within an Institution Collaborative Visit With Another Accrediting Agency.. 25 Coordinated Visit With Other Agencies Length of Visit Assignment of Site Visit Team Appointment of Team Chairperson Responsibilities of the Team Chairperson Responsibilities of the Team Member Nursing Education Unit Responsibilities 27 Agenda for the Visit Visiting Off-Site Campuses Sample Agenda for Accreditation Visit Visit Arrangements 30 Housing Travel.. 30 Food 30 Fees. 30 The Site Visitors Report.. 31 The Report General Information Site Visit Information Evaluation of Standards and Criteria Staff Review Evaluation Review Panel 32 Assignments of the Evaluation Review Panel Members Conduct of the Meeting Nursing Program Representative Attendance at the ERP Meeting Evaluation Review Panel Procedures 34 Commission.. 35 Time Line for Evaluation Process Program Evaluators Eligibility for Selection as Program Evaluator Site Visitor Evaluation Review Panel Member.. 37 Appeal Panel Member V. GENERAL POLICIES Policy #1: Conflict of Interest Ethical Imperatives Ethical Guidelines Responsibilities of Program Seeking Accreditation Responsibility of Site Visitors, Commissioners and Staff. 40 Actions to be Avoided by Program Evaluators and Commissioners. 40 Confidentiality and Communications.. 41 Disclosure Memorandum 41 Policy # 2: Representation on Evaluation Review Panels and Commission Clinician/Practitioner Representation.. 42 Public Members Policy # 3: Eligibility for Accreditation iii

5 Policy # 4: Types of Commission Actions on Applications for Accreditation Initial Accreditation. 44 Continuing Accreditation 44 Accreditation with Condition or Warning Status Focused Report 45 Policy # 5: Notification of Commission Decisions The Program Other Groups to be Informed 48 Information Provided the Secretary, US Department of Education Policy # 6: Delay/Advancement of Continuing Accreditation Visit or Delay of an Interim Report Policy # 7: Withdrawal Voluntary Withdrawal from NLNAC Accreditation. 50 NLNAC Withdrawal of Accreditation.. 50 Policy # 8: Opportunities for Third Party Comments on Programs Scheduled for Evaluation Policy # 9: Public Disclosure About the Program/School 51 Policy # 10: Appeal Process Decisions Eligible for Appeal Notice of Appeal Appointment of an Appeal Panel Procedures for Governing the Appeal Process Documents for the Hearing The Hearing. 53 The Decision 53 Policy # 11: Public Notice of Proposed Policy Changes. 54 Policy # 12: Records on File 54 VI. MONITORING POLICIES AND PROCEDURES Policy # 13: Interim Report Purpose 55 Review Process Guide for Preparation of Interim Report Organization of the Interim Report Program Actions.. 56 Format. 57 Submission.. 57 Policy # 14: Reporting Changes 57 Substantive Change Change in Ownership Branch Campus Policy # 15: Distance Education Definition of Distance Education Considerations for Implementing Distance Education Policy # 16: Program Closing Closing an Accredited Program.. 62 Preparation of Closing Report Policy # 17: State Board of Nursing Approval Policy # 18: Accreditation Status of the Governing Organization.. 64 Policy # 19: Focused Visit Policy # 20: Complaints Against an Accredited Program Policy # 21: Complaints Against the National League for Nursing Accrediting Commission iv

6 Policy # 22: Program Accreditation Status in Relation to State and Other Accrediting Agency Actions Policy # 23: Public Notice Of Proposed New Or Revised Standards and Criteria.. 69 Policy # 24: Assessment Of The Adequacy Of Standards And Criteria, NLNAC Process and Practices 69 The Process Of Review.. 69 Aspects of the Review Reliability of NLNAC Processes 70 Communications and Broad Consultation Practices Planned use of Data Analysis Evaluation of Site Visit Annual Report. 71 NLNAC Ongoing Systematic Program of Review What Will Be Evaluated: NLNAC Standards And Criteria.. 73 NLNAC Processes NLNAC Communications And Broad Consultation v

7 SECTION II: INTERPRETIVE GUIDELINES Introduction.. 77 Directions for Use 77 Glossary for Interpretive Guidelines Differentiated Education: Creating What Must Be 83 Core Competencies Adapted By NLNAC. 85 References References for Core Competencies. 88 References for Standards 88 Guidelines for Preparing the List of Individuals and Groups Interviewed.. 89 Guidelines for Preparing the Categories of Documents Reviewed. 90 MASTER S DEGREE NURSING PROGRAMS Standard I: Mission and Governance Standard II: Faculty.. 93 Standard III: Students Standard IV: Curriculum and Instruction Standard V: Resources Standard VI: Integrity Standard VII: Educational Effectiveness BACCALAUREATE DEGREE NURSING PROGRAMS Standard I: Mission and Governance Standard II: Faculty Standard III: Students Standard IV: Curriculum and Instruction Standard V: Resources Standard VII: Integrity Standard VI: Educational Effectiveness. 117 ASSOCIATE DEGREE NURSING PROGRAMS Standard I: Mission and Governance Standard II: Faculty 121 Standard III: Students 123 Standard IV: Curriculum and Instruction Standard V: Resources Standard VI: Integrity Standard VII: Educational Effectiveness vi

8 DIPLOMA NURSING PROGRAMS Standard I: Mission and Governance... Standard II: Faculty.. Standard III: Students.. Standard IV: Curriculum and Instruction.... Standard V: Resources..... Standard VI: Integrity... Standard VII: Educational Effectiveness PRACTICAL NURSING PROGRAMS Standard I: Mission and Governance... Standard II: Faculty.. Standard III: Students... Standard IV: Curriculum and Instruction..... Standard V: Resources... Standard VI: Integrity.. Standard VII: Educational Effectiveness vii

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10 I. INTRODUCTION MISSION The National League for Nursing Accrediting Commission (NLNAC) supports the interests of nursing education, nursing practice, and the public by the functions of accreditation. Accreditation is a voluntary, self-regulatory process by which non-governmental associations recognize educational institutions or programs that have been found to meet or exceed standards and criteria for educational quality. Accreditation also assists in the further improvement of the institutions or programs as related to resources invested, processes followed, and results achieved. The monitoring of certificate, diploma, and degree offerings is tied closely to state examination and licensing rules, and to the oversight of preparation for work in the profession. PURPOSE To provide specialized accreditation for programs of nursing education, both post-secondary and higher-degree, which offer either a certificate, a diploma, or a recognized professional degree (Master s, Baccalaureate, Associate, Diploma, and Practical Nursing). GOALS Promulgate a common core of standards and criteria for the accreditation of nursing programs. Strengthen educational quality through assistance to associated nursing education units, by evaluation processes, functions, publications, and research. Advocate self-regulation in nursing education. Promote peer review. Foster educational equity, access, opportunity, mobility, and preparation for employment based upon type of nursing education. Serve as gatekeeper to Title IV-HEA programs for which NLNAC is the accrediting agency. These include some practical nursing and all hospital diploma programs eligible to participate in programs administered by the U.S. Department of Education (USDOE) or other federal agencies. NLNAC Accreditation Manual 2004 Edition Section I I: Introduction p.1

11 RECOGNITION The National League for Nursing Accrediting Commission is recognized as the accrediting body for all types of nursing education by: U.S. Department of Education (USDOE) U.S. Uniformed Nursing Services (USUNS) Veterans Health Administration, Department of Veteran Affairs (VHA) National Council of State Boards of Nursing (NCSBN) State Boards of Nurse Examiners (SBNE) Council for Higher Education Accreditation (CHEA) Association of Specialized and Professional Accreditors (ASPA) Pan American Health Organization (PAHO) U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing (USHHS) Employers National, regional and specialized accreditors that provide oversight in regard to federal funding eligibility must be reviewed by the U.S. Department of Education to ensure that the accrediting body meets specific standards established by Congress. The U.S. Secretary of Education is charged with review of accrediting bodies and providing recognition to those accrediting agencies that meet the Secretary s criteria. Students in institutions or programs accredited by a USDOE recognized agency are eligible for federal financial aid assistance and other needed resources. NLNAC also meets the recognition standards of The Council for Higher Education Accreditation (CHEA). CHEA, a non-governmental organization, recognizes regional, specialized, and professional accrediting bodies to ensure quality, accountability, and improvement in higher education. p.2 Section I-I: Introduction NLNAC Accreditation Manual 2004 Edition

12 BENEFITS OF ACCREDITATION NLNAC accreditation is a voluntary peer review process to enhance quality improvement in nursing education. Accreditation: Provides recognition that a nursing education program has been evaluated and periodically re-evaluated by a qualified, independent group of respected and competent peers who have found it to be meeting appropriate post-secondary, and higher educational purposes in a satisfactory manner. Assures professional development opportunity and validation for faculty. Is a gateway to licensure and eligibility for entitlement programs. Identifies areas needing development. Fosters on-going, self-examination, re-evaluation, and focus on the future. Aids in student recruitment and retention. Assists employers seeking graduates who are competent nurses. Facilitates career and education decision-making. Promotes professional and educational mobility of program graduates. Enables student eligibility for funding support from federal and state agencies, and foundations for those programs that do not have regional or national accreditation. NLNAC Accreditation Manual 2004 Edition Section I I: Introduction p.3

13 PHILOSOPHY OF ACCREDITATION The NLNAC accreditation program is founded on the belief that specialized accreditation contributes to the centrality of nursing for the public good and provides for the maintenance and enhancement of educational quality through continuous self-assessment, planning, and improvement. Accreditation indicates to the general public and to the educational community that a nursing program has clear and appropriate educational objectives and is working to achieve these objectives. Emphasis is placed upon the total nursing program and its compliance with established standards and criteria in the context of its mission/philosophy as well as current and future nursing practice. Accrediting agencies share responsibility with faculty and clinicians for the development of accreditation standards, criteria, policies and procedures for participation in accreditation, and for review of accreditation processes and changing them as needed. NLNAC supports the continuation and strengthening of voluntary specialized accreditation by peers as a principal means of public accountability and ongoing improvement. Specialized accreditation sets standards for programs and insures, through the self-study process and accreditation review, the promotion of effective education and program improvement. Since the nursing education unit analysis is closely related to the governing organization itself, NLNAC activities will, when possible, be coordinated with other officially recognized regional and specialized accrediting bodies. Standards and criteria for accreditation, indicators that document compliance, and policies and procedures are based on principles widely accepted and tested in general and professional education. All those involved in the process must be aware of current developments in education and nursing; the effectiveness of the current standards, criteria, policies, and procedures; and to the evidence of need for change. A systematic ongoing review of all components of the accreditation process is essential to ensure an up to date, reliable, and valid accrediting process. p.4 Section I-I: Introduction NLNAC Accreditation Manual 2004 Edition

14 HISTORY OF NURSING ACCREDITATION 1893 The American Society of Superintendents of Training Schools for Nurses, forerunner of the National League for Nursing, was founded for the purpose of establishing and maintaining a universal standard of training for nurses National League of Nursing Education published Standard of Curriculum for Schools of Nursing Accrediting activities in nursing education were begun by many different organizations National League of Nursing Education published A Curriculum Guide for Schools of Nursing, the last of its type by the organization National League of Nursing Education initiated accreditation for programs of nursing education for registered nursing The formation of National Nursing Accrediting Service unifying accreditation activities in nursing. It was discontinued in 1952 when accreditation activities were consolidated under the National League for Nursing The U.S. Department of Education recognized the National League for Nursing and included it on the initial list of recognized accrediting agencies. NLN (later NLNAC), has been continually recognized by the U.S. Department of Education since this date The NLN Board of Directors established a policy charging each educational council with the responsibility for developing its own accreditation program. The program was conducted through the NLN three membership units: the Council of Baccalaureate and Higher Degree Programs; the Council of Diploma and Associate Degree Programs; (the Diploma and Associate Degree Programs separated into two councils in 1965), and the Council of Practical Nursing Programs (1966). The accreditation program and services were administered by NLN professional staff Federal funding for nursing education under the Nurse Training Act was contingent upon the compliance of schools of nursing with Title VI of the Civil Rights Act of Council on Post-secondary Accreditation (COPA) recognized the NLN Accreditation Program Outcome criteria were incorporated into Standards and Criteria for all accredited programs NLN Board of Governors approved the recommendation of the NLN Accreditation Committee to institute core standards and criteria NLN Board of Governors approved establishment of an independent entity within the organization to be known as the National League for Nursing Accrediting Commission (NLNAC). NLNAC Accreditation Manual 2004 Edition Section I I: Introduction p.5

15 HISTORY OF NURSING ACCREDITATION (continued) 1997 January, the NLNAC began operations with sole authority and accountability for carrying out the responsibilities inherent in the accreditation processes. Fifteen Commissioners were appointed: nine nurse educators, three nursing service executives, and three public members. The Commissioners assumed responsibilities for the management, financial decisions, policy making, and general administration of the NLNAC. The peer review process was strengthened with the formation of program specific Evaluation Review Panels NLNAC continued collaborative work with specialty organizations to strengthen application of standards for advanced practice nursing programs. Advanced practice nurses were invited to serve as clinicians in the site visit teams January, the U.S. Department of Education Secretary renewed NLNAC recognition as a nationally recognized accrediting agency for nursing education January, NLNAC received continuing recognition by the Council for Higher Education Accreditation (CHEA) NLNAC was incorporated as a subsidiary of the National League for Nursing U.S. Department of Education renewed NLNAC recognition as a nationally recognized accrediting agency for nursing education. p.6 Section I-I: Introduction NLNAC Accreditation Manual 2004 Edition

16 PRODUCTS AND SERVICES Initial accreditation and continuing accreditation of approximately 200 nursing programs per year Continuous monitoring of approximately 1500 programs per year NLNAC Accreditation Manual with Interpretive Guidelines by Program Type for Post Secondary and Higher Degree Programs in Nursing NLNAC Interpretive Guidelines for standards and Criteria by program type o Master s Degree Programs in Nursing o Baccalaureate Degree Programs in Nursing o Associate Degree Programs in Nursing o Diploma Programs in Nursing o Practical Nursing Programs NLNAC Directory of Accredited Nursing Programs Forums o Self-Study o Program Evaluator Consultation/Mentoring Annual Report and Analysis NLNAC website; NLNAC Accreditation Manual 2004 Edition Section I I: Introduction p.7

17 PERSONS RESPONSIBLE FOR ACCREDITATION Board of Commissioners Volunteer Program Evaluators Site Visitors (Nurse Educators and Clinicians) Evaluation Review Panelists Appeal Panelists Professional Staff Title Name Phone Ext. Executive Director Barbara R. Grumet, JD 451 Deputy Director Carol Gilbert, PhD, RN 407 Deputy Director Ngozi O. Nkongho, PhD, RN 465 Administrative Staff Title Name Phone Ext. Director of Finance & Ricki DeSantis 362 Operations Administrator for Joe Luiz Ortiz 493 Accounting & Information Systems Support Staff Title Name Phone Ext. Special Assistant Anthony Bugay 261 Special Assistant Alex Mariquit 247 Special Assistant Jocelyn Pineda 319 Administrative Assistant Dolores Caggiano 253 Administrative Assistant Yvonne Lopez 409 Administrative Assistant Michael Philips 114 p.8 Section I-I: Introduction NLNAC Accreditation Manual 2004 Edition

18 II. THE COMMISSION OVERALL STRUCTURE OF THE COMMISSION NLNAC is governed by fifteen Commissioners who are elected by the members of NLN at the NLN annual meeting. The legal basis for the foundation and structure of the Commission is outlined in the Bylaws and the Articles of Incorporation. NLNAC is incorporated under the laws of the state of New York. BOARD OF COMMISSIONERS Nine (9) Commissioners are nurse educators representing NLNAC accredited programs, three (3) Commissioners represent the public, and three (3) Commissioners represent nursing service. Commissioners are diversified and assure balanced representation from across identified constituencies insofar as possible. No Governor, officer, or employee of the National League for Nursing or employee of NLNAC may serve as a Commissioner. The Board of Commissioners set accreditation policy, makes accreditation decisions and makes administrative, budget and policy decisions. Commissioners serve as chairperson of the program specific evaluation review panels. Decision of accreditation status is made by the Commissioners, based on review of program materials, site visitors and recommendation of the Evaluation Review Panel. NLNAC Accreditation Manual 2004 Edition Section I-II: Commission p.9

19 MEMBERS OF THE BOARD OF COMMISSIONERS NURSE EDUCATORS: Term Janice R. Ellis, PhD, RN Director and Professor Associate Degree Nursing Program Shoreline Community College Seattle, Washington Janice R. Ingle, DSN, RN (Retired) Dean of Health Sciences Southern Union State Community College Opelika, Alabama Frances D. Monahan, PhD, RN Professor Department of Nursing SUNY Rockland Community College Suffern, New York Term Annette Hallman, PhD, RN, C Director Covenant School of Nursing Lubbock, Texas Grace Newsome, EdD, APRN, RN, BC, FNP Professor of Nursing North Georgia College & State University Dahlonega, Georgia Marilyn K. Smidt, MSN, RN Director of Nursing Programs Grand Rapids Community College Grand Rapids, Michigan Term Patricia R. Forni, PhD, RN, FAAN Professor College of Nursing University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma Phyllis Turner, PhD, RN Senior Researcher School of Nursing East Carolina University Greenville, North Carolina Ann B. Schlumberger, EdD, RN Chairperson and Professor Department of Nursing University of Arkansas at Little Rock Little Rock, Arkansas NURSING EXECUTIVES: Term T. Charlene Robertson, MSN, RN Chief Nurse Executive (Retired) Memorial Healthcare System Chattanooga, Tennessee Term Lois A. Manning, MSN, MS, PHN, RN Director of Public Health Nursing Ventura County Public Health Department Oxnard, California Term Patricia R. Messmer, PhD, RN, BC, FAAN Nurse Researcher Miami Children s Hospital Miami, Florida PUBLIC MEMBERS: Term Raymond S. Andrews, Jr., JD Trustee Donaghue Medical Research Foundation West Hartford, Connecticut Term Robert Sintich, EdD Provost Dean of Academic and Student Services Warren County Community College Washington, NJ Term Robert E. Parilla, PhD Senior Consultant Academic Search Consultation Service President Emeritus Montgomery College Gaithersburg, Maryland p.10 Section I-II: Commission NLNAC Accreditation Manual 2004 Edition

20 ORGANIZATIONAL STRUCTURE NATIONAL LEAGUE FOR NURSING ACCREDITING COMMISSION NLN Board of Governors NLNAC Board of Commissioners NLNAC Executive Director Professional Staff Administrative Staff Legend: Program Evaluators Cooperating Direct Support Staff NLNAC Accreditation Manual 2004 Edition Section I-II: Commission p.11

21 III. ACCREDITATION STANDARDS AND CRITERIA FOR ACADEMIC QUALITY OF POST SECONDARY AND HIGHER DEGREE PROGRAMS IN NURSING A. NLNAC Definition of Quality The core values of accreditation emphasize learning, community, responsibility, integrity, value, quality, and continuous improvement through reflection and analysis. They require that the nursing program measures itself by exacting standards, honors high aspiration and achievement, and expects all persons associated with the program to recognize its responsibility to provide a supportive and humane environment in which people interact with each other in a spirit of cooperation, openness, and mutual respect. Accreditation standards are agreed upon rules to measure quantity, extent, value, and quality. Criteria are statements which identify the variables that need to be examined in evaluation of a standard. NLNAC criteria are presented to peer reviewers as statements that represent an accurate description of an accredited program. Peer review is a long established and effective component of program evaluation in education settings. In education, peer review is used too help determine which programs to accredit. Peer reviewers know the current thinking in the various program types, the curriculum rules and conventions, and are trained to identify program compliance with standards and criteria. Program specific expertise is preserved at the point of criteria documentation, program evaluation conducted by peers from like programs at the time of the site visit, during evaluation review panel deliberations, and upon appeal. Quality in education ensures high levels of opportunity for student learning and student achievement. Accreditation is an affirmation of certain values central to thinking about postsecondary and higher education appropriate mission, organization structures, processes, functions, and resources aligned with core values and each other, collegiality, and continuous self-improvement. NLNAC accredits all types of nursing education programs in a variety of post-secondary and higher education settings, including vocational technical agencies, community college, hospitals, proprietary schools, professional schools, seminaries, colleges and universities, and other institutions which offer diplomas, certificates, and/or academic degrees. p.12 Section I-III: Standards & Criteria NLNAC Accreditation Manual 2004 Edition

22 B. NLNAC Accreditation Standards: I. Mission/Governance There are clear and publicly stated missions and/or philosophy and purposes appropriate to post-secondary or higher education in nursing. VII. Educational Effectiveness There is an identified plan for systematic evaluation including assessment of student academic achievement. II. Faculty There are qualified and credentialed faculty, appropriate to accomplish the nursing education unit purposes and strengthen its educational effectiveness. VI. Integrity Integrity is evident in the practices and relationships of the nursing education unit. III. Students The teaching and learning environment is conducive to student academic achievement. V. Resources Resources are sufficient to accomplish the nursing education unit purposes. IV. Curriculum and Instruction The curriculum is designed to accomplish its educational and related purposes. C. Understanding standards and criteria in the evaluation of nursing education units. The singular function of nursing is the improvement of the human condition. Each certificate, diploma, or degree has an identifiable, discrete set of specific outcomes. Post-secondary and higher education provide for the development of the learner s ability to think for oneself, to master analytical problem solving, to apply scientific knowledge, and to make value judgments within the context of the specific program type. Thus, education requires a broad academic orientation, and depth and breadth of intellectual skills translated into competencies so as to fulfill nursing s function in all types of nursing from practical nursing through advanced practice nursing at the master s level. Standards: agreed upon rules for the measurement of quantity, extent, value, and quality. Criteria: statements which identify the variables that need to be examined in evaluation of a standard NLNAC Accreditation Manual 2004 Edition Section I-III: Standards & Criteria p.13

23 D. Standards and Criteria STANDARDS I. Mission & Governance There are clear and publicly stated mission and/or philosophy and purposes appropriate to post-secondary or higher education in nursing. CRITERIA 1. Mission and/or philosophy of the nursing education unit is congruent with that of the governing organization, or differences are justified by the nursing education unit purposes. 2. Faculty, administrators, and students participate in governance as defined by the governing organization and the nursing education unit. 3. Nursing education unit is administered by a nurse who is academically and experimentally qualified, and who has authority and responsibility for development and administration of the nursing education unit. 4. Policies of the nursing education unit are consistent with those of the governing organization, or differences are justified by nursing education purposes. II. Faculty There are qualified and credentialed faculty, appropriate to accomplish the nursing education unit purposes and strengthen its educational effectiveness. 5. Faculty members (full and part-time) are academically and experientially qualified, and maintain expertise in their areas of responsibility. 6. Number and utilization of full- and part-time faculty meet the needs of the nursing education unit to fulfill its purposes. 7. Faculty performance is periodically evaluated to assure ongoing development and competence. 8. The collective talents of the faculty reflect scholarship through teaching, application, and the integration and discovery of knowledge as defined by the institution and the nursing education unit. III. Students The teaching and learning environment is conducive to student academic achievement. 9. Student policies of the nursing education unit are congruent with those of the governing organization, publicly accessible, non-discriminatory, and consistently applied; differences are justified by the nursing education unit purposes. 10. Students have access to support services administered by qualified individuals that include, but are not limited to: health, counseling, academic advisement, career placement, and financial aid. 11. Policies concerned with educational and financial records are established and followed. p.14 Section I-III: Standards & Criteria NLNAC Accreditation Manual 2004 Edition

24 STANDARDS IV. Curriculum & Instruction The curriculum is designed to accomplish its educational and related purposes. V. Resources Resources are sufficient to accomplish the nursing education unit purposes. CRITERIA 12. Curriculum developed by nursing faculty flows from the nursing education unit philosophy/mission through an organizing framework into a logical progression of course outcomes and learning activities to achieve desired program objectives/outcomes. 13. Program design provides opportunity for students to achieve program objectives and acquire knowledge, skills, values, and competencies necessary for nursing practice. 14. Practice learning environments are selected and monitored by faculty and provide opportunities for a variety of learning options appropriate for contemporary nursing. 15. Fiscal resources are sufficient to support the nursing education unit purposes commensurate with the resources of the governing organization. 16. Program support services are sufficient for the operation of the nursing education unit. 17. Learning resources are comprehensive, current, developed with nursing faculty input, and accessible to faculty and students. 18. Physical facilities are appropriate to support the purposes of the nursing education unit. VI. Integrity Integrity is evident in the practices and relationships of the nursing education unit. 19. Information about the program intended to inform the general public, prospective students, current students, employers and other interested parties, is current, accurate, clear, and consistent. 20. Complaints about the program are addressed and records are maintained and available for review. 21. Compliance with Higher Education Reauthorization Act Title IV eligibility and certification requirements is maintained. VII. Educational Effectiveness There is an identified plan for systematic evaluation including assessment of student academic achievement. 22. There is a written plan for systematic program evaluation that is used for continuous program improvement. 23. Student academic achievement by program type is evaluated by: graduation rates, licensure/certification pass rates, job placement rates, and program satisfaction. NLNAC Accreditation Manual 2004 Edition Section I-III: Standards & Criteria p.15

25 PLANNING FOR SYSTEMATIC PROGRAM EVALUATION (SPE) Principles Systematic program evaluation involves the process of determining whether the various parts and the entire program are in fact, achieving its mission, goals, objectives, and outcomes. Multiple indicators are used to determine program effectiveness in the preparation of competent nurses. A central concern of accreditation is that the evaluation and assessment processes be directed toward achievement of program goals and result in program improvement on an ongoing basis. Programs develop overall evaluation plans unique to their own needs and interests as a means of coordinating outcomes with goals and objectives. They must select methods of assessment to generate data relevant to their individual outcomes and establish levels of achievement, and is the results of the evaluation findings for improving program quality. Program goals and objectives should be evaluated in terms of: o educational appropriateness o relevance to constituent needs o expectations of practitioners in the field o relation to the program mission o relevance to the expectations of and responsibilities to the publics that nursing aims to serve NLNAC does not mandate specific evaluation techniques, procedures or use of specific instruments for outcomes assessment by programs. NLNAC encourages programs to select assessment methods that are based upon the evaluation question being addressed within the context of their own evaluation. Program evaluation in this framework facilitates program revision and improvement, supports decisions regarding curriculum change, enhancement of approaches to teaching, changing clinical teaching sites, and finding new role models. It also allows the faculty and staff to address student perceptions about inconsistencies among what the faculty teach, what students see in actual practice, and what work place requirements exist. Furthermore, it encourages program selfexamination as well as auditing of what occurs. p.16 Section I-III: Standards & Criteria NLNAC Accreditation Manual 2004 Edition

26 Elements for Systematic Program Evaluation Including Assessment of Student Academic Achievement AREA ACTIVITY The Plan: Component Levels of Achievement Frequency Assessment Methods Identify specific components with Standards and Criteria Define expected levels of achievement for each component Establish time frames for assessment of all plan components Select and/or develop procedures, and/or instruments/tools to measure each component Implementation of the Plan: Results of Data Collection & Analysis Data collected as prescribed Data analyzed and aggregated Data trended Verification that evaluation findings are used in decision making for program development, revision, and maintenance NLNAC Accreditation Manual 2004 Edition Section I-III: Standards & Criteria p.17

27 IV. ACCREDITATION PROCESSES AND PROCEDURES PLANNING FOR ACCREDITATION Nursing education units considering accreditation should contact NLNAC to be assigned a member of the professional staff as their mentor. The mentor service is provided to facilitate faculty self review and planning. The faculty and administrative officers of the program decide when the program is ready for initial evaluation. The decision should be based on an in-depth self-study of the program in relation to the NLNAC standards and criteria. When the NLNAC Commission grants accreditation to a program, all students who graduated during or after the semester the site visit was performed will be recognized as graduates of an accredited nursing program. Initial Accreditation A governing organization that offers a program not previously accredited by the Commission initiates the process through its chief executive officer. The chief executive officer of the governing organization for the nursing education unit must authorize the NLNAC to conduct the accreditation process by submitting the official authorization form sent from the Commission. Preferably, this communication should be made at least a year in advance of the time when the faculty believes that eligibility conditions will have been met and the program will be ready for an accreditation evaluation. A nursing program may withdraw its application for initial accreditation and discontinue the process at any time up to six weeks prior to the date of the site visit. Once the site visit occurs, the nursing program is not eligible to withdraw from the process. Continuing Accreditation Planning for continued accreditation is an ongoing process. A program must be visited and reevaluated at specified intervals to ensure continuing compliance with the accreditation standards and criteria. The NLNAC staff notifies the program of a pending visit approximately one year in advance. Dates for the site visits are scheduled in consultation with the nurse administrator as the program must be in full operation during the visit. Once the site visit occurs, the nursing program is not eligible to withdraw from the process. Official authorization to conduct the NLNAC accreditation process is secured from the chief executive officer of the governing organization and the nurse administrator for the nursing education unit. The program will receive an authorization from the NLNAC approximately one year before the visit is to take place. If the nurse administrator of an NLNAC accredited program chooses to cancel the accreditation process, notification of cancellation must be submitted in writing to the Commission, which will p.18 Section I-IV: Processes & Procedures NLNAC Accreditation Manual 2004 Edition

28 then take formal action and remove the program from the official list of the NLNAC accredited programs. If a program is notified about its need to comply with a Commission action and does not respond, the program will be removed from the official list of NLNAC accredited programs by the Commission at its next scheduled meeting. Accreditation of Programs within Multi-Campus Institutions When a governing organization has multiple campuses and is accredited as one institution, the nursing education units may choose to seek NLNAC accreditation either as one unit, or as separate units. If the nursing education units choose to separate accreditation, all nursing education units offering the same program type must stand for accreditation. The decision should be based on the following consideration: The governing organization s legal regional accrediting body policy on accrediting institutions with multiple campuses. If the regional accrediting body allows each campus of a multi-campus institution to have its own administrative structure and offer its own curriculum, the nursing education units may seek accreditation as separate entities. The governing organization s governance and administrative structure. If the governing organization offers separate curricula on each campus, and has separate faculty and administrative structures to provide these curricula, the nursing education units may seek accreditation as separate units offering the same program type. If the nursing education units are run as a single unit, with one administrative structure, facility, and curriculum, the nursing education units should seek accreditation as a single program offered at multiple sites. The State Board of Nursing policy on governing organizations with multiple campuses. If the State Board of Nursing permits governing organizations with multiple campuses to offer separate nursing programs on each campus, all nursing education units may seek separate accreditations. If a governing organization with multiple campuses decides to seek separate NLNAC accreditation for each campus, each nursing education unit pays full annual accreditation fees and site visit fees, as a separate entity. Each nursing education unit then stands for accreditation individually and submits its own self-study and has a separate visit, review process by the evaluation panel and action by the Commission. NLNAC Accreditation Manual 2004 Edition Section I-IV: Processes and Procedures p.19

29 EVALUATION PROCESS The NLNAC accreditation process includes the following steps: Staff consultation Program preparation of the Self-Study Report (periodic report on ongoing evaluation) Team site visit for program evaluation by program-specific site visitors Team Report (Site Visitor Report) Staff review Evaluation Review Panel with program-specific expertise Staff review and referral to the Commission Commission accreditation decision Appeal panel (when appropriate) The NLNAC process for the evaluation of nursing education programs is a comprehensive fourstep process, with the self-study as the first step. The second step is the site visit. In the third step, a peer evaluation review panel examines the reports written by and about the program. The final step is a review of the process and the decision on accreditation status by the NLNAC Board of Commissioners. Each site visit is conducted by a team of nursing educators with program specific expertise and a clinician (2-3 site visitors). Each evaluation review panel is composed of program evaluators (educators) representing specific program types, different geographic locations, and diverse institutional types and sizes. The evaluation review panel meets twice a year, except the diploma panel, which meets once a year. The panels make recommendations for initial and continuing accreditation status to the Commission. The Commission reviews the accreditation process, accepts staff reports, makes decisions about recommendations on applications for initial and continuing accreditation, and provides programmatic advice. STAFF CONSULTATION NLNAC professional staff is available to assist a program preparing for an accreditation visit in whatever way best meets the needs of the nursing faculty. Programs applying for initial accreditation will be assigned an NLNAC professional staff member as a mentor to assist the program in it s preparation for accreditation at the time the program contacts NLNAC of its intent to apply for initial accreditation. Applicants for initial accreditation are expected to attend a self-study forum. Dates and locations are posted on the NLNAC website ( p.20 Section I-IV: Processes & Procedures NLNAC Accreditation Manual 2004 Edition

30 SELF-STUDY Programs applying for accreditation must conduct a self-study to determine to what extent the program meets the accreditation standards and criteria. This systematic approach to data collection provides a basis for: Identifying the strengths of the program; Diagnosing difficulties in the program; Making decisions about needed improvements and program growth through continuous scrutiny, examination, re-examination, and redefinition. The process of self-study represents the combined effort of governing organization administrators, nursing education unit administrators, faculty, staff, students, and other individuals concerned with the nursing program. All those concerned with the program should participate in the self-study process. Broad participation leads to an understanding of the total program. The self-study process includes the following activities based on the nursing education unit s program evaluation plan: A thorough exploration of the mission and/or philosophy, purposes and services of the program An assessment of the validity of the mission and/or philosophy and purposes of the program in relation to current trends and needs in nursing education and practice An evaluation of the extent to which the nursing program is achieving its mission and/or philosophy and purposes based on an analysis of all its activities A careful consideration of various ways and means by which the mission and/or philosophy and purposes may be more fully attained. Conclusions derived from the ongoing data accumulation and review have two benefits: A basis for continuing development and improvement of the program and its services A basis for evidence of how both the program s stated mission and/or philosophy and purposes, and the accreditation standards and criteria are being met These findings should be clearly set forth in the self-study report to be submitted to the Commission. Self-Study Report The self-study report is the primary document used by the site visit team, the evaluation review panels, and the Board of Commissioners to understand the nursing program. The report must be based upon the NLNAC accreditation standards and criteria in effect at the time of the review. (Accreditation standards and criteria become effective on the Commission approval date. Programs scheduled for review within twelve months of revision of the standards and criteria may elect to use the current or the former version of the standards and criteria). NLNAC Accreditation Manual 2004 Edition Section I-IV: Processes and Procedures p.21

31 Faculty and administrators are responsible for presenting evidence that clearly indicate how the standards and criteria are being met. Members of the site visit team will use the self-study report in preparation for their visit to the program. Guidelines for Writing the Self -Study The self-study report is written by the nursing education unit using the most recent edition of the NLNAC Accreditation Manual with Interpretative Guidelines by Program Type for Post Secondary and Higher Degree Programs in Nursing. The self-study document must include program history, context, and self-evaluation related to the standards and criteria, and program plans for future development and improvement. Program-specific presentation of the standards and criteria and glossary can be found in the Interpretative Guidelines section of this document. There are four sections to the self-study report: Section One: Executive Summary Section Two: Standards and Criteria: Mission & Governances, Faculty, Students, Curriculum & Instruction, Resources, Integrity Section Three: Standards and Criteria: Educational Effectiveness Section Four: Appendix Section One: Executive Summary The Executive Summary is a brief presentation of the nursing education unit, how it fits within the governing organization, and the extent to which it is in compliance with the NLNAC Standards and Criteria. In addition to offering basic demographic information about the nursing education unit and the governing organization, it puts the nursing program into focus within its institution and its community. It offers key evidence demonstrating how the program is in compliance with each of the Standards for accreditation. Finally, it presents an analysis of the nursing education unit s strengths and areas needing improvement. Content a) General Information: Program type(s) being reviewed, purpose(s) of the visit, date of the visit; name and address of governing organization; name, credentials, and title of chief executive officer of governing organization; name of governing organization accrediting body and accreditation status (date of last review and action); name and address of nursing education unit; name, credentials, and title of nurse administrator of the nursing education unit; telephone, fax number, and address of nurse administrator; name of State Board of Nursing and approval status (date of last review and action); NLNAC standards and criteria used to prepare the self-study report. b) Introduction: Place the nursing program in context by describing how it fits within the nursing education unit (if more than one program is offered) and how the nursing education unit fits within the governing organization and community, student population (number of full- and part-time students, by program type) and faculty cohort (number of full- and part-time, by program type). p.22 Section I-IV: Processes & Procedures NLNAC Accreditation Manual 2004 Edition

32 c) History of the Nursing Education Unit: Year nursing program(s) was/were established; length of program(s) in credits and time; history of the nursing education unit; NLNAC accreditation history (include date of initial accreditation); differentiated education; number of campuses or satellite sites offering the nursing program(s) and distance education offerings (if appropriate); other nursing accreditation (e.g. Council on Certification of Nurse Anesthetists, Nurse Midwifery). d) Summary of Standards and Criteria: An overview reflecting the major findings that demonstrate program compliance with each standard. e) Analysis and Summary of Strengths and Areas Needing Improvement: Conclusions with a listing of strengths, areas needing improvement and future plans. Section Two: Standards I-VI and Criteria 1-21 Section two provides the opportunity for the nursing education unit to demonstrate the extent to which it is in compliance with the Standards: Mission and Governance, Faculty, Students, Curriculum and Instruction, Resources, and Integrity. The self-study report is expected to address each standard and its relevant criteria using all of the items listed in the Documentation confirms subsection for each criterion. The use of the Documentation confirms items assures that the program has fully addressed all aspects of each criterion. The Interpretative Guidelines section provides the Documentation confirms subsection for each criterion within each standard. The narrative presentation should be clear and succinct. Tables, graphs, and/or presentations of sections of the nursing education unit s evaluation plan may also be used as a means to simplify and organize information to demonstrate trends and changes over time. Suggestions of material/indicators and Tables that may facilitate the presentation of each standard are also offered in the Interpretative Guidelines section of the Manual. Nursing education units submitting one self-study report for a multiple program visit are expected to address each program type offered, beginning with the most basic program and progressing to the most advanced program, demonstrating the extent to which each is meeting each criterion. Faculty are expected to clearly differentiate between the educational programs offered. Section Three: Standard VII and Criteria Educational Effectiveness This section is a presentation of the nursing education unit s plan for systematic evaluation of the unit and the results of the ongoing assessment. In addition to the presentation of the plan, the narrative should address how findings related to all the standards have been used for program maintenance, revision and development. When addressing criterion 23, the discussion should include all four achievement measures. Section Four: Appendix The appendix is for supplemental materials that support information discussed within the body of self-study report. NLNAC Accreditation Manual 2004 Edition Section I-IV: Processes and Procedures p.23