ACEN Accreditation Manual – Section II Policies

POLICY #1
Code of Conduct and Conflict of Interest


To ensure that all matters dealing with the accreditation of programs by the Accreditation Commission for Education in Nursing (ACEN) are conducted with integrity, fairness, impartiality, and objectivity, the ACEN has adopted this policy addressing conflict of interest, conduct, and confidentiality.

 

CONFLICT OF INTEREST FOR PEER EVALUATORS

In all circumstances, not only conflicts of interest but also the appearance of conflicts of interest must be avoided. All peer evaluators (site visitors, Evaluation Review Panel members, Commissioners, Appeal Panel members) and any other individuals who act on behalf of the ACEN shall not have direct involvement with and/or participate in any decision-making capacity for a nursing program if they have an actual or potential conflict of interest with the program. Actual or potential conflicts of interest may include but are not limited to the following:

  1. Being a current or former employee of the governing organization that is under review
  2. Being a current student, former student, or graduate of the governing organization that is under review
  3. Maintaining employment in the same state (U.S. and U.S. Territories) or in the same non-U.S. country as the nursing education unit and/or nursing program that is under review
  4. Having served as a peer evaluator in the past five years on any ACEN accreditation matter involving the nursing program that is under review
  5. Having served as a consultant in the past five years on any accreditation matter involving the governing organization, nursing education unit, or nursing program that is under review
  6. Having served in an evaluation role in the past five years for an agency other than the ACEN regarding the same governing organization, nursing education unit, or nursing program that is under review, including but not limited to membership on the state regulatory agency for nursing site visit teams, institutional accreditation teams, or evaluation committees for boards of trustees or regents, or similar entity for non-U.S. governing organization/nursing program
  7. Having been paid or otherwise profited or appeared to profit from service in the past five years to the governing organization, nursing education unit, or nursing program that is under review
  8. Having affiliations or close personal or professional relationships in the past five years with key personnel in the governing organization, nursing education unit, or nursing program that is under review
  9. Having immediate family members who are current employees, board members, or students enrolled at the governing organization that is under review
  10. Having a current financial interest in the governing organization that is under review, including but not limited to ownership of shares of stock in the governing organization or any parent of the governing organization, excepting shares or interests held indirectly (such as but not limited to in mutual funds, insurance policies, or blind trusts); in addition, having any immediate family members with any of the above financial interests
  11. Having primary employment as a nurse educator at a non-ACEN-accredited nursing program
  12. Having any other relationship or reason that could serve as an impediment to rendering an impartial, objective, and professional judgment regarding the nursing program that is under review

 

CONDUCT AND ETHICAL GUIDELINES FOR NURSING PROGRAMS AND PEER EVALUATORS

Responsibilities of Nursing Programs Seeking Accreditation

  1. It is the responsibility of each nursing program to facilitate a thorough and objective appraisal of its nursing program.
  2. Nursing programs may veto a peer evaluator if it can be demonstrated in writing to the ACEN Chief Executive Officer that an actual or a potential conflict of interest exists.
  3. Any perceived inadequacies of the ACEN procedures or processes should be reported by the nurse administrator of the nursing program to the ACEN Chief Executive Officer at the time of the occurrence rather than withheld until after the ACEN Board of Commissioners makes an accreditation decision.

Responsibilities of Peer Evaluators

  1. Any Commissioner or member of the Evaluation Review Panel who was a member of a site visit team for a nursing program under consideration or resides in or is currently employed in the same state as the program under consideration must recuse her/himself from the Evaluation Review Panel or Commission discussion about the program and abstain from voting.
  2. When the nursing program with which a Commissioner is employed is being considered for accreditation or appeal, the Commissioner will recuse her/himself from the portion of the ACEN Board of Commissioners’ meeting agenda concerned with the evaluation of that program and abstain from voting.
  3. Peer evaluators are required to refrain from accepting membership on a team, recuse themselves from the discussion during the review of any program if their presence would constitute or appear to constitute a conflict of interest, and abstain from voting if a conflict of interest is identified.

Actions to be Avoided by Peer Evaluators

  1. Advertising of one’s status as an ACEN peer evaluator for the purpose of consulting
  2. Soliciting consultation arrangements with programs preparing for accreditation review
  3. Giving advice to a nursing program or consulting for a nursing program for a period of two years after serving as a peer evaluator on any ACEN accreditation matter related to that nursing program
  4. Offering definitive answers related to ACEN policies and procedures or Standards and Criteria

 

CONFLICT OF INTEREST, CONDUCT, AND ETHICAL GUIDELINES FOR ACEN STAFF

In all circumstances, not only conflicts of interest but also the appearance of conflicts of interest must be avoided. No staff member shall have direct involvement with a nursing program if they have an actual or potential conflict of interest with the program.

Staff members should inform the ACEN Chief Executive Officer where an actual or potential conflict of interest exists. A conflict of interest exists if a staff member:

  1. Was a compensated consultant, appointee, employee of, or candidate for employment at the governing organization, nursing education unit, or nursing program within the past five years
  2. Is a graduate of the governing organization
  3. Has a close personal or familial relationship with persons at the governing organization
  4. Has a strong bias regarding the governing organization, nursing education unit, or nursing program
  5. Has any other relationship or reason that could serve as an impediment to acting in an impartial, objective professional manner toward the governing organization, nursing education unit, or nursing program
  6. Has a current financial interest in the governing organization under review, including but not limited to ownership of shares of stock in the governing organization or any parent of the governing organization, excepting shares or interests held indirectly (such as but not limited to in mutual funds, insurance policies, or blind trusts), or has any immediate family members with any of the aforementioned financial interests

In addition, staff members are prohibited from accepting fees, awards, or honorary degrees from a governing organization with a nursing program that is accredited by the ACEN.

 

CONFIDENTIALITY AND COMMUNICATIONS FOR PEER EVALUATORS AND ACEN STAFF

To ensure that all matters dealing with the accreditation of nursing programs are conducted with integrity, fairness, impartiality, and objectivity, individuals who participate in ACEN activities, including but not limited to peer evaluators and ACEN staff members, must maintain confidentiality with regards to all non-public information related to the accreditation review and consideration of a nursing program by the ACEN. Accordingly, peer evaluators and ACEN staff members shall conduct themselves as follows:

  1. Documents, reports, and other materials prepared by the program for the ACEN must be treated as confidential materials in the absence of specific policies that make clear the degree and extent of their exposure. The ACEN will release materials only in response to a valid court order or otherwise as may be required by law.
  2. All materials pertinent to the nursing program under review are considered confidential materials prepared for use by the ACEN and should not be shown to or discussed with anyone other than peer evaluators and ACEN staff members as appropriate and when necessary.
  3. Hold confidential the accreditation decision issued by the ACEN Board of Commissioners must be held confidential. The decision will be communicated to the program in writing only by the ACEN Chief Executive Officer.
  4. A peer evaluator or ACEN staff member shall not share with a governing organization/nursing program employee or any other person of the review proceedings.
  5. Any request by a peer evaluator for additional information from the governing organization/nursing program following a site visit or related to an Evaluation Review Panel must be directed to the ACEN staff. There will be no direct communication between a peer evaluator and the governing organization and/or nursing program under review except in preparation for an upcoming site visit.

 

DISCLOSURE AND COMMITMENT TO COMPLY WITH ACEN CODE OF CONDUCT AND CONFLICT OF INTEREST POLICY #1

Prior to each site visit, Evaluation Review Panel meeting, or Board of Commissioners meeting, each peer evaluator will sign electronically or by hand an attestation that they agree to comply with all aspects of the ACEN Code of Conduct and Conflict of Interest Policy #1. Annually, each ACEN staff member will sign electronically or by hand an attestation that they agree to comply with all aspects of the ACEN Code of Conduct and Conflict of Interest Policy #1.

 

Policy #1 History
Revised November 2015
Edited October 2016
Edited March 2019
Revised July 2020

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