Implementing the 2013 Standards and Criteria

Sharon J. Tanner, EdD, RN
Chief Executive Officer, National League for Nursing Accrediting Commission

This column provides information on accreditation for nursing programs of all types. Readers may submit questions to the National League for Nursing Accrediting Commission. General questions of interest to a wide audience will be addressed in this column while more specific questions or those requiring confidentiality will be answered directly.

Following a year-long review process throughout 2012, the new 2013 NLNAC Accreditation Standards were released in January 2013. The review of the Accreditation Standards is undertaken entirely by a corp of volunteers who are committed to ensuring that nursing education is strengthened by the self-regulatory process of accreditation. The NLNAC utilizes an extensive review process it developed in accordance with the Regulations of the U.S. Department of Education, which require regular review of each agency’s standards as part of the federal recognition process for accrediting agencies. The NLNAC process involved approximately 70 dedicated volunteers who gave of their time and energy to serve on one of the six program-specific subcommittees for practical, diploma, associate, baccalaureate, master’s, and clinical doctorate programs. The volunteers represented more than 30 states and Puerto Rico. The composition of the subcommittees was reflective of the diversity in nursing education today as there were nurse administrators and faculty members representing governing organizations of all sizes, characteristics, and geographic locations and nursing education programs of all sizes, method of instructional delivery, and program type. These volunteers contributed their experience in nursing education along with their expertise in quality initiatives to the process. In addition to the nurse educators, nurses from clinical practice served on each of the subcommittees to bring the perspective of nursing service to the table in the ongoing dialogue regarding the competencies for graduates, safe practice, and current trends and issues in healthcare.

In addition to the volunteers, all nursing constituents were represented in the more than 11,000 comments that were received in the two open comment periods, first for Draft 1 and then again a few months later for Draft 2. During the open comment periods, the NLNAC received comments from students, faculty, nurse administrators, college and university staff and administrators, state regulatory agencies, accrediting agencies, public interest groups, nursing associations, and members of the public. Each comment was carefully reviewed and thoughtfully considered as the Standards were drafted, revised, edited, and finalized. We salute the thousands of our colleagues who were active participants in the process and supported the volunteers in the development of the new 2013 NLNAC Accreditation Standards.

QOur master’s nursing program is scheduled for its next accreditation site visit in Spring 2014. We understand that the new 2013 Standards and Criteria are available. Do we use the 2008 or the 2013 Standards when we write our Self-Study Report?

AFollowing the review and revision process of the NLNAC Accreditation Standards, there is a one year phase-in period for the transition from one set of Standards to the next. The NLNAC-accredited nursing programs are not expected to fully adopt the 2013 Standards until January 1, 2014, based on the January 2013 publication date. So, if your visit is in the Spring 2014 Accreditation Cycle, you and your colleagues will be developing the Self-Study Report using the 2013 Standards. I would highly encourage you to attend one of the 2013 Self-Study Forums offered throughout the year to become familiar with any changes in the Standards. Also, you will want to obtain a copy for each faculty member and administrator of the 2013 Standards from the NLNAC website so that your planning and timeline development for the self-review of the program and Self-Study Report process can be based on the new Standards.

QThe faculty and I are in a little bit of a panic. Our baccalaureate and associate nursing programs are scheduled for a site visit in September 2013. We attended a recent workshop and heard about the 2013 Standards and Criteria, but we have already written a great deal of the Self-Study Report. Do we need to revise the Report or address any new Criteria? Please advise us as we hope to finish the Self-Study Report prior to the end of spring semester since the faculty are not on campus in the summer.

AThere is no reason to panic; please know that it is fine for you to have developed the Self-Study Report based on the 2008 Standards. In fact, you and the faculty are to be congratulated for getting an early start on the Report and having a definite deadline for completion of the project. This should also give you plenty of time to prepare the documents for the onsite review by the site visit team. All nursing programs scheduled for accreditation visits in the Spring 2013 and Fall 2013 Accreditation Cycles may use either the 2008 or 2013 Standards. We encourage all of the nursing programs to have their reports in process a year in advance, so the preparation work should be well underway for any program being visited in the Fall 2013 Cycle. However, it is never too early for you and the faculty to begin the review of the new Standards such that any changes are included in your meetings and discussions related to curriculum review, data analysis, or future planning for the programs.

QOur nursing faculty host a retreat at the end of each spring semester during which we conduct a thorough review of our systematic plan of evaluation. The Evaluation Committee is responsible for presenting the data from each of the nursing courses along with the evaluations from the students, facilities, and communities of interest. We have noted that the Accreditation Standards have changed. Are we expected to incorporate the new Standards into our evaluation plan this year?

AAll accredited nursing programs are expected to begin the process of “retiring” the 2008 Standards and moving to the 2013 Standards this year. One of the ways to do so is to fully incorporate the 2013 Standards and Criteria into your systematic plan of evaluation. You will be pleased to know that there have been few changes in the Standards; however, there are some new and/or revised Criteria that should be carefully reviewed for your program. As you are aware, it is an expectation that each nursing program demonstrate compliance with Standard 6 Outcomes through the ongoing and systematic assessment of all student learning outcomes, program outcomes, and the NLNAC Standards. A trend that was noted when the 2008 Standards were released is that nursing programs were slow to adopt the Standards and revise their evaluation plans accordingly. I would encourage you to use the retreat time this spring to engage the faculty in drafting whatever revisions or changes are needed to ensure that you begin the collection of data in accordance with the new Standards and Criteria. If your next accreditation visit is within the next few cycles, you will want to demonstrate that the data have been collected, analyzed, and trended as required and that any new or revised Criteria have been part of your assessment plans.

This is a non-final version of an article published in final form in the NURSE EDUCATOR Journal. March/April 2013 Vol.38, No.2 http://journals.lww.com/nurseeducatoronline/toc/2013/03000