ACEN ACCREDITATION MANUAL • SECTION I GENERAL INFORMATION • SECTION II POLICIES • SECTION III STANDARDS AND CRITERIA • GLOSSARY
ACEN 2017 Accreditation Manual – Section I
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- ACEN Organizational Structure
- The Commission
- ACEN Staff
- Accreditation Standards and Criteria for Academic Quality of Postsecondary and Higher Degree Programs in Nursing
- Accreditation Processes and Procedures
- Accreditation Cycles
- Planning for Accreditation
- Overview of the Initial or Continuing Accreditation Process
- Candidacy Process
- Initial Accreditation
- Continuing Accreditation
- Self-Review and Self-Study Report
- The Initial or Continuing Accreditation Site Visit
- Multiple Nursing Programs within a Nursing Education Unit
- Coordinated Site Visits with Other Agencies
- Length of the Initial or Continuing Accreditation Site Visit
- Assignment of Peer Evaluators on a Site Visit Team
- Team Chairperson
- Team Members
- Responsibilities of the Nursing Program
- Travel Arrangements
- Agenda for the Initial or Continuing Accreditation Site Visit
- Visiting Off-Site Locations of the Nursing Program
- Access to Hybrid/Online Nursing Courses
- Internet Access while on Campus and at the Hotel
- The Site Visit Report
- Evaluation Review Panel
- Board of Commissioners
- Peer Evaluators
The Accreditation Commission for Education in Nursing (ACEN) supports the interests of nursing education, nursing practice, and the public by the functions of accreditation. Accreditation is a voluntary, peer-review, 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.
The purpose of the ACEN is to provide specialized accreditation for all levels of nursing education and transition-to-practice programs.
Nursing Education Accreditation:
The ACEN is recognized by the United States Department of Education (USDE) as a specialized accrediting agency for nursing education programs located in the United States and its territories.
The ACEN is recognized by the Council for Higher Education Accreditation (CHEA) for nursing education programs in the United States and its territories as well as for international nursing education programs.
The ACEN accredits all types of nursing programs, including clinical doctorate/DNP specialist certificate, master’s/post-master’s certificate, baccalaureate, associate, diploma, and practical nursing programs.
The ACEN accredits nursing programs in secondary, postsecondary, and hospital-based governing organizations that offer certificates, diplomas, or degrees.
The ACEN serves as a Title IV-HEA Gatekeeper for some practical nursing programs and hospital-based programs eligible to participate in financial aid programs administered by the USDE or other federal agencies.
The ACEN accredits non-credit transition-to-practice programs at all levels of nursing licensure.
The ACEN accredits non-credit transition-to-practice programs offered by academic institutions (e.g., university, college, career center) and/or healthcare agencies (e.g., hospitals, long-term care).
As the leading authority in nursing accreditation, the goal of the ACEN is to be a supportive partner in strengthening the quality of nursing education and transition-to-practice programs through:
- Supporting nursing education and transition-to-practice programs in obtaining and maintaining accreditation
- Promoting peer review
- Advocating for self-regulation
- Fostering quality, equity, access, opportunity, mobility, and preparation for practice, or transition-to-practice, at all levels of nursing preparation
- Developing standards and criteria for accreditation
The ACEN is recognized as the accrediting body for all types of nursing education by:
- United States Department of Education (USDE)
- Council for Higher Education Accreditation (CHEA)
National, regional, and specialized accreditors that oversee federal funding eligibility must be reviewed by the USDE to ensure that the accrediting body meets specific standards established by Congress. The Secretary of Education for the USDE is charged with review of accrediting bodies and providing recognition to those accrediting agencies that meet the Secretary of Education’s criteria. Students in institutions or programs accredited by a USDE-recognized agency may be eligible for federal financial aid assistance and other needed resources.
CHEA is a national and international advocate for academic quality through accreditation. The ACEN is recognized by CHEA as a programmatic accreditor for all levels of nursing education in the United States, its territories, internationally, and is inclusive of those programs delivered via distance education.
ACEN accreditation is a voluntary peer-review process intended to enhance quality improvement in nursing education. Accreditation has:
- Student benefits:
- Provides useful information for students’ career and education decision-making
- Enables student eligibility for funding support from federal and state agencies, and foundations
- Facilitates transfer of credits
- Is required for admission to many undergraduate and graduate nursing programs, as well as by some state regulatory agencies or employers
- Faculty benefits:
- Heightens faculty members’ and administrators’ awareness and responsiveness to areas needing development
- Offers professional development opportunity and validation
- Community benefits:
- Assists employers seeking graduates who are competent practitioners
The ACEN 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 and criteria, policies, and procedures for participation in accreditation and review of accreditation processes. The ACEN 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 through the self-study process and accreditation review process and ensures the promotion of effective education and program improvement. Because the nursing education unit analysis is closely related to the governing organization itself, ACEN activities will be coordinated with those of other officially recognized regional and specialized accrediting bodies as well as state agencies when possible.
Standards and criteria for accreditation, materials that document compliance, 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 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.
ACEN AND THE HISTORY OF NURSING ACCREDITATION
The ACEN has a long-standing history with nursing accreditation in the United States. It was the first nursing accrediting agency. Please see the ACEN website for additional information about the history of the ACEN.
- Initial and continuing accreditation site visits (domestic and international) of approximately 150–200 nursing programs per year
- Continuous monitoring of more than 1,200 nursing education programs per year
- ACEN Directory of Accredited Nursing Programs (electronic database)
- Continuing education and professional development through events:
- Candidacy Mentoring Program
- Advisory Review Program
- Observer Program
- Mentoring by Professional Staff
- ACEN Accreditation Manual
- Bridges and Signal Flame (electronic newsletters)
- Report to Constituents
- Analysis of ACEN Annual Reports
- Analysis of Accreditation Cycles
- ACEN website: www.acenursing.org
2. ACEN ORGANIZATIONAL STRUCTURE
3. THE COMMISSION
OVERALL STRUCTURE OF THE COMMISSION
The ACEN is governed by a 17-member Board of Commissioners. The Commissioners are elected by the representatives of ACEN-accredited nursing programs. The legal basis for the foundation and structure of the commission is outlined in the bylaws and the Articles of Incorporation. The ACEN is incorporated under the laws of the State of New York.
- There are 11 Commissioners who are nurse educators representing ACEN-accredited programs, three Commissioners who represent the public, and three Commissioners who represent nursing service.
- Commissioners are diversified and ensure balanced representation from across identified constituencies insofar as possible.
- The Board of Commissioners sets accreditation policy and makes accreditation, administrative, budget, and policy decisions.
- Commissioners serve as chairpersons of the program-specific Evaluation Review Panels.
- Decision of accreditation status is made by the Commissioners based on review of program materials, including but not limited to the Self-Study Report/Focused Site Visit Report/Follow-Up Report, the Site Visit Report/Focused Site Visit Report/Follow-Up Visit Report from peer evaluators, and the recommendation of the Evaluation Review Panel.
- No current governor, current officer, or current/former employee of the NLN or its subsidiaries, or current employee of the ACEN, may serve as a Commissioner.
Names, credentials, and affiliations of Commissioners are available online.
4. ACEN STAFF
The ACEN staff maintain operational functions of the office and support the Chief Executive Officer (CEO), Board of Commissioners, and nursing programs. Names and credentials of staff are available online.
5. ACCREDITATION STANDARDS AND CRITERIA FOR ACADEMIC QUALITY OF POSTSECONDARY AND HIGHER DEGREE PROGRAMS IN NURSING
The core values of accreditation emphasize learning, community, responsibility, integrity, value, quality, and continuous improvement through reflection and analysis.
Peer review is a long-established and effective process that promotes institutions and academic programs embracing quality assurance and quality improvement to become stronger and better institutions and programs by setting standards of educational quality. It is used by the ACEN to help determine which programs meet or exceed established standards and criteria for educational quality in nursing education. The ACEN peer evaluators are familiar with contemporary practices in various program types and receive training from the ACEN to make informed recommendations about a program’s compliance with the ACEN Standards and Criteria.
Quality in nursing education ensures high levels of opportunity for student learning and achievement. Accreditation is an affirmation of values central to postsecondary and higher education, including appropriate mission, organizational structures, processes, and functions; resources aligned with core values; collegiality; and continuous improvement.
The ACEN accredits all types of nursing education programs leading to a diploma, certificate, or degree in a variety of postsecondary and higher education settings, including vocational-technical schools, hospitals, professional schools, community/technical colleges, and colleges/universities.
UNDERSTANDING ACEN STANDARDS AND CRITERIA IN THE EVALUATION OF NURSING EDUCATION UNITS
Each certificate, diploma, or degree has an identifiable, discrete set of specific end-of-program student learning outcomes and program outcomes. Postsecondary and higher education provide for the development of learners’ ability to think for themselves, master analytical problem-solving, apply scientific knowledge, and make value judgments within the context of the specific program type. Thus, education requires a broad academic orientation, depth, and breadth of intellectual skills translated into competencies so as to fulfill nursing’s functions in all types of nursing.
Standard – Agreed-upon expectations to measure quantity, extent, value, and educational quality.
Criteria – Statements that identify the elements that need to be examined in evaluation of a Standard.
The current version of the ACEN Standards and Criteria become effective on the date specified by the Board of Commissioners. Programs scheduled for review within 12 months of the ACEN Standards and Criteria effective date may elect to use the current or former version of the ACEN Standards and Criteria.
6. ACCREDITATION PROCESSES AND PROCEDURES
The ACEN has two accreditation cycles annually: the Fall Cycle (July 1 to December 31) and the Spring Cycle (January 1 to June 30). During each of the cycles, there is a 6 to 7-week period during which the initial and continuing accreditation site visits are scheduled.
Nursing programs considering accreditation should contact the ACEN to begin the candidacy process. As part of this process, nursing programs will be assigned a member of the professional staff as their mentor. The mentoring service is provided to facilitate faculty self-review and planning. The nurse administrator, program faculty, and administrative officers of the governing organization determine when the program is ready to apply for candidacy and the initial accreditation site visit. The decision should be based on an in-depth self-study of the program in relation to the ACEN Standards and Criteria.
Note: Upon granting of initial accreditation by the ACEN Board of Commissioners, the effective date of initial accreditation is the date on which the nursing program was approved by the ACEN as a candidate program that concluded in the Board of Commissioners granting initial accreditation. Accreditation is not retroactive for students who graduated prior to the program achieving candidate status with the ACEN. See ACEN Policy #34.
OVERVIEW OF THE INITIAL OR CONTINUING ACCREDITATION PROCESS
The ACEN accreditation process includes the following primary steps:
*An Appeal Committee may be convened only when initial or continuing accreditation is denied by the Board of Commissioners.
Programs seeking initial accreditation with the ACEN must start with the candidacy process. The ACEN process for nursing programs seeking initial accreditation after achieving candidate status or continuing accreditation is a comprehensive, four-step process starting with the program’s self-reflection regarding its compliance with the ACEN Standards and Criteria and as presented in its Self-Study Report. The second step is the site visit of the program resulting in the peer evaluators documenting their assessment and accreditation recommendation regarding the program’s compliance with the ACEN Standards and Criteria in the Site Visit Report. In the third step, a program-specific Evaluation Review Panel examines the reports written by and about the program (Self-Study Report and Site Visit Report) reaching their own independent judgement and accreditation recommendation regarding the program’s compliance with the ACEN Standards and Criteria. The final step is a review of the process by the ACEN Board of Commissioners. While considering the peer evaluators’ judgement and accreditation recommendations, the Commissioners also reach their own independent judgement regarding the program’s compliance with the ACEN Standards and Criteria and make an accreditation decision.
A nursing program seeking initial accreditation must apply for candidacy. A nursing program offered by a single governing organization or a nursing program offered by multiple governing organizations that have formed a consortium may be eligible for ACEN accreditation. If a consortium seeks accreditation, all governing organizations within the consortium must offer the same program type leading to an authorized degree or certificate/diploma.
- All governing organizations within the consortium must meet approval and accreditation requirements as stated by the ACEN; see Policy #3 Eligibility for Initial and Continuing Accreditation.
- The consortial nursing program must meet approval requirements as stated by the ACEN; see Policy #3 Eligibility for Initial and Continuing Accreditation.
- The consortial nursing program must meet the ACEN definition for being a single nursing program; see ACEN Glossary.
Candidate status is granted after the ACEN professional staff review the nursing program’s potential to achieve ACEN accreditation through a review of the Candidacy Presentation. Programs applying for initial accreditation will be assigned an ACEN professional staff member once they have begun the candidacy process. A program seeking accreditation must:
- Complete the Candidacy Eligibility Application. After eligibility has been confirmed, submit payment for the required fee. See Schedule of Accreditation Fees for Domestic Programs and Schedule of Accreditation Fees for International Programs.
- After eligibility has been confirmed and within the designated timeframe, submit a Candidacy Presentation based upon the guidelines.
NOTE: The candidacy process differs for international nursing programs. Information regarding this process is available in the Supplement of International Programs.
All materials submitted are reviewed by the ACEN professional staff. Applicants are notified if they are approved for candidacy, are deferred, or are disapproved. Approval for candidacy is granted when the nursing program (a) demonstrates it is currently compliant with the requirements of the Candidacy Presentation and candidacy process or (b) demonstrates an ability to be compliant with the requirements during the candidacy period. A program may also be differed or disapproved. See Policy #34 Candidacy for Governing Organization/Nursing Program Seeking Initial Accreditation.
An overview of the candidacy process:
Programs that achieve candidate status must publicly disclose its candidate status. See Policy #34 Candidacy for Governing Organization/Nursing Program Seeking Initial Accreditation.
If a program’s candidacy expires prior to scheduling an initial accreditation site visit, then the program must restart the candidacy process to renew its candidate status. The candidacy process can be restarted at any time after either being disapproved or when the program’s candidacy has expired.
Each governing organization/nursing program making a Candidacy Presentation to ACEN or granted candidacy agrees to certain requirements concerning financial obligation, choice of law, jurisdiction, and venue. See Policy #28 Litigation and Policy #38 Arbitration.
Programs pursuing candidacy and initial accreditation with the ACEN must notify the ACEN of changes that occur in the program during the entire candidacy process as both eligibility for candidacy and candidate status are based upon the information provided in the Candidacy Eligibility Application or the Candidacy Presentation. Changes that occur can affect the program’s eligibility to pursue the process and/or achieve initial accreditation with the ACEN. Therefore, programs must notify the ACEN of changes, which include but are not limited to changes in nurse administrator, change in status with the state regulatory agency or the accrediting body of the governing organization, changes in curriculum/options, potential addition of a new location, or implementation of distance education. Contact your ACEN mentor for guidance related to any change and the potential need to report a change. The ACEN must be notified of all changes no less than four months prior to the change or as soon as possible for any unexpected changes. The notification should be in writing and should address the selected criteria from the Candidacy Presentation related to the change (e.g. all of the Standard 4 Curriculum criteria for a change in the curriculum and/or new option). Failure to notify the ACEN of changes may delay or jeopardize a nursing program from being approved for candidacy; hosting an initial accreditation site visit; or being granted initial accreditation by the Board of Commissioners. See ACEN Policy #34 Candidacy for Governing Organization/Nursing Program Seeking Initial Accreditation.
A governing organization that offers a program not accredited by the ACEN initiates the candidacy process through its Chief Executive Officer and nurse administrator. The Chief Executive Officer of the governing organization for the nursing program/nursing education unit as well as the nurse administrator must authorize the ACEN to conduct the accreditation process by submitting the Official Authorization for Candidacy Process Form. Once candidacy status has been achieved, the Chief Executive Officer of the governing organization and the nurse administrator must authorize the scheduling/hosting of the initial accreditation site visit using the Information Form for Accreditation Site Visit. A program seeking initial accreditation must achieve candidacy prior to scheduling the initial accreditation site visit (see section on candidacy process above).
A nursing program may discontinue the initial accreditation process at any time. A program seeking initial accreditation can also withdraw from the process at any point prior to being reviewed by the Board of Commissioners.
NOTE: In order for the ACEN to properly discharge its responsibilities to the USDE pursuant to 34 CFR Section 602.28 and per Policy #3 Eligibility for Initial and Continuing Accreditation, an applicant for candidacy must disclose and certify that neither the governing organization nor the nursing program is the subject of certain circumstances.
The program will be required to disclose and certify this information at the time that Official Authorization for Candidacy Process Form is signed and again when the program applies for the initial accreditation site visit. Information submitted by the program will be kept confidential and will only be utilized by the ACEN in its report to the USDE as required. The information provided by the governing organization/nursing program will not be utilized in determining the program’s candidacy or its initial accreditation with the ACEN. The achievement of a candidate status as well as achieving initial accreditation will be based upon the program’s ability to demonstrate compliance with the current ACEN Standards and Criteria.
Planning for continuing accreditation is an ongoing process. A program must be visited and re-evaluated at specified intervals to ensure continuing compliance with the ACEN Standards and Criteria. The ACEN staff notify the program of a pending visit approximately 18 months in advance. Dates for the continuing accreditation site visit are scheduled in consultation with the nurse administrator, as the program must be in full operation during the visit.
Official authorization to conduct the ACEN accreditation process is secured from the Chief Executive Officer of the governing organization and the nurse administrator for the nursing program. The Information Form for Accreditation Site Visit is available on the ACEN website for the program to complete approximately 18 months before the visit is to take place.
If an ACEN-accredited program seeks to delay or reschedule a visit, refer to Policy #6 Delay/Advancement of Continuing Accreditation Visit. If an ACEN-accredited program seeks to voluntarily withdraw from ACEN accreditation, refer to Policy #7 Voluntary Withdrawal from ACEN Accreditation.
The ACEN professional staff are available to assist programs preparing for an initial or continuing accreditation site visit. The ACEN website also provides a wide variety of online resources for programs, including but not limited to the ACEN Accreditation Manual, the ACEN Glossary, the forms to use for scheduling an initial or continuing accreditation site visit, and various resources related to preparation of the Self-Study Report and for the site visit, preparation of a Follow-Up Report, reporting Substantive Changes, and preparation of the Focused Site Visit Report.
Continuing education is offered to provide program faculty and leaders information about the accreditation processes and details regarding the preparation of the Self-Study Report. All programs seeking initial and continuing accreditation are encouraged to participate in these offerings. See the ACEN website for additional information.
Advisory Review is an opportunity for an ACEN-accredited program to receive feedback from an ACEN professional staff member assigned to the Advisory Review regarding draft program documents as the program prepares for a continuing accreditation site visit. Examples of documents could include a portion(s) of the Self-Study Report, faculty profile table, or systematic evaluation plan. This is an optional resource for currently accredited programs and is not a requirement for continuing accreditation. Professional staff feedback indicates the staff member’s best judgment but does not guarantee that the Board of Commissioners will determine that the program complies with the ACEN Standards and Criteria. An Advisory Review may be conducted in one of three formats, which include teleconference, videoconference, or in-person review. Additional information about an Advisory Review is accessible on the ACEN website, including the fee for this service.
The Observer Experience provides a nursing program with the opportunity to send a program representative on an accreditation site visit as an observer. This typically occurs one year to 18 months prior to an upcoming accreditation site visit. The Observer Experience enables the program representative to observe every component of site visit process, including orientation as a peer evaluator and team preparation prior to the site visit. A nursing program submits a request to have an observer on an upcoming visit to a nursing program who has consented to have an observer. The governing organization for the observer is responsible for all costs of the observer in this experience. See ACEN Policy #32 Observer on Site Visit Team as well as the website for additional information regarding being an observer on a site visit team.
SELF-REVIEW AND SELF-STUDY REPORT
Any program preparing for initial or continuing accreditation must submit a Self-Study Report to demonstrate the extent to which the program meets the ACEN Standards and Criteria. The Self-Study Report is due to the peer evaluators that visit the program and to the ACEN office no later than six weeks prior to the date of the initial or continuing accreditation site visit.
The process of self-study represents the combined efforts of the governing organization administrators, nursing program administrators, faculty, staff, students, and other individuals concerned with the nursing program(s). All those associated with the program(s) should participate in the self-study process. Broad participation leads to an understanding of the total program.
The Self-Study Report is a primary document used by the peer evaluators visiting the program, the peer evaluators on the Evaluation Review Panel, and the Board of Commissioners to understand the nursing program.
- The report must be based on the ACEN Standards and Criteria in effect at the time of review and the most recent edition of the ACEN Accreditation Manual. ACEN Standards and Criteria become effective on the date specified by the Board of Commissioners. Programs scheduled for review within 12 months of the ACEN Standards and Criteria effective date may elect to use the current or former version of the ACEN Standards and Criteria.
- Faculty and administrators are responsible for presenting narrative and evidence that clearly demonstrate the extent to which the program meets the ACEN Standards and Criteria. Peer evaluators visiting the program will use the Self-Study Report in preparation for their visit to the program.
The ACEN Guidelines for Written Reports are available to assist programs in preparing for an upcoming initial or continuing accreditation site visit.
THE INITIAL OR CONTINUING ACCREDITATION SITE VISIT
The purpose of the initial or continuing accreditation site visit is to determine the extent to which the program meets the ACEN Standards and Criteria by clarifying, verifying, and amplifying the information (narrative/evidence) presented in the Self-Study Report. Based on findings, the peer evaluators visiting the program will make a recommendation relative to the accreditation status of the nursing program(s).
Onsite review of the program by peer evaluators is an essential part of the accreditation process. It provides the program an opportunity to demonstrate and highlight information presented in its Self-Study Report and provides for interaction among peer evaluators and stakeholders: administrators, faculty, students, staff, and the public. In addition, the initial or continuing accreditation site visit provides peer evaluators an opportunity to see the nursing program firsthand. The peer evaluators conduct an independent analysis and make professional judgments on the extent to which the program meets the ACEN Standards and Criteria; their judgments and accreditation recommendation are documented in the Site Visit Report. These peer evaluators verify congruence between the Self-Study Report and the actual practices of the program so that the peer evaluators on the Evaluation Review Panel and Board of Commissioners have a clear and complete understanding of the program.
Multiple Nursing Programs within a Nursing Education Unit
The ACEN encourages nursing education units offering more than one type of nursing program (clinical doctorate/DNP specialist certificate, master’s/post-master’s certificate, baccalaureate, associate, diploma, and/or practical) to request that all programs be reviewed for continuing or initial accreditation at the same time. The nursing education unit will prepare one Self-Study Report for all of the programs and host one site visit for all of the programs.
Coordinated Site Visits with Other Agencies
The ACEN welcomes the opportunity to cooperate with other accreditation and approval-granting agencies (e.g., state regulatory agency for nursing). The goal is to increase efficiency and decrease faculty workload while maximizing outcomes. Two options are available: the collaborative and the coordinated visit.
To arrange either a collaborative or a coordinated visit, the nurse administrator initiates the process by submitting a request to the ACEN. The ACEN staff then work with the institutional/program administrators and faculty members to achieve their goal.
For a coordinated site visit, the program prepares materials separately for each agency team. The two teams share an agenda and conduct a site visit that meets each agency’s requirements. However, the representative from another agency is not a member of the ACEN site visit team. The ACEN peer evaluators and the other representative may participate jointly in such activities as conferences with faculty, students, and other groups. Many of the activities of the ACEN peer evaluators and the representative will be carried out separately as the purposes of ACEN accreditation may differ from those of other accrediting/approval-granting bodies. At the conclusion of the site visit, each site visit team writes a report that documents the extent to which the program meets the agency’s respective standards and criteria or regulations.
Length of the Initial or Continuing Accreditation Site Visit
The initial or continuing accreditation site visit is typically scheduled for a minimum of three days. However, the length depends on several factors, including size and complexity of the nursing program, geographical locations of the various resources used for student learning experiences, the number of nursing programs involved, and coordination of the visit with other agencies. Correspondence from the ACEN will indicate the inclusive dates of the visit.
Assignment of Peer Evaluators on a Site Visit Team
Each initial or continuing accreditation site visit is conducted by a team of nursing educator peers with program-specific expertise and when appropriate, a clinician. The number of peer evaluators on a site visit team for review of a single program typically has a minimum of three members. Graduate programs offering advanced practice nursing options will have at least one team member with current advanced practice certification.
The ACEN staff will appoint the team of peer evaluators and notify the nurse administrator in advance of the visit. The nurse administrator should contact the ACEN staff in writing if a possible conflict of interest is identified with a peer evaluator. If a peer evaluator becomes ineligible or unable to serve, another peer evaluator with comparable qualifications will be appointed.
The ACEN staff will assign peer evaluators considering their expertise with multiple program factors, including but not limited to:
- Program type(s)
- Size of program(s) and governing organization
- Method(s) of program delivery
- Setting (urban, suburban, or rural)
- Governance of the governing organization (public, private, religious affiliation, etc.)
A peer evaluator is eligible to be a team chairperson for an initial or continuing accreditation site visit after serving on a minimum of three teams as a peer evaluator.
The team chairperson assumes the following responsibilities:
- Acts as official spokesperson for the team of peer evaluators
- Reviews all content of the ACEN accreditation information packet upon receipt
- Coordinates planning with the team members
- Conducts the team orientation and subsequent team meetings
- Receives and reviews the electronic files from the nurse administrator listing information on all individuals and groups interviewed by the team members and all documents reviewed in the evidence room
- Allocates responsibilities for various activities to ensure optimum utilization of team members and adequate coverage of all areas during the visit, including interviews and conferences with key personnel on and off campus
- Requests additional information as necessary
- Notifies the nurse administrator of the arrival of the team members and plans the time for the first meeting
- Conducts periodic conferences with the nurse administrator
- Arranges for the exit meeting with the nurse administrator and any persons the nurse administrator invites to be present
- Collates and edits the Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report to ensure completeness and clarity
- Emails the completed Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report to the ACEN within one week following the site visit
- Available for additional clarifications regarding the Site Visit Report during the Evaluation Review Panel preparation process; team members may receive requests for further clarifications up to the Sunday prior to Evaluation Review Panel meetings. Site visit team members are not required to be accessible to the Evaluation Review Panel reviewers during the actual Evaluation Review Panel proceedings.
- Assumes the additional responsibilities stated under “Responsibilities of the Team Members”
The team member assumes the following responsibilities.
When the ACEN accreditation information packet is received:
- Reviews all content of the packet
When the materials from the program are received:
- Reviews all materials
- Prepares a draft copy of the Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report findings and submits draft to the team chair for areas as assigned one week prior to the site visit
- Makes a list of findings from the Self-Study Report/Follow-Up Report that require additional verification, amplification, or verification at the time of the initial or continuing accreditation site visit
Upon arrival at the site:
- Assumes responsibility to collect data cooperatively and make observations
- Further develops Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report based on findings of the initial or continuing accreditation visit
- Participates in the exit meeting with the nurse administrator and any persons invited to be present
After the visit:
- Retains a copy of the final Self-Study Report, Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report, and any other resource materials used/developed during the site visit; then discards all materials no earlier than the Sunday prior to Evaluation Review Panel meetings and no later than the conclusion of Evaluation Review Panel
- Available for additional clarifications regarding the Site Visit Report during the Evaluation Review Panel preparation process; team members may receive requests for further clarifications up to the Sunday prior to Evaluation Review Panel meetings. Site visit team members will not be required to be accessible to the Evaluation Review Panel reviewers during the actual Evaluation Review Panel proceedings
Responsibilities of the Nursing Program
- Provides the team chair with an electronic file that lists the names, credentials, and titles of individuals and group members interviewed by the peer evaluators during the initial or continuing accreditation site visit
- Provides the team chair with an electronic file listing all documents including dates available in the supporting evidence by defined category
- Provides computers and printer(s) for the team members if requested by the team to use throughout the site visit
- Establishes a work room in which confidential materials for the peer evaluators are assembled and where the team members can read and work during the site visit
- Obtains any necessary written permissions required prior to the site visit (e.g., review of records and visits to clinical agencies)
- Assembles supporting evidence. See the ACEN Guidelines for Written Reports for suggested documents to include.
The supporting evidence will be used during the initial or continuing accreditation site visit and left with the nursing program upon completion of the site visit. Peer evaluators will ask to review records of faculty and students. The student record review includes both academic and financial aid records.
Programs for which all or part of the curriculum is delivered in a language other than English should make provisions for an interpreter to be present throughout the initial or continuing accreditation site visit and to make certain that all program documents are available in English for review by the peer evaluators.
Additional information related to the materials for the supporting evidence is available in the ACEN Guidelines for Written Reports.
See the Travel Policy for initial or continuing accreditation site visit arrangements for domestic programs.
See the Supplement for International Programs for initial or continuing accreditation site visit arrangements specific to international programs.
Agenda for the Initial or Continuing Accreditation Site Visit
At least six weeks prior to the scheduled initial or continuing accreditation site visit, a tentative agenda for the site visit is prepared by the nurse administrator and sent to the team chairperson along with a copy of the class and clinical laboratory schedules and the completed technology assessment form. See the ACEN website Report Writing and Site Visit Preparation Resources for a sample agenda for a site visit. Activities typically planned to take place during the initial or continuing accreditation site visit include for all locations and methods of delivery:
- Preliminary, interim, and closing meetings with the nurse administrator (and any persons invited to be present)
- Meetings with:
- faculty (all levels, all program options, and all locations)
- administrative officers of the governing organization
- nursing students (all levels, all program options, and all locations)
- the public for third-party comments
- student support service personnel (all locations)
- nursing service personnel (as appropriate)
- Visits to:
- appropriate on-campus and off-campus facilities and resources
- selected clinical agencies to observe and meet with students
- Review of:
- curricular and other materials prepared by the faculty (all levels and all program options)
- appropriate records of faculty, students, and recent graduates (all levels, all program options, and all locations)
- additional information to clarify, verify, and amplify the Self-Study Report
- Classroom and clinical observations for on-campus and off-campus locations and methods of delivery; must include all programs under review whether face-to-face or using distance education modalities
Visiting Off-Site Locations of the Nursing Program
Prior to the visit, programs with branch campuses or off-campus instructional sites must discuss with the team chairperson alternative methods for the visiting team to evaluate additional locations on which the program is offered. If locations are more than one hour apart in driving distance, the nurse administrator should communicate with the ACEN professional staff regarding visits to the additional locations. See ACEN Guidelines for Written Reports.
Access to Hybrid/Online Nursing Courses
Prior to the visit, programs with hybrid or online nursing courses must provide all peer evaluators access to the courses. The access to the courses should be provided with the Self-Study Report at least six weeks prior to the initial or continuing accreditation visit and continue throughout the visit.
Internet Access while on Campus and at the Hotel
The nursing program is also responsible for making sure that the peer evaluators have access to the Internet in the campus work room during the initial or continuing accreditation site visit. Information Technology (IT) support should be available to the peer evaluators during the site visit if needed. The nursing program should also ensure Internet access is available at the hotel where the peer evaluators are staying during the site visit.
The site visit team chairperson is responsible for presenting an accurate, complete, and well-organized Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report to the ACEN within one week after the conclusion of the initial or continuing accreditation site visit. Team members review the final report prior to submission to the ACEN.
ACEN Staff Review
All Site Visit Reports/Follow-Up Visit Reports/Focused Site Visit Reports are reviewed by the ACEN professional staff. If questions arise, the site visit team is contacted for clarification.
A draft copy of the Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report is emailed to the nurse administrator of the nursing program/nursing education unit for review and correction of errors of fact within eight weeks after the conclusion of the site visit. An email with the completed Nurse Administrator Response Form attached must be received by the ACEN within one week after the nursing program/nursing education unit receives the draft report.
The Nurse Administrator Response Form provides the program the opportunity to submit errors of fact within the report as well as substantive comments related to the facts at the time of the site visit. The Nurse Administrator Response Form is reviewed by the ACEN Staff and is shared with the team as needed, who then decides whether the report is to be changed. After this decision and any necessary changes are made, the report becomes final. The final Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report and the Nurse Administrator Response Form will become part of the permanent materials relating to the initial or continuing accreditation site visit.
The final Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report will be emailed to the nurse administrator. The peer evaluators that visited the program will also receive a copy of the final report prior to the Evaluation Review Panel meeting via email.
The Evaluation Review Panel members are appointed by the ACEN Board of Commissioners. The role of the Evaluation Review Panel is to continue the peer review process, conduct its own independent analysis on the extent to which the program meets the ACEN Standards and Criteria, make an accreditation recommendation, and to ensure the consistent application of the ACEN Standards and Criteria among programs of the same type. The panel reviews the findings as presented in the Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report compared to the Self-Study Report/Follow-Up Report/Focused Site Visit Report of the program(s) and make its recommendation for accreditation status to the Board of Commissioners. Documents relative to developments occurring after the initial or continuing accreditation site visit may be used in the deliberations. The Evaluation Review Panel member may request additional information/clarification during their review of the materials. The site visit team members may be contacted by the professional staff prior to the Evaluation Review Panel meeting to assure an accurate understanding of the Site Visit Report/Follow-Up Visit Report/Focused Site Visit Report.
The Evaluation Review Panel also validates the work of the peer evaluators that visited the program and extends it by noting points of agreement and raising any questions where disagreement or a lack of clarity exists. The aim is to provide consistency in the findings for the program type.
Nursing Program Representative Attendance at the Evaluation Review Panel Meeting
The nurse administrator and one additional program representative may attend the deliberations of the Evaluation Review Panel about the program in person or the program may participate in the Evaluation Review Panel deliberations by telephone conference call. The attendees are observers during the presentation of the program, Evaluation Review Panel deliberations, and vote; attendees will not be asked to respond to questions or to clarify information. At the conclusion of the Evaluation Review Panel deliberations, the nurse administrator is invited to address the panel with regards to the overall process.
The Board of Commissioners has the sole authority to determine the accreditation status of programs. Composed of nurse educators, nursing clinicians/practitioners, and public members, the Board of Commissioners bases its decisions on its own independent analysis and professional judgment on the extent to which the program meets the ACEN Standards and Criteria, while considering the previous peer evaluators’ judgement and recommendations, as well as the consistent application of the ACEN Standards and Criteria within and across all program types. The entire Board of Commissioners makes the accreditation decision at a regularly scheduled meeting (typically, March and September). Documents relative to the review process of the program are used in the Commissioners’ deliberations. Documents relative to developments occurring after the initial or continuing accreditation site visit may be used in the deliberations. In cases where accreditation is denied, programs have the opportunity to present their case in an impartial hearing before an independent Appeal Committee per Policy #10 Appeal Process and Submission and Review of New Financial Information Subsequent to Adverse Action.
To assist the nursing program in future planning, the nurse administrator receives a copy of the Summary of Deliberations of the Evaluation Review Panel and the Commissioners’ decision letter.
Peer evaluators make recommendations to the Board of Commissioners. Peer evaluators are knowledgeable about common, contemporary, and best practices within the various program types, appropriate curricula, and conventions as well as current trends in healthcare, nursing education, and/or nursing practice.
Eligibility for Selection as a Peer Evaluator
Eligibility to serve as an ACEN peer evaluator is dependent on the following requirements:
See ACEN Policy #1 Code of Conduct and Conflict of Interest.
See ACEN Policy #2 Representation on the Site Visit Teams, Evaluation Review Panels, and Board of Commissioners.
Clinical Doctorate and Master’s Programs
- Earned doctoral degree from an accredited college/university and a graduate degree with a major in nursing or related field from an accredited college/university
Baccalaureate, Associate, Diploma, and Practical Programs
- Graduate degree with a major in nursing or related field from an accredited college/university
- Graduate degree with a major in nursing or related field from an accredited college/university
- Currently hold a full-time faculty, part-time faculty, or administrative appointment in an ACEN-accredited program
- Previously held a full-time faculty or administrative appointment in an ACEN-accredited program and now holds a part-time faculty or administrative appointment in an ACEN-accredited program
- Held a full-time faculty, part-time faculty, or administrative appointment in an ACEN-accredited program and is retired for no more than two years from this position
- Held a full-time faculty or administrative appointment in an ACEN-accredited program and then held a part-time faculty or administrative appointment in an ACEN-accredited program and is retired for no more than two years from the part-time position
- Knowledge of postsecondary and/or higher education; curriculum and instructional methods; current issues in nursing education and practice
- Expertise in communication, group dynamics, information literacy, use of technology, best practices in educational and clinical settings
- Contributions in scholarship/research, practice, community service, professional service
- Full-time or part-time position in a clinical practice environment
- Knowledge of current nursing practice, contemporary issues in healthcare settings, transition of new graduates into nursing practice
- Expertise in communication, group dynamics, information literacy, use of technology, best practices for patient health and safety
- Contributions in scholarship/research, practice, community service, professional service
We encourage you to self-nominate or nominate nurse educators and nurse clinicians/practitioners to serve as a peer evaluator.
Emeriti Peer Evaluators
Emeriti peer evaluators are nurse educators or nurse clinicians/practitioners who have continuous service as a peer evaluator; maintained expertise in the ACEN peer review process; receive consistent positive feedback from ACEN staff, other peer evaluators, and nurse administrators; and were appointed by the Board of Commissioners as Peer Evaluator Emeritus. The emeritus status can be granted two years after retirement from full-time faculty, part-time faculty, or administrative appointment in an ACEN-accredited program or two years after retirement from serving as a full-time or part-time clinician/practitioner. The emeritus appointment is recognition of the peer evaluators’ ongoing engagement and maintenance of expertise in the ACEN peer review process. The considerations for being appointed an emeriti peer evaluator are required for someone to continue serving as an emeriti peer evaluator.
Selection, Appointment, and Maintaining Eligibility as a Peer Evaluator
All peer evaluators are selected through mechanisms and criteria established by the ACEN.
Individuals identified by staff, nominated by a colleague, or self-nominated must submit a letter of interest, current curriculum vitae/résumé, and a letter of recommendation. After ACEN staff review of submitted materials, selected individuals will be invited to become peer evaluators and must participate in the peer evaluator professional development offered by the ACEN.
Peer evaluators are eligible to serve for an indefinite period of time if they receive ongoing positive site visit performance evaluations, remain current with the accreditation process, and continue to meet eligibility requirements; see Policy #1 Code of Conduct and Conflict of Interest and Policy #2 Representation on Site Visit Teams, Evaluation Review Panels, and the Board of Commissioners. A list of the current program evaluators is accessible on the ACEN website.
Peer evaluators are evaluated by the members of the site visit team and the nurse administrator following each initial or continuing accreditation site visit.
Required training is initially completed in an online program, and brief updates are provided each accreditation cycle for all peer evaluators prior to the assigned visit.
An honorarium will be provided to the peer evaluator after a visit is completed.
Evaluation Review Panel Members
Members of the Evaluation Review Panel are program-specific and appointed by the Board of Commissioners. The ACEN professional staff review candidates based on information from current members of the Evaluation Review Panel, peer evaluators, Commissioners, and accredited programs and recommend their names to the Board of Commissioners. Members of the Evaluation Review Panel must be eligible peer evaluators.
Members of the Evaluation Review Panel pool are eligible to serve for an indefinite period of time as long as a person remains an eligible peer evaluator. Panels are filled by program-specific peer evaluators selected from the list of members.
Members of the Evaluation Review Panel are required to complete online training initially completed as well as the brief updates provided prior to each Evaluation Review Panel.
Required online training is initially completed and all members of the Evaluation Review Panel are expected to participate in a briefing session held prior to each Evaluation Review Panel to update panel members.
Panels are filled by program-specific peer evaluators selected from the list of members.
Appeal Committee Members
Members of the Appeal Committee must have knowledge of and experience with the peer-review process. The nurse educator and nursing clinician/practitioner members must be currently eligible peer evaluators. Commissioners cannot serve on the Appeal Committee.
The Appeal Committee consists of individuals selected from a Board of Commissioners-approved list of the individuals qualified to serve as members of the Appeal Committee. Members of the Appeal Committee pool are eligible to serve for an indefinite period of time as long as a person remains an eligible peer evaluator. See Policy #10 Appeal Process and Submission and Review of New Financial Information Subsequent to Adverse Action. A list of the individuals who have been appointed to the Appeal Committee is accessible on the ACEN website.
The ACEN shall maintain a roster of arbitrators. An arbitrator may be nominated by any governing organization/nursing program whether accredited by the ACEN or not, by the proposed arbitrator, or by ACEN Staff. There shall be no limit to the number of persons who may be nominated by any entity, and there shall be no limit to the number of arbitrators on the roster, though the ACEN will endeavor to have at least 12 persons listed on the roster. Arbitrators will be composed of nurse educators, nurse clinicians, and the public, and may not include current ACEN Board of Commissioners members or current ACEN appeal committee members. The term an arbitrator may remain on the roster is five years unless otherwise removed or resigned. The term of an arbitrator may be renewed, and there is no limit to the number of terms an arbitrator may serve. The ACEN will endeavor to ensure that the roster of arbitrators is representative of the diversity of ACEN-accredited programs.
The ACEN Chief Executive Officer (CEO) shall review the qualifications of any nominated arbitrator and shall accept, reject, or request further information concerning the nominated arbitrator. The CEO’s decision is final and not reviewable. A person who has previously been nominated as an arbitrator and rejected may be re-nominated.
An arbitrator must be a nurse educator, nurse clinician, or a representative of the public.
- For an arbitrator serving as a nurse educator, the majority of the person’s career experience must be as a nurse educator with a minimum of ten years’ experience in nursing education.
- For an arbitrator serving as a nurse clinician, the majority of the person’s career experience must be as a nurse clinician with a minimum of ten years’ experience in a role as a nurse clinician.
- For an arbitrator serving as a representative of the public the individual may have experience from inside or outside higher education. If a representative is from inside higher education then the representative may be currently working at a governing organization with a nursing program however, the representative must be from outside the nursing profession and from outside the accreditation of nursing programs. If a representative is from outside higher education then the representative may be currently working at a governing organization associated with nursing however, the representative must be from outside the nursing profession and from outside the accreditation of nursing programs.
- An arbitrator need not be a lawyer or have legal training, though both are considered desired qualifications.
- An arbitrator need not have any formal training in arbitration, though such training is considered a desired qualification.
- No person who is a current or previous employee of the ACEN may serve as an arbitrator.
- No person who is a current or previous employee with any nursing education accrediting agency, the American Association of Colleges of Nursing (AACN), or the National League for Nursing (NLN) may serve as an arbitrator.