ACEN 2023 Standards and Criteria


2023 ACCREDITATION MANUAL  •  SECTION I GENERAL INFORMATION  •  SECTION II POLICIES  •  SECTION III STANDARDS AND CRITERIA  •  GLOSSARY


ACCREDITATION MANUAL – SECTION III

2023 STANDARDS AND CRITERIA

Standard 1 Administrative Capacity and Resources
Standard 2 Faculty
Standard 3 Students
Standard 4 Curriculum
Standard 5 Outcomes

Standard 1 Administrative Capacity and Resources

The mission and/or philosophy of the nursing program reflects the governing organization’s mission, goals, and/or values. The governing organization and nursing program have administrative capacity and resources that support effective delivery of the program and facilitate the achievement of the end-of-program student learning outcomes and program outcomes for each nursing program type, and additionally for graduate programs the role-specific nursing competencies.

Criterion 1.1

The mission, goals and/or values of the governing organization are evident in the mission, goals, values, and/or philosophy of the nursing program.

Criterion 1.2

      • The nurse administrator and nursing faculty have formal representation in governing organization and nursing program governance activities.
      • Students have opportunities to participate in governance activities for the governing organization and the nursing program.

Criterion 1.3

Communities of interest have opportunities to provide input into nursing program processes and/or decision-making.

Criterion 1.4

The nurse administrator is a nurse who:

      • holds educational qualifications as required by the:

    • governing organization and
    • regulatory agencies;
      • holds nursing licensure, and certification as applicable, consistent with the assigned roles and responsibilities; and

      • is experientially qualified for the assigned roles and responsibilities.

Criterion 1.5

The nurse administrator:

      • is oriented and mentored in the assigned roles and responsibilities;

      • develops and maintains expertise in the assigned responsibilities, including administration and leadership of the nursing program; and

      • has sufficient time for the assigned roles and responsibilities.

Criterion 1.6

The nurse administrator has the authority to:

      • administer and lead the nursing program;

      • prepare the nursing program budget with faculty input; and

      • administer fiscal resources allocated to the nursing program.

Criterion 1.7

When present, faculty and/or staff who assist or support nursing program administration:

      • hold the educational qualifications as required by the:

    • governing organization and
    • regulatory agencies;
      • are experientially qualified for their assigned roles and responsibilities;

      • are sufficient in number; and

      • have sufficient time for their assigned roles and responsibilities.

Criterion 1.8

The nursing program has sufficient and sustainable fiscal resources to support the program at all locations and for all methods of delivery.

Criterion 1.9

The nursing program has sufficient and sustainable physical resources to support the program at all locations and for all methods of delivery.

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Standard 2 Faculty

Faculty are educationally and experientially qualified for their assigned roles and responsibilities, maintain expertise, and are regularly evaluated to support the achievement of the end-of-program student learning outcomes and program outcomes for each nursing program type, and additionally for graduate programs the role-specific nursing competencies.

Full- and part-time faculty include those individuals teaching and/or evaluating students in didactic, clinical, and/or laboratory settings.

Criterion 2.1

Full-time faculty are nurses who:

      • hold the educational qualifications as required by the:

    • governing organization and
    • regulatory agencies;
      • hold nursing licensure, and certification as applicable, consistent with their assigned roles and responsibilities;

      • are experientially qualified for their assigned roles and responsibilities; and

      • are sufficient in number.

Criterion 2.2

Part-time faculty are nurses who:

      • hold the educational qualifications as required by the:

    • governing organization and
    • regulatory agencies;
      • hold nursing licensure, and certification as applicable, consistent with their assigned roles and responsibilities;

      • are experientially qualified for their assigned roles and responsibilities; and

      • are sufficient in number.

Criterion 2.3

Non-nurse faculty who teach nursing courses:

      • hold the educational qualifications as required by the:

    • governing organization and
    • regulatory agencies;
      • are experientially qualified for their assigned roles and responsibilities; and

Criterion 2.4

Policies for nursing faculty are comprehensive and consistent with those of the governing organization; justification is provided for any policy differences.

Criterion 2.5

      • Full-time faculty are oriented and mentored in their assigned responsibilities.

      • Part-time faculty are oriented and mentored in their assigned responsibilities.

Criterion 2.6

Full-time faculty develop and maintain current expertise in their teaching responsibilities, including (but not limited to):

      • evidence-based teaching/instructional strategies that are relevant for all methods of delivery;

      • standards of clinical practice;

      • assessment and evaluation methods; and

      • principles of diversity, equity, and/or inclusion.

Criterion 2.7

Part-time faculty develop and maintain current expertise in their teaching responsibilities, including (but not limited to):

      • evidence-based teaching/instructional strategies that are relevant for all methods of delivery;

      • standards of clinical practice;

      • assessment and evaluation methods; and

      • principles of diversity, equity, and/or inclusion.

Criterion 2.8

      • Full-time faculty performance is regularly evaluated for effectiveness in their assigned responsibilities.

      • Part-time faculty performance is regularly evaluated for effectiveness in their assigned responsibilities.

Criterion 2.9

Preceptors, when used:

      • hold the educational qualifications as required by the:

    • nursing program and
    • regulatory agencies;
      • hold licensure, and certification as applicable, consistent with their assigned roles and responsibilities;

      • are experientially qualified for their assigned roles and responsibilities,

      • are oriented, mentored, and monitored; and

      • have clearly documented responsibilities, which may include input into student evaluation.

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Standard 3 Students

Student policies and services support the achievement of the end-of-program student learning outcomes and program outcomes for each nursing program type, and additionally for graduate programs the role-specific nursing competencies.

Criterion 3.1

The nursing program’s current ACEN accreditation status and the ACEN contact information is accurate and readily accessible to the public.

Criterion 3.2

The following nursing program or governing organization policies are publicly accessible, current, non-discriminatory, and implemented as published; justification is provided when nursing policies differ from the governing organization:

      • admissions;

      • progression;

      • graduation;

      • formal complaints and grievances procedures; and

      • technology requirements.

Criterion 3.3

Governing organization or nursing program records for resolution of formal complaints or formal grievances include evidence of:

      • due process; and

      • timely resolution in accordance with the governing organization or nursing program polices or procedures.

Criterion 3.4

Student records maintained by the nursing program are kept secure and are in compliance with applicable policies/procedures of the governing organization and regulatory agencies.

Criterion 3.5

Changes in nursing program policies/procedures are clearly and consistently communicated to students in an effective and timely manner.

Criterion 3.6

Student support services are commensurate with the needs of nursing students, regardless of location, methods of delivery, or program option.

Criterion 3.7

      • Learning and technology resources for nursing students are selected by the faculty and relevant to the educational level at which students are being prepared.

      • Students are oriented to and receive support for learning and technology resources.

      • Learning and technology resources are current and accessible regardless of location, methods of delivery, or program option.

Criterion 3.8

Students are informed of their responsibilities regarding any financial assistance.

Criterion 3.9

Compliance with the Higher Education Reauthorization Act, Title IV eligibility and certification requirements is maintained, including having a:

      • plan to improve the federal loan default rate, as applicable; and

      • written, comprehensive federal student loan repayment program addressing student loan information, counseling, and monitoring.

Criterion 3.10

Federal financial aid record maintenance complies with federal guidelines.

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Standard 4 Curriculum

The curriculum supports the achievement of the end-of-program student learning outcomes for each nursing program type, and additionally for graduate programs, the role-specific nursing competencies; and is consistent with safe practice in contemporary healthcare environments.

Criterion 4.1

The nursing curriculum has one set of end-of-program student learning outcomes that:

      • are based on contemporary professional nursing standards, guidelines, and/or competencies; and

      • apply to all program options and reflect the educational level at which students are being prepared.

Additionally, for Graduate Programs:

      • integrate role-specific nursing competencies applicable to each program option.

Criterion 4.2

Course student learning outcomes are organized to demonstrate progression to facilitate the students’ achievement of:

      • the end-of-program student learning outcomes.

Additionally, for Graduate Programs:

      • the role-specific nursing competencies.

Criterion 4.3

Teaching/instructional strategies and learning activities in all learning environments are varied, appropriate for the method of delivery, and incorporate learning and technology resources to facilitate the students’ achievement of course student learning outcomes.

Criterion 4.4

The nursing curriculum is:

      • developed by the faculty and regularly reviewed for currency; and

      • implemented as published.

Criterion 4.5

The nursing program of study includes:

Undergraduate Programs:

      • General education courses/concepts that enhance nursing knowledge and practice for the educational level at which students are being prepared.

      • Nursing courses that facilitate student achievement of course student learning outcomes and end-of-program student learning outcomes.

Graduate Programs:

      • General education courses/concepts that enhance nursing knowledge and practice for the educational level at which students are being prepared.

      • Nursing courses that facilitate student achievement of course student learning outcomes, end-of-program student learning outcomes, and role-specific nursing competencies.

Criterion 4.6

Course credits and/or clock hours for all nursing courses in the program of study, including ratios for contact hours, comply with requirements of the:

      • governing organization and

      • regulatory agencies.

Additionally for Graduate Programs:

      • certifying agencies, as applicable.

Criterion 4.7

Emphasizing the role of the nurse at the educational level for which students are being prepared, the curriculum incorporates contemporary concepts in all learning environments, including, but not limited to:

      • diversity, equity, inclusion, and/or social determinants of health;

      • evidence-based practice, research, and/or scholarship;

      • information literacy;

      • interprofessional collaboration and delegation; and

      • professional identity and scope of practice.

Criterion 4.8

If used, skills and/or simulation laboratory learning environments and experiences:

      • reflect evidence-based nursing practice;

      • include healthcare technology;

      • meet regulatory agencies requirements for skills laboratory and/or simulation, as applicable; and

For Undergraduate Programs:

      • reflect the educational level at which students are being prepared to facilitate the achievement of the course student learning outcomes and end-of-program student learning outcomes.

For Graduate Programs:

      • reflect the educational level at which students are being prepared to facilitate the achievement of the course student learning outcomes, end-of-program student learning outcomes, and role-specific nursing competencies.

Criterion 4.9

Clinical/practicum learning environments and experiences:

      • have current written agreements that specify expectations for all parties for the protection of the student;

      • reflect evidence-based nursing practice;

      • meet regulatory agencies’ requirements for clinical/practicum learning environments, as applicable; and

For Undergraduate Programs:

      • reflect the educational level at which students are being prepared to facilitate the achievement of the course student learning outcomes and end-of-program student learning outcomes.

For Graduate Programs:

      • reflect the educational level at which students are being prepared to facilitate the achievement of the course student learning outcomes, end-of-program student learning outcomes, and role-specific nursing competencies.

Criterion 4.10

Formative and summative student evaluation methods:

      • are utilized throughout the curriculum in all learning environments;

      • are varied and appropriate for all methods of delivery; and

      • align with the progression of course student learning outcomes.

NOTE, DIPLOMA PRE-LICENSURE REGISTERED NURSING PROGRAMS ONLY:
In the absence of requirements by a governing organization’s accrediting agency or regulatory agencies, the maximum number of credit hours is 90, including no more than 50 credit hours of nursing courses. The 90 credit hours must include all credit hours of general education courses or equivalent clock hours.

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Standard 5 Outcomes

Nursing program assessment demonstrates the extent of student learning at or near the end of the program as well as program outcome achievement using a systematic plan for evaluation (SPE).

The faculty create and implement a written SPE* for each nursing program type to determine the extent of the achievement of each end-of-program student learning outcome and program outcome, and additionally for graduate programs the role-specific nursing competencies, to inform program decision-making to maintain or improve student and program performance.

*Programs seeking initial accreditation are required to have data from the time that the nursing program achieves candidacy with the ACEN.

 Criterion 5.1

The systematic plan for evaluation describes the process for regular summative nursing program-level assessment of student learning outcome achievement. The faculty will:

      • use a variety of appropriate direct outcome assessment methods to ensure comprehensive summative assessment for each end-of-program student learning outcome;

      • establish a specific, measurable expected level of achievement outcome statement for each summative assessment method;

      • collect aggregate assessment data at regular intervals (determined by the faculty) to ensure sufficiency of data to inform decision-making and disaggregate the data to promote meaningful analysis; provide justification for data that are not disaggregated;

      • analyze assessment data (aggregate and/or disaggregate) at regular intervals (determined by the faculty) and when necessary, implement actions based on the analysis to maintain and/or improve end-of-program student learning outcome achievement;

      • maintain documentation for the three most recent years of the assessment data (aggregate and/or disaggregate), the analysis of data, and the use of data analysis in program decision-making to maintain and/or improve students’ end-of-program student learning outcome achievement; and

      • share the analysis of the end-of-program student learning outcome data with communities of interest.

Additionally for Graduate Programs:

      • The systematic plan for evaluation describes the process for regular summative nursing program-level assessment for role-specific nursing competencies for each program option, which may be aligned with the end-of-program student learning outcomes or assessed separately.

Criterion 5.2

The written systematic plan for evaluation describes the process for annual assessment of the nursing program completion rate. The faculty will:

      • calculate the on-time program completion rate for each program option from the first nursing course through completion of the courses required for conferral of a certificate, diploma, or degree;

      • establish a specific, measurable expected level of achievement outcome statement for on-time program completion for each program option and provide a rationale for each expected level of achievement;

      • collect aggregate program completion rate data annually and disaggregate the data to promote meaningful analysis; provide justification for data that are not disaggregated;

      • analyze program completion rate data (aggregate and/or disaggregate) annually and when necessary, implement actions based on the analysis to maintain and/or improve program completion rate;

      • maintain documentation for the three most recent years of the data (aggregate and/or disaggregate), the analysis of data, and the use of data analysis in program decision-making to maintain and/or improve students’ success in completing the program; and

      • share the analysis of the program completion rate data with communities of interest. 

Criterion 5.3

The written systematic plan for evaluation describes the process for annual assessment of the licensure and/or certification examination pass rate (when required for practice). The faculty will:

      • examine aggregate examination pass rate data (licensure and/or certification) secured from regulatory and/or certifying agencies. The most recent annual pass rate OR the mean pass rate for three most recent years must meet at least one of the following based on the total number of test-takers:

    • 80% or greater for all first-time test-takers; or
    • 80% or greater for all first-time test-takers and repeaters; or
    • at or above the national/territorial mean based on the nursing program type.
      • disaggregate the pass rate data to promote meaningful analysis; provide justification for data that are not disaggregated;

      • analyze program licensure and/or certification examination pass rate data (aggregate and/or disaggregate) annually and when necessary, implement actions based on the analysis to maintain and/or improve students’ examination pass rate success;

      • maintain documentation for the three most recent years of the aggregated and/or disaggregated data, the analysis of data, and the use of data analysis in program decision-making to maintain and/or improve students’ success in passing the licensure and/or certification examination; and

      • share the analysis of the licensure and/or certification examination pass rate data with communities of interest.

Criterion 5.4

The written systematic plan for evaluation describes the process for annual assessment of the job placement rate. The faculty will:

      • use appropriate assessment methods to request job placement data from all graduates based on the role for which graduates are prepared. For students who hold licensure/certification as a registered or advanced practice nurse upon admission to the nursing program, assessment may include, but is not limited to, professional/personal growth, career advancement, and/or a new role specialty with the degree/certificate achievement;

      • establish a specific, measurable expected level of achievement outcome statement for job placement in the role for which graduate are prepared and provide a rationale for the expected level of achievement;

      • collect sufficient aggregate post-graduation job placement rate data annually including the response rate and disaggregate the data to promote meaningful analysis; provide justification for data that are not disaggregated;

      • analyze sufficiency of job placement rate data annually and when necessary, implement actions to maintain and/or improve data sufficiency;

      • analyze aggregate job placement rate data (aggregate and/or disaggregate) annually and when necessary, implement actions based on the analysis to maintain and/or improve the job placement rate;

      • maintain documentation for the three most recent years of the data (aggregate and/or disaggregate), the analysis of data, and the use of data analysis in program decision-making to maintain and/or improve students’ success in obtaining a job in a role for which the program prepared them; and

      • share the analysis of the job placement rate data with the communities of interest.

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