ACCREDITATION MANUAL • SECTION I GENERAL INFORMATION • SECTION II POLICIES • SECTION III STANDARDS AND CRITERIA • GLOSSARY
ACEN Accreditation Manual
GLOSSARY
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Academic Engagement – Active participation by a student in an instructional activity related to the student’s course of study that:
- Is defined by the institution in accordance with any applicable requirements of its state or accrediting agency.
- Includes, but is not limited to:
- Attending a synchronous class, lecture, recitation, or field or laboratory activity, physically or online, where there is an opportunity for interaction between the instructor and students;
- Submitting an academic assignment;
- Taking an assessment or an examination;
- Participating in an interactive tutorial, webinar, or other interactive computer-assisted instruction;
- Participating in a study group, group project, or an online discussion that is assigned by the institution; or
- Interacting with an instructor about academic matters.
- Does not include, for example:
- Living in institutional housing;
- Participating in the institution’s meal plan;
- Logging into an online class or tutorial without any further participation; or
- Participating in academic counseling or advisement.
See ACEN definitions in this Glossary for methods of delivery, distance education, and regular and substantive interaction.
Academic Progression Models – Models for the delivery of nursing education programs that facilitate progression from one level of nursing education and/or practice to a higher level of nursing education and/or practice. May include articulation agreements or partnerships among colleges/universities, including but not limited to, concurrent or dual enrollment programs. Certificates or degrees offered by an ACEN-accredited program must be awarded to students who complete the ACEN-accredited program of study, regardless of whether they complete the additional requirements specified in a concurrent or dual-enrollment agreement.
Academically Qualified – See Qualified, Academically
Accreditation – See Credentialing
Additional Location – A facility that is geographically apart from the main campus and at which the governing organization offers at least 50% of a nursing program; this facility may qualify as a branch campus or an off-campus instructional site.
Administrative Capacity – The actual capabilities and resources available to the governing organization and nursing education unit that directly support the mission and purpose of the governing organization and the mission and purpose of a nursing education unit in the achievement of a nursing program’s end-of-program student learning outcomes and program outcomes.
Advanced Practice Registered Nurse (APRN) – Licensure classification for nurses who have advanced education, knowledge, and skills in one of four practice roles: clinical nurse specialist, nurse practitioner, certified registered nurse anesthetist, or certified nurse midwife.
Annual Report – Information an ACEN-accredited program is required to submit to the ACEN on an annual basis.
Alternative Methods of Delivery – Methods of delivering nursing courses in a nursing program and/or a nursing program option that differ from traditional in-person/in-a-classroom instructional methods where the faculty and the students are in the same location at the same time. See: Methods of Delivery.
Approval – See Credentialing
Area Needing Development (AND) – Peer evaluators determined based on their professional judgment that evidence demonstrates a nursing program is in compliance with an Accreditation Standard; however, evidence also demonstrates that an opportunity for improvement is available to enhance the quality of the nursing program.
Asynchronous Learning – Learning and instruction that do not occur in the same place or at the same time.
[/toggle]Branch Campus – An additional location of a governing organization that is geographically separate from and independent of the main campus of the governing organization. A location is independent of the main campus if the location meets all the following Criteria:
- is permanent in nature;
- offers courses in nursing program leading to a degree, certificate, or other recognized educational credential;
- has its own faculty and administrative or supervisory organization; and
- has its own budgetary and hiring authority.
A branch campus is not an off-campus instructional site.
[/toggle]Candidacy – The beginning process for a nursing program seeking accreditation with the ACEN.
Candidate Status – Candidate status is granted after a review of the potential of a nursing program to achieve ACEN accreditation. Candidacy does not constitute pre-accreditation as defined by the U.S. Department of Education. See the ACEN Accreditation Manual – Section I General Information for additional information regarding the Candidacy process.
Certification – See Credentialing
Chief Executive Officer (CEO) – The official who has the primary responsibility of carrying out the mission and purpose of the governing organization. In some circumstances, there may be an overall governing organization CEO and a local or campus CEO (e.g., a chancellor of the overall governing organization and a president of a campus).
Clinical/Practicum Learning Experiences – Direct, hands-on, planned learning activities with patients across the lifespan, interaction with the interprofessional team, and interaction with the patient’s family and friends that are sufficient and appropriate to achieve the end-of-program student learning outcomes, program outcomes, and/or role-specific professional competencies, and are overseen by qualified faculty who provide feedback to students in support of their learning. Clinical/practicum learning experiences must be consistent with the level of academic preparation and post-graduation scope of practice; and are required for all nursing students enrolled in any undergraduate or graduate program, including all students enrolled in post-licensure undergraduate programs, graduate programs, all program options in any undergraduate and graduate programs, and/or certificate program options.
Closing Report – A written plan developed by a governing organization/nursing education unit that provides for the equitable treatment of students should a governing organization/nursing education unit, or a nursing program location that provides 50% or more of a nursing program, cease to operate before all students have completed their nursing program of study. See ACEN Policy #16 Closings for additional information and the procedures that must be followed.
Communities of Interest – A group of people, identified by the nursing education unit, who influence nursing program processes, decision-making of a nursing education unit, the end-of-program student learning outcomes, and the program outcomes of a nursing program. Examples include, but are not limited to, students, graduates, healthcare employer representatives, governing organization representatives, state regulatory agency representatives, and members of the public.
Competent – having the necessary and sufficient ability, knowledge, skill, and experience to do something successfully and/or achieve a purpose.
Complaints and Grievances – A formal, written allegation against a nursing program, typically expressed as a written, signed statement. Complaints and/or grievances are defined by the nursing education unit and/or the governing organization. An accredited nursing education program is expected to maintain a record of all complaints against the program since the last ACEN accreditation visit including documentation of due process and resolution.
Compliance – Peer evaluators determined based on their professional judgment that evidence demonstrates a nursing program is in compliance with an Accreditation Standard.
Continuing Accreditation – The cyclical peer review process for an accredited nursing program to maintain accreditation with the ACEN.
Contractual Agreement – Typically, one in which a nursing program enters an agreement for receipt of courses or portions of courses (e.g., general education courses) delivered by another college/university or service provider to educate the program’s students.
Note: See ACEN Policy #30 Agreement for Education-Related Component from an External Source and Policy #14 Reporting Substantive Changes
Consortia Relationship – Typically, one in which two or more governing organizations/nursing education units share the responsibility of developing and delivering nursing courses or a nursing program, in whole or part. This does not include clinical agreements for student learning experiences required by a nursing program. See ACEN Policy #3 Eligibility for Accreditation and Policy #30 Agreement for Education-Related Component from an External Source for additional information and the procedures that must be followed.
Contemporary Nursing Practice – Professional nursing knowledge, skills, and behaviors that are based on current research and professional standards of the present time.
Core Values – Those beliefs or ideals that form the foundation for the work of a governing organization and/or nursing education unit.
- Accredited – The status of public recognition that a nationally recognized accrediting agency grants to an institution or educational program that meets the agency’s established requirements.
- Accreditation – The 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.
- Approval – The term generally referred to by most state regulatory agencies for nursing to describe authorization of nursing education programs meeting minimal standards as defined in the state nurse practice act and/or rules and regulations.
- Certification – The process by which an organization, association, voluntary agency, or state regulatory agency grants recognition that an individual possesses predetermined knowledge and/or skills specified for practice in an area of specialization.
- Licensure – The process by which a governmental agency gives affirmation to the public that the individuals engaged in an occupation or profession have minimal education, qualifications, and competence necessary to practice in a safe manner.
Criteria – Statements which identify the elements that need to be examined in evaluation of a standard.
Currently Enrolled – In reference to a nurse administrator or nursing faculty member, continuously enrolled as a graduate student in good standing and successfully completing a minimum of 6–9 semester credits per calendar year until the graduate degree is earned.
Curriculum Integrity – Demonstration of the soundness of a nursing program of study that develops from the mission/philosophy in an organized manner across a sequence of courses. The mission/philosophy and selected professional standards, guidelines, and competencies result in the faculty identifying end-of-program student learning outcomes that are specific and measurable.
Curriculum Rigor – Demonstration there is progression of knowledge, skills, and behaviors throughout a curriculum and that the curriculum is appropriately challenging for the level of contemporary nursing practice for which the program is preparing graduates.
[/toggle]Default Rate – The percentage of student borrowers at each governing organization who fail to remain current with repayment of their Federal financial aid student loans during the reporting period specified by the United States Department of Education.
Delivery Formats – Methods used to transfer knowledge, skills, and behavior from an instructor to a student. See: Methods of Delivery.
Distance Education – See: Methods of Delivery.
- Note: See ACEN Policy #15 Distance Education for additional information and the procedures that must be followed if a program uses any form of distance education.
Distance Technology – Instructional methods that may include but are not limited to one-way or two-way transmissions, audio, video, the Internet, and/or computer technologies.
Diversity Concepts – Knowledge about persons, communities, regions, countries, cultures, and ethnicities other than one’s own.
DNP Specialist Certificate – A selected series of courses that are a subset of courses within a clinical doctorate program specific to one area of practice (e.g., certificates in nursing administration, certificates in nursing education, certificate as a family nurse practitioner) which are taken after an individual is already credentialed with a doctorate degree in nursing in a different specialty.
Due Process – A disciplined, analytical decision-making procedure in which relevant standards are applied by a properly constituted and authorized body, using a method that is based on published rules of procedure and is free of improper influence.
[/toggle]Evidence-Based – Actions, processes, or methodologies that are grounded in and flow from the translation of credible, substantive, and current research.
Exclusive Faculty – See Faculty
Expected Level of Achievement (ELA) – A measurable index identified by the faculty that reflects a desired outcome. An ELA should be high enough as to be genuine and encourage continuous improvement, but not so high as to be idealistic and, thus, unachievable.
Experientially Qualified – See Qualified, Experientially
[/toggle]- Faculty, Non-Nursing – Non-nurses who teach and evaluate nursing students, are academically qualified, and are assigned to teach a nursing course, such as a dietician, pharmacologist, or physiologist. Non-nurse faculty are not faculty members who teach general education courses. Non-nurse faculty are not guest speakers/invited presenters who teach selected topics in a nursing course.
- Faculty, Nursing – Nurses who teach and evaluate nursing students, are academically qualified, and have experience in the content areas in which they teach. See definition of Nurse Administrator and Nursing Program Coordinator.
- Full-time Faculty – Persons who teach and/or evaluate nursing students, have a full-time employment status at the governing organization, and whose current primary workload responsibilities are teaching and/or evaluating students in a nursing program. See definition of Nurse Administrator and Nursing Program Coordinator.
- Part-time Faculty – Persons who teach and/or evaluate nursing students, have an appointment that is less than a full-time status at the governing organization, and whose current primary workload responsibilities are teaching and/or evaluating students in a nursing program. See definition of Nurse Administrator and Nursing Program Coordinator.
- Exclusive Faculty – Persons who teach and/or evaluate nursing students in only one nursing program within a single nursing education unit, whether having a full-time or part-time employment status at the governing organization.
- Shared Faculty – Persons who teach and/or evaluate nursing students in more than one program within a nursing education unit or program/department within the same governing organization, whether having a full-time or part-time employment status at the governing organization.
Faculty Development – Activities that facilitate faculty maintenance or enhancement of expertise. Examples include, but are not limited to, certification, continuing education, formal advanced education, clinical practice, research, publications, and other scholarly activities.
Faculty Workload – Percentages of time that reflect the manner in which the governing organization and/or nursing education unit characterizes, structures, and documents the nature of faculty members’ teaching and non-teaching responsibilities. Workload duties include, but are not limited to, teaching, advisement, administration, committee activity, service, practice, research, and other scholarly activities.
Full-time Faculty – See Faculty
[/toggle]Gatekeeper – A person or agency that is responsible for monitoring a governing organization’s compliance with the Higher Education Reauthorization Act, Title IV.
Geographic Region – In reference to the Substantive Change process, an area serving the same/similar population of students and communities as the original/main location of a nursing program, an off-campus instructional site, or a branch campus. See ACEN Policy #14 Reporting Substantive Changes for additional information and the procedures that must be followed.
Geographically Separate – An off-campus instructional site or branch campus that is located physically apart from the main campus of the governing organization.
Good Cause – Sufficient grounds to extend the accreditation at the conclusion of a nursing program’s maximum monitoring period, which results in Continuing Accreditation for Good Cause. A nursing program’s accreditation can be extended for good cause if a nursing program satisfies all the principles for Good Cause.
Note: See ACEN Policy #4 Types of Commission Actions for Initial and Continuing Accreditation for additional information and the procedures that must be followed.
Governing Organization – The institution with overall responsibility and authority for a nursing education unit and a nursing program (e.g., university, college, hospital/medical center, career center).
Governing Organization System – Multiple governing organizations operating under the same company.
Graduate Degree – A master’s degree or doctoral degree.
[/toggle]Inactivation of a Nursing Program – A period of time during which no new students are admitted into a nursing program; therefore, there will be no graduates from the nursing program for an intervening period of time.
A nursing education unit may inactivate a nursing program for a limited period of time per the schedule below:
| Type of Program | Length of Time Program May be Inactive |
| Practical | Up to one calendar year after the last graduate completes the nursing program. |
| Diploma | Up to two calendar years after the last graduate completes the nursing program. |
| Associate | Up to one calendar year after the last graduate completes the nursing program. |
| Baccalaureate | Up to two calendar years after the last graduate completes the nursing program. |
| Master’s | Up to one calendar year after the last graduate completes the nursing program. |
| Doctorate of Nursing Practice | Up to one calendar year after the last graduate completes the nursing program. |
| Post-Master’s Certificate | Due to program length, inactivation is not applicable; nursing program must be in continuous operation or closed. |
| DNP Specialist Certificate | Due to program length, inactivation is not applicable; nursing program must be in continuous operation or closed. |
If a nursing education unit does not reactivate a nursing program within the period of time specified in the table above, then the nursing program is considered closed and removed from the list of accredited programs. To restart the nursing program, the nursing education unit must reapply for initial accreditation with ACEN.
Inactivation of an Off-Campus Instructional Site – A period of time during which a nursing education unit does not offer 1) a nursing program and the nursing courses for the nursing program or 2) a nursing program option and the nursing courses for the nursing program option at an approved off-campus instructional site for five academic years. See ACEN Policy #14 Reporting Substantive Changes for additional information and the procedures that must be followed.
Information Literacy – The ability to identify what information is needed for a specific purpose and to access, evaluate, and use all forms of information in achieving that purpose.
Initial Accreditation – The first peer review process for a Candidate nursing program seeking accreditation with the ACEN.
Instructional Technology – The methods and delivery systems used by faculty to convey course content to students.
Interprofessional – Sharing of information among two or more healthcare professionals from different disciplines who are working together as a team with a common purpose and mutual respect to improve patient outcomes.
[/toggle]Job Placement Rate – Percentage of graduates, typically within one year of graduation, who are employed in a position for which a nursing program prepared them. The expected level of achievement (ELA) for job placement rate is determined by the faculty based on program demographics, such as the characteristics of the nursing education unit and the region where the nursing education unit is located. Program demographic considerations include, but are not limited to program type, local hiring practices, historical job placement rate, the governing organization’s job placement rate for students in other health science programs, state job placement rate for similar programs, group of peer programs, or ACEN data, etc.
[/toggle]Laboratory Personnel – Person without teaching or evaluation responsibilities who works in a skills/simulation laboratory with specified expertise that supports and/or facilitates student learning experiences.
Laboratory personnel who support/facilitate student learning experiences in a skills/simulation laboratory must hold educational and experiential qualifications as required by the governing organization, the state, and the governing organization’s accrediting agency, and must be qualified for assigned responsibilities. In the absence of requirements set by the state and/or the governing organization’s accrediting agency, the governing organization must set appropriate educational and experiential qualifications for assigned responsibilities in the skills/simulation laboratory.
For example:
- If the governing organization, the state, and/or the governing organization’s accrediting agency require laboratory personnel who support/facilitate student learning experiences in a skills/simulation laboratory to hold a graduate degree in nursing, then the laboratory personnel who support/facilitate student learning experiences in a skills/simulation laboratory must hold a graduate degree in nursing, unless there is an approved and documented waiver from the requiring agency.
- If the governing organization, the state, and/or the governing organization’s accrediting agency do not have requirements for laboratory personnel that support/facilitate student learning experiences in a skills/simulation laboratory, then the governing organization must set appropriate educational and experiential qualifications for assigned responsibilities in the skills/simulation laboratory. The governing organization may set qualification requirements that do not include a graduate degree in nursing.
Letter of Notification – A letter from the nurse administrator of a nursing program, or his/her designee, to the ACEN Chief Executive Officer summarizing a Substantive Change and pertinent information thereto appertaining.
Note: See ACEN Policy #14 Reporting Substantive Changes for additional information and the procedures that must be followed.
Licensure – See Credentialing
Location – Sites where a nursing program is delivered, in whole or part, including the main location, off-campus instructional sites, and branch campuses.
Note: See ACEN Policy #14 Reporting Substantive Changes for additional information and the procedures that must be followed when adding or closing an additional location. See Branch Campus/Off-Campus Instructional Site.
[/toggle]Methods of Delivery – The methods used by faculty to deliver instruction of a nursing course.
Traditional Education – An educational method of delivery of nursing courses in which instruction occurs when a student and instructor are physically in the same place at the same time (e.g., face-to-face). This method of delivery may be web-enhanced/supported.
Distance Education – An educational method of delivery of nursing courses in which instruction occurs when a student and instructor are not physically in the same place. Instruction may be synchronous or asynchronous. Distance education uses one our more distance technology to support regular and substantive interactions between the instructor and students. See ACEN definition of academic engagement, distance technology, and regular and substantive in this Glossary.
Hybrid Education – An educational method of delivery of nursing courses in which instruction occurs using both distance and traditional education methods of delivery. Hybrid education, regardless of the percentage of the traditional education time it replaces, is considered a form of distance education by the ACEN.
Note: See ACEN Policy #14 Reporting Substantive Change for additional information about the procedures that must be followed when a program changes its method of delivery from the method of delivery currently approved by the ACEN.
Mentored – A formal or informal process through which a more experienced individual advises, guides, and/or coaches another individual who is less experienced or is transitioning to a new position or employment setting.
Mission/Philosophy – The governing organization and/or nursing education unit statement that designates fundamental beliefs and characteristics and provides guidance and direction for a nursing program and services offered.
[/toggle]Non-compliance – Peer evaluators determined based on their professional judgment that evidence demonstrates a nursing program is not in compliance with an Accreditation Standard.
Nurse Administrator – The nurse with responsibility and authority for the administrative and instructional activities of a nursing education unit and nursing programs within the governing organization (e.g., dean, chairperson, director, etc.). The ACEN does not consider the nurse administrator a faculty member, regardless of the teaching responsibilities or classification by the governing organization. The nurse administrator:
- must have continuous, active, daily, and direct responsibility and authority at all locations for the nursing program.
- must continually have adequate time and resources on a daily basis at all locations to administer the nursing program.
- must oversee the daily governing organization, nursing education unit, and nursing program matters such as, but not limited to, personnel matters, student matters, curricular matters, and resources matters.
Nursing Program Coordinator – A person assigned a range of administrative/coordinating responsibilities to assist the nurse administrator in the fulfillment of the goals of the nursing education unit and achieving a nursing program’s end-of-program student learning outcomes and program outcomes. If a person’s workload of assigned administrative/coordinating responsibilities are 51% or greater, the ACEN does not consider this person a faculty member, regardless of teaching responsibilities and classification by the governing organization.
Note: Governing organizations use a variety of terms to describe individuals who act in an administrative/coordinating capacity. Such titles include, but are not limited to clinical coordinator, skills laboratory coordinator, simulation coordinator, associate nursing director, etc.
Single Nursing Education Unit – A unit within a governing organization that offers one or more nursing programs; all nursing programs within a nursing education unit must be administered by a single nurse administrator with the responsibility and authority for all nursing programs. If a governing organization elects to have a different nurse administrator for one or more nursing programs, then each nursing program with a different nurse administrator is a separate nursing education unit. The ACEN retains the right to determine whether a nursing education unit is a single nursing education unit.
Single Nursing Program – Determination of whether a nursing program is a single nursing program offered at different sites or actually multiple nursing programs depends on several factors. The ACEN retains the right to determine whether a nursing program is a single nursing program and whether a location at which a nursing program is offered must hold separate accreditation. Factors used by the ACEN to determine program status are described below.
Method of Delivery:
When 51% or more of the nursing program is offered in a traditional method of delivery, the nursing program and all locations where the nursing program is offered must be in the same state and under the jurisdiction of the same state regulatory agency for nursing.
When 51% or more of the nursing program is offered through a distance education method of delivery, it is possible for the nursing program and all locations where the nursing program is offered to be in the same state or in different states, and under the same or different state regulatory agency. If two or more state regulatory agencies are involved, the nursing program must meet all the requirements set by each state regulatory agency for the nursing program.
A nursing program is a single nursing program when all the following criteria are met:
1. The nursing program is within a single governing organization that is accredited through an institutional accrediting agency recognized by the ACEN.
2. The nursing program is located only on a governing organization’s main campus and/or off-campus instructional site.
3. A single degree, certificate, or diploma is awarded from the same governing organization to students who successfully complete the nursing program.
4. A single NCSBN program code for the nursing program offered by the single governing organization.
5. There is one nursing program of study for each nursing program option offered by the single governing organization.
6. There is one set of end-of program student learning outcomes and program outcomes utilized for the nursing program offered by the single governing organization.
7. There is a systematic plan of evaluation in place that addresses the end-of program student learning outcomes and program outcomes for the nursing program offered by the single governing organization.
8. There is one nurse administrator for the nursing program. See ACEN definition for nurse administrator in this Glossary.
9. All nursing program and nursing education unit personnel at all locations must report to the nurse administrator.
10. There is one group of faculty members for the nursing program who continually function as a faculty of the whole on a daily basis within a set of established faculty policies through their organization and decision-making processes and continually have input into the curriculum development, delivery, and evaluation.
11. There is a single set of policies governing all nursing students enrolled in the nursing program that is established by a single governing organization and a single nursing education unit.
The ACEN retains the right to determine whether a nursing program is a single nursing program and whether a location at which a nursing program is offered must hold separate accreditation.
Nursing Program Length – Total number of credit/quarter/clock hours required to complete the defined nursing program of study allocated over a specific number of academic terms (semester/trimester/quarter); the nursing program of study is inclusive of all prerequisite courses, general education courses, and nursing courses required.
Note: For undergraduate nursing programs, if first aid certification, cardiopulmonary resuscitation (CPR) certification, being a certified nursing assistant (CNA), or being a medical assistant (MA) is/are required prerequisites for admission, these requirements/courses do not count toward the total number of credit/quarter/clock hours for the defined nursing program of study, whether these requirements/courses are credit or non-credit. All other credit courses that are required prerequisites and/or requirements for admission (e.g., general biology, medical terminology) do count toward the total number of credit/quarter/clock hours.
When first aid, CPR, and CNA certification are part of the defined nursing program of study or taken as elective courses that are part of the defined nursing program of study, these courses count toward the total number of credit/quarter/clock hours.
Nursing Program Option – Program of study designed for a subset of students within a nursing program. Nursing program options include, but are not limited to, pre-licensure options, post-licensure completion options, bridge options, traditional options, accelerated options, evening/weekend options, full- and part-time options, specialized concentrations/tracks, etc.
Note: See ACEN Policy #14 Reporting Substantive Changes additional information and the procedures that must be followed when adding or closing a nursing program option.
Nursing Program Type – The clinical doctorate, DNP specialist certificate, master’s, post-master’s certificate, baccalaureate, associate, diploma, and practical curriculum offered by a governing organization that leads to the awarding of a degree, diploma, or certificate.
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