How the Self-Study Forum Prepares Faculty for a Site Visit


By Keri-Nunn Ellison, EdD, MSNEd, RN, CNE | Director | ACEN
Bridges, Volume XIII – Issue 4, November 2019

Self_Study Forum in Atlanta, March 2019When it comes to preparing for an accreditation site visit, the ACEN provides a number of resources for faculty. Many resources are available on the ACEN website; however, one of the most effective strategies for preparing faculty for a site visit is to attend a Self-Study Forum. The Self-Study Forum is an intensive, day-and-a-half continuing education workshop designed to facilitate understanding of the ACEN Standards and Criteria, give guidance on how to write the Self-Study Report, and prepare the governing organization’s faculty for the onsite visit. The Self-Study Forum also provides an opportunity for attendees to network with other ACEN-accredited program faculty and administrators as well as the ACEN Directors.

The Self-Study Forum is an excellent opportunity to interact directly with both the ACEN Directors and your nurse faculty colleagues to gain a deeper understanding of each Criterion within the ACEN Accreditation Standards. During the Self-Study Forum, the Directors give real-life examples and interactive guidance on how to write the Self-Study Report and prepare for an accreditation site visit. Common challenges and Criteria frequently cited as areas needing development or as in non-compliance are emphasized throughout the Forum.

The purpose of the Self-Study Forum is to help participants develop an understanding of the Standards and Criteria and how they can apply the Criteria to their own programs. The Forum provides detailed information about the 2017 Standards and Criteria and helps attendees learn how to tell more effectively the program’s story of compliance. The presentation style is interactive. Learning exercises for each Standard are included throughout the Forum, including activities designed to increase familiarity with the Criteria, identification of strategies for maintaining compliance, and demonstrating said compliance to peers. A special focus of the Forum is on Standard 6 Outcomes, and participants are asked to bring their own Systematic Plan of Evaluation (SPE) so the ACEN Directors can help attendees to evaluate their plan through comparison to the ACEN Criteria.

Self-Study Forums are beneficial for nurse administrators, faculty, staff of ACEN-accredited programs (or Candidate programs), and anyone considering ACEN accreditation. The Self-Study Forum is recommended for any program preparing for an initial or continuing accreditation site visit, or for programs on Conditions, Warning, or Good Cause. While attendance is beneficial for a program at any stage in the accreditation process, the most benefit can be gained by attending 2–3 years prior to the next scheduled site visit. Self-Study Forums are typically held 2–3 times each year in different locations around the United States. Please click here for the upcoming offerings. We hope to see you at a Self-Study Forum soon!

The ACEN and KABONE Announce a Partnership

ATLANTA, September 16 , 2019 – On Friday, July 19, 2019, the Accreditation Commission for Education in Nursing (ACEN) and the Korean Accreditation Board of Nursing Education (KABONE) signed a memorandum of understanding, which entered the organizations into a cooperative partnership. The signing parties were Dr. Hee Soon Kim, the President of the KABONE and Dr. Marsal P. Stoll, Chief Executive Officer of the ACEN. The document was signed during the Merging Accreditation and Innovation: 2019 ACEN Nursing Education Accreditation Conference, which took place at the Atlanta Marriott Marquis (as pictured).

KABONE is both an accrediting and a regulatory agency located in Seoul, South Korea that specializes in accrediting baccalaureate and associate nursing programs. As the ACEN and KABONE both agree that there is a recognized need for providing accreditation of nursing education programs in order to promote and ensure quality of nursing education, they also agree that an organization’s accreditation standards and criteria should reflect the values of the nursing profession and accountability to the public.

The agencies anticipate participating in activities of mutual interest regarding accreditation for nursing programs. The memorandum excerpt below details some potential future interactions:

  1. Exchange appropriate and relevant information and issues (e.g., standards and procedures’ revisions)
  2. Opportunity to observe the evaluation process (e.g., site visit process)
  3. Reciprocal visits for common interests and objectives (e.g., conference invitation as a speaker or participant, meeting between representatives)
  4. Other ongoing basis activities of mutual interest regarding accreditation for nursing programs

When KABONE established their standards and criteria in 2004, the framework, values, and mission greatly matched what the ACEN (then, the NLNAC) had established. The memorandum was a long time coming, as the ACEN has had ongoing communications and a relationship with KABONE as early as 2007. Finding themselves to be in solidarity, the ACEN and KABONE began in 2007 to have ongoing communications regarding nursing program accreditation. Dr. Sharon Tanner, who was CEO of the ACEN (then NLNAC) in 2007, and Dr. Grace Newsome both visited South Korea. During their trip, they gave presentations related to accreditation processes, peer review, and quality evaluation. They also met with South Korean universities and nursing leaders to discuss South Korea’s establishment of nursing program accreditation. KABONE representatives also visited the ACEN office in 2007, and the relationship dedicated to serving nursing program accreditation became more firmly established.

These interactions grew into invitations for the ACEN professional staff to speak at KABONE conferences held in South Korea during 2012, where Dr. Suzette Farmer, Associate Director of the ACEN, presented information related to accreditation and ACEN outcomes assessment practices. Dr. Farmer was also given the opportunity to discuss nursing program accreditation progress, student learning outcomes, and program outcomes with some of South Korea’s nursing leaders. In 2014, Dr. Nell Ard was also extended the invitation to give presentations regarding clinical nursing education for the enhancement in clinical competency as well as learning outcomes and quality management in nursing education.

The ACEN is delighted to enter this formalized collaboration with the KABONE, seeking the best nursing program accreditation practices and eager to serve nursing students on the international scale.

ACEN – Around the World


By Nell Ard, PhD, RN, CNE, ANEF | Director | ACEN
Bridges, Volume XIII – Issue 3, August 2019

Were you aware that the ACEN has nursing programs accredited around the world? The ACEN has a long history of accrediting nursing programs in the United States – since 1938. The ACEN also accredits nursing programs in United States territories, including: Puerto Rico, the Virgin Islands, and Guam. The first program in Puerto Rico accredited with the ACEN was in 1963; currently, there are over 20 accredited nursing programs in Puerto Rico with other programs pursing the accreditation process. The University of the Virgin Islands was initially accredited in Fall 1987, while the University of Guam was initially accredited in Fall 1996.

The ACEN has been recognized as an accrediting agency by both the United States Department of Education (USDE) since 1952 and the Council for Higher Education Accreditation (CHEA) since 2001. With the CHEA recognition, the ACEN has the opportunity to accredit nursing programs internationally, since the ACEN is the only nursing accrediting agency recognized by CHEA. It is the CHEA recognition that allows the ACEN to accredit international nursing programs.

The first international nursing program was accredited by the ACEN in 2000; however, it was not until 2010 that the ACEN initially developed and released a position statement regarding the accreditation of international nursing programs. Since then, the ACEN continues to seek to broaden the impact of accreditation by encompassing programs across the globe; this resulted in a revised position statement in August 2018.

Currently, there are six international nursing programs accredited, four programs with a Candidate Status, and four programs actively pursuing the Candidacy process. The countries with currently accredited nursing programs include Scotland, Saudi Arabia, the Sultanate of Oman, Turkey, and Jordan; countries having programs with a Candidate status include Jordan, Kuwait, and Columbia.

The ACEN Standards and Criteria are broad enough to enable all programs to demonstrate compliance in a variety of ways. Just as the domestic programs may differ in how they demonstrate compliance with the Standards and Criteria, the ACEN recognizes that some international programs may demonstrate Criteria achievement differently based upon nursing education in that country/region and as with some domestic programs, some of the Criteria may not be applicable.

International programs seeking and maintaining ACEN accreditation utilize the same Standards and Criteria; they follow the same peer-review process as the programs in the U.S. and its territories. International programs are also expected to adhere to all ACEN policies, including, but not limited to: reporting substantive changes, publishing program outcomes data to constituents, and submitting annual reports to the ACEN.

The ACEN provides the international nursing programs access to the same resources as domestic programs as well as access to resources specific to international programs. Additionally, the ACEN has also developed an Accreditation Manual Supplement for International Programs. The supplement provides the international programs with information regarding the candidacy process specific to international programs as well as international site visits. This supplement addresses the potential need for interpreter/translator services during accreditation visits, cultural sensitivity, and security needs during onsite visits.

The Candidacy process for an international program varies slightly with the process for domestic programs; these variations are to provide additional support and to promote success with the accreditation process. The International Candidacy Eligibility Application Form requires the program to provide additional information regarding the potential for the program to be successful with the accreditation process, including, but not limited to: information about the administration, faculty, curriculum, and finances.

Similar to domestic programs, when an international program is deemed eligible to pursue the international candidacy process, the program is assigned a professional staff member to be a mentor during the Candidacy process. The mentor works with the program during the candidacy period and assists the program faculty through the submission of the Candidacy Presentation; this presentation includes the same selected Standards and Criteria to be considered for Candidacy as the review for domestic programs. However, a variation in the international Candidacy Presentation process is the inclusion of an onsite Consulting Visit. The purpose of the onsite Consulting Visit is to verify that the program faculty and institutional administration understand the ACEN accreditation process and Standards and Criteria. Additionally, the consulting visit will verify that the program has the resources for a successful initial accreditation visit as well as maintaining accreditation once achieved. During the Consulting Visit, the professional staff members review all of the Standards and Criteria and provide the program with specific, detailed feedback to support the program in the accreditation process.

The benefits to international nursing programs to pursue the accreditation process with the ACEN include, but are not limited to:

  • Increasing the global reach of the program,
  • Helping students meet the U.S. undergraduate- and graduate-level nursing program admission requirements,
  • Facilitating the transfer of credits,
  • Providing recognition that the nursing program has been evaluated, and periodically reevaluated, by a qualified independent group of peers, and
  • Demonstrates the extent to which the program meets appropriate educational purposes and standards of educational quality specific to nursing education.

Having ACEN-accredited nursing programs around the world provides the ACEN to partner with those programs in ensuring quality nursing education is available globally. While there are many similarities in nursing education globally, having the opportunity to network with nurse educators and programs from around the world, the ACEN-accredited international programs provide depth and diversity to the ACEN and its constituents. The ACEN is the leading authority for nursing education accreditation in the United States, its territories, and around the world!

Mingle with Marcy, August 2019


Your CEO Answers Frequently Asked Questions

By Dr. Marcy Stoll, EdD, MSN | CEO | ACEN
Bridges, Volume XIII – Issue 3, August 2019

Is a program pursuing candidacy and initial accreditation with the ACEN required to submit substantive changes?

A nursing program seeking initial accreditation must apply for Candidacy. The ACEN encourages all nursing programs to be accredited for graduates to have the maximum educational and career benefits of their education. Contrary to rumors, a nursing program does not have to have graduates or outcomes data before being accredited by the ACEN. All existing nursing programs should seek initial accreditation as soon as possible and all new nursing programs should seek initial accreditation so the first cohort of graduating students graduate from an accredited nursing program.

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 ACEN professional staff 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 visit, or being granted initial accreditation by the Board of Commissioners.

Learn more about Candidacy here.

How often are programs reviewed by the ACEN after being granted initial accreditation?

Initial accreditation is the first peer review process for a candidate nursing program seeking accreditation with the ACEN. Once a nursing program is granted initial accreditation, continuing accreditation is the cyclical peer review process for an accredited nursing program to maintain accreditation with the ACEN.

The first continuing accreditation peer review process occurs five years after initial accreditation is granted, and then the continuing accreditation peer review process occurs every eight years thereafter.

There are two reasons why a continuing accreditation peer review process would occur sooner than between the customary cyclical review process.

    1. The nursing program made or will make a significant change in the nursing program. This is known as “substantive change” and the change is so significant that the ACEN Board of Commissioners authorizes a focused visit. The Focused Visit Report provides information related to the program’s compliance with a selected number of ACEN Standards and Criteria. The Standards and Criteria to be reviewed are based on the reason for the focused visit, such as the addition of a new off-campus instructional site (e.g., where the didactic component of the nursing courses are taught) or implementation of distance education. Note, the addition of a clinical site is not a significant change in the nursing program, thus not a substantive change. See the ACEN Glossary for helpful definitions.The Focused Visit Report differs from the Substantive Change Prospectus. While the Substantive Change Prospectus outlines a proposed substantive change or describes a substantive change that occurred (e.g., decline in program outcomes), the purpose of the Focused Visit Report is to demonstrate a nursing program’s continuing compliance with the Accreditation Standards approximately six months after implementation of the substantive change.

      Learn more about a focused visit here.


  1. The second reason there may be a visit between accreditation cycles is related to follow-up. If a program is found in non-compliance with one or more Accreditation Standards and placed on conditions, warning, or good cause by the Board of Commissioners, then a follow-up report is required.Learn more about a follow-up visit here.


Schedule of Fees

The ACEN continuously looks for ways to reduce costs in order to maintain a fair and reasonable fee structure. In fact, the fee schedule for nursing programs located in the U.S. and U.S. territories has remained the same for four consecutive years, and the fee schedule for international nursing program was significantly reduced in 2019.

Candidacy is the process the ACEN uses for nursing programs seeking initial accreditation regardless of geographic location. However, the Candidacy process differs for international nursing programs. Information regarding the process for international nursing program is available here.

Candidacy is an affordable process where fees are billed in portions depending on what part of the process a nursing program is in.

  • The fee schedule for nursing programs located in the U.S. and U.S. territories is available here.
  • The fee schedule for international nursing programs is available here.
  • An Illustration of Cost with Timeline was created to clarify the costs associated with candidacy and initial accreditation.

From Candidacy to Accreditation

Austin Community College’s Journey as the First in Texas to Offer an RN-to-BSN Program

By Nina Almasy, DNP, RN, CNE | Department Chair, Professional Nursing | Austin Community College; And Patricia Recek, MSN, RN | Dean of Health Sciences | Austin Community College
Bridges, Volume XIII – Issue 3, August 2019

In the summer of 2017, the professional nursing department at Austin Community College (ACC) embarked on the journey to develop and implement the RN-to-BSN program by August 2018. In alignment with the college mission, the program aimed to meet the local needs of preparing the nursing workforce at the baccalaureate level by offering an affordable and accessible program in the region.

The journey could be described as a two-step process with an intricate timeline, resembling the famous Texas Two-Step dance. The two major steps of this journey included (a) obtaining all necessary approvals from various regulatory entities and (b) obtaining accreditation. The program had to obtain approval of several regulatory entities, including the college’s Board of Trustees, The Board of Nursing, and the governing organization’s regulatory entities: the Texas Higher Education Coordinating Board and the Commission on Colleges of the Southern Association of Colleges and Schools.

It was essential that at each step, the timeline for each entity’s needed approval was carefully considered. For example, for submission of the ACEN Candidacy Eligibility Application, ACC needed to include documentation that the program proposal was sent both to the state’s Board of Nursing and the governing organization’s regulatory entities, which are the Texas Higher Education Coordinating Board and the Commission on Colleges of the Southern Association of Colleges and Schools.

Achievement of these two essential steps required ongoing intricate partnership among various stakeholders and entities within and outside the college—and most importantly, keen attention to the timelines to successfully complete both steps.

Early in the program development stages, in order to better understand the local need, the department created the RN-to-BSN Advisory Committee, which is comprised of key area healthcare nurse leaders and nursing schools. In addition, several needs-assessment surveys and focus groups were conducted.

Program and curriculum development was guided by a review of the literature and best practices, as well as consideration of professional guidelines and baccalaureate essentials and competencies. The faculty worked diligently to ensure that the assessment and evaluation methodology for end-of-program student learning outcomes was carefully considered, as they developed the curriculum.

Obtaining nursing education accreditation that was effective for the first graduates of the program was one of the most important steps. We at ACC were committed to ensuring that our BSN graduates were eligible to apply to graduate schools, should they choose to do so. ACC’s associate degree program has been accredited by ACEN for several years, and the relationship with the ACEN had been a positive and collaborative one that allowed us to move forward to candidacy. ACC reached out to then ACEN and Dr. Nell Ard in August 2018 to determine if this aggressive timeline was achievable. Dr. Ard was so responsive from the very beginning, providing essential information to ensure we were progressing correctly.

The journey from ACEN candidacy to accreditation could be described as a collaborative, collegial process. Once the candidacy process began and the program applied for initial accreditation, an ACEN professional staff member, Dr. Ard, was assigned as a mentor and resource. The department chair of the program sought the expertise and supportive guidance offered by the mentor. This mentorship support was key in ensuring that the program not only met candidacy requirements, but also ensured that the program met the ACEN Standards and Criteria. Additionally, the ACEN website offered invaluable information and resources that were useful to the faculty and administrators throughout the entire accreditation process. It is safe to say that no stone was left unturned on the ACEN website!

The candidacy process involved ongoing review of the curriculum and the systematic plan for evaluation by a team of faculty and college leadership. Upon granting candidacy status, the ACEN also provided two comprehensive, independent reviews of the Candidacy presentation conducted by the ACEN professional staff. The faculty carefully examined the two reviews and staff input, then made necessary adjustments and revisions to the systematic plan for evaluation to ensure that the program is not only high quality, but also on track to meeting all ACEN Standards and Criteria for initial accreditation.

ACC was granted candidacy in June 2018, had the site visit in February 2019, and is awaiting action from the commission in September 2019, the final step in our accreditation journey.

When and How to Start the Candidacy Process


By Greg Donaldson | Report Processing and Quality Assurance | ACEN
Bridges, Volume XIII – Issue 3, August 2019

When to Start the Candidacy Process (Eligibility)

Accreditation Candidacy with the ACEN cannot be discussed without first discussing what it means to become eligible for Candidacy. The distinction between eligibility and official Candidacy is of paramount importance. In fact, one of the most common questions presented to ACEN professional staff members is, “What is the difference between eligibility and Candidacy?”

Eligibility simply means that a governing organization/institution and a nursing program meet the ACEN required prerequisites and has been approved to submit a Candidacy Presentation to the ACEN. A program eligible for Candidacy is not automatically a Candidate for ACEN accreditation. It is only after the review and approval of a Candidacy Presentation that a nursing program becomes an official ACEN Candidate, and the program is listed as such on the ACEN website. More information regarding the Candidacy eligibility process can be found in Policy #3 Eligibility for Initial and Continuing Accreditation.

Assuming that a program has been deemed eligible for Candidacy, another common question is “When should I submit my program’s Candidacy Presentation?” The short answer to this question is that a Candidacy Presentation must be submitted within one year of the date of eligibility. Please note, however, that programs applying for accreditation will be assigned an ACEN professional staff member to mentor the program leaders and faculty members after eligibility is confirmed. Though a Candidacy Presentation can be submitted at any point after eligibility is confirmed, the ACEN strongly advises programs to submit Candidacy Presentations only after conferring with the assigned professional staff mentor. Throughout the entire Candidacy process, the ACEN professional staff mentor is the best available resource for any nursing program.

How to Start the Candidacy Process (Submitting a Candidacy Presentation)

A nursing program seeking Candidacy will receive a letter verifying its eligibility. From the date of this letter, the program has 30 days in which to submit its eligibility fee payment and one year in which to submit the Candidacy Presentation. 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, which is sent to the program with the letter confirming eligibility. When the signed Authorization is received, ACEN professional staff members can officially begin reviewing the Candidacy Presentation.

Essentially, a Candidacy Presentation is a condensed version of a Self-Study Report. A Candidacy Presentation does not include all of the ACEN Standards, and those Standards included (Standards 2, 4, 5, and 6) are limited to certain criteria within these Standards. The written Candidacy Presentation should be developed by the program leaders and faculty members and submitted electronically by emailing the document to Dr. Nell Ard. Please use the following link to find more information regarding how to compose a Candidacy Presentation:

All materials submitted are reviewed by the ACEN professional staff. Applicants receive written notification whether the program is approved for Candidacy, deferred, or disapproved. Approval for Candidacy is granted when the nursing program demonstrates it is currently compliant with the requirements of the Candidacy Presentation as well as the Candidacy process, or demonstrates the ability to be compliant during the Candidacy period. Additional information about Candidacy can be found in Policy #34 in the ACEN Accreditation Manual.

Questions along the way

Each nursing program is unique, so it is natural that program leaders and faculty members need to ask questions specific to their program. The ACEN cannot put enough emphasis on the importance of reaching out to the professional staff mentor.

Understanding the ACEN Accreditation Cycle Timeline

Timeline to Candidacy


By Matt Middlebrooks | Candidacy and Content Editor | ACEN
Bridges, Volume XIII – Issue 3, August 2019

At ACEN, we are often asked, “How long will it take for my program to become accredited if I apply today?” The answer, as to many of life’s great questions, is: “it depends.”

Ultimately, much of the Candidacy timeline’s length is determined by the program leaders and nursing faculty rather than by the ACEN. It takes some time to complete the Candidacy Eligibility Application, and potentially a significant amount of time to complete the Candidacy Presentation which is a condensed version of the Self-Study Report covering selected Standards and Criteria. This article provides the program information about components of the process and the time that each takes to assist the program in developing a timeline for achieving Candidacy and initial accreditation.

Once the Candidacy Eligibility Application has been submitted, it takes the ACEN an average of a week to review the application and respond in writing via email. At this point, assuming the program was deemed eligible, the program leaders and nursing faculty can begin working on the Candidacy Presentation. As this is an in-depth document that requires time to prepare (see our guidelines for more detail), the time it takes will vary from program to program. We highly advise that you first work with your assigned professional staff mentor for the Candidacy process before submitting your Presentation. Your professional staff mentor, one of the ACEN professional staff, will assist you in clarifying questions related to the Candidacy Presentation and the required components, which can assist you in “telling the program’s story” and providing every possible advantage in the process. The maximum amount of time to submit the Candidacy Presentation is one year, as eligibility expires one year after it is granted.

Once program leaders and nursing faculty submit the Candidacy Presentation, it’s time for the next step of ACEN review. The ACEN professional staff, who are professional nurse educators, complete a comprehensive review of the Presentation and generate extensive feedback for the benefit of the program leaders and nursing faculty in achieving compliance with the ACEN Standards and Criteria; this process can take up to six weeks to complete. If the professional staff identify that the program is currently compliant with the requirements of the Candidacy Presentation as well as the Candidacy process, or demonstrates the ability to become compliant during the Candidacy period, then the ACEN will designate your program as a Candidate for accreditation.

If the professional staff’s review identifies non-compliance or cannot determine whether the program is able to achieve compliance by the time of the site visit, fear not! Rather than outright deny Candidacy, the ACEN can defer a Candidacy decision in such cases. This extends the eligibility period for up to a year, allowing program leaders and nursing faculty to resubmit the Candidacy Presentation after working with the assigned professional staff mentor to remedy areas needing improvement that were identified in the first review.

Whether it takes one year or two to achieve Candidacy, the next step is scheduling the initial accreditation site visit. The Candidacy period lasts for two years, so program leaders and nursing faculty may elect to host the initial site visit in an available accreditation cycle during the Candidacy period. Application deadlines are always March 1 for a Fall accreditation visit or July 1 for a Spring accreditation visit. The program must have achieved Candidate status prior to requesting an initial accreditation visit. Program leaders and nursing faculty will also need to write the complete Self-Study Report in preparation for an initial accreditation site visit.

Once the visit has taken place, the Self-Study Report and accompanying Site Visit Report will be reviewed by the Evaluation Review Panel, which convenes in January for a Fall cycle and June for a Spring cycle. The final step of the peer review process is a review by the ACEN Board of Commissioners, which meets in March for the Fall cycle and September for the Spring cycle. The program will be notified within 30 calendar days of the Board’s decision.

All told, if everything takes the maximum amount of time possible, the Candidacy process can last as long as four years from the time a Candidacy Eligibility Application is submitted to hosting the initial visit with the additional six months for the final decision. Programs can also complete the overall process from application to site visit in as little as nine months. Even for longer cases, though, there is good news: due to recent revisions to ACEN Policy #34, the effective date of initial accreditation is the date on which the Candidacy period leading to the initial accreditation decision began!

As always, feel free to contact your staff at the ACEN office for more information or to ask any questions you might have. We’re always glad to help, and are looking forward to working with you and your colleagues on your journey to Candidacy and ACEN accreditation.

Welcome to the Newly Elected Members of your BOC


THE VOTES ARE IN! Effective October 1st, 2019, these newly and reelected Commissioners will join the Board of Commissioners who govern your ACEN:

Newly Elected

Shari Gholson
(Nurse Educator)


Dr. Shari Gholson, DNP, RN, CNE has 33 years of nursing experience, including 20 years in nursing education. She is a professor of nursing at West Kentucky Community and Technical College and is serving as Dean of the Nursing Division and program coordinator of the Associate Degree Nursing Program since 2006.

Shari earned her Doctorate in Nurse Practice from Northern Kentucky University, Master’s Degree in Nursing from Vanderbilt University (clinical nurse specialist) and a bachelor’s degree in nursing from Murray State University. She also holds the Certified Nurse Educators credential. She has served the college in a number of leadership roles including faculty representative to the WKCTC Board of Directors, chair of the Kentucky Community and Technical College Nursing Curriculum Committee, and has presented at local, state, national, and international conferences/workshops.

Dr. Gholson has served as an ACEN site visitor since 2013, a team chair since 2015, and an Evaluation Review Panel member since 2016. She is a member of several professional associations including Sigma Theta Tau International, American Nurses Association, National League for Nursing, Kentucky Deans and Directors, Kentucky Council of Associate Degree Nursing, and Kentucky Nurses Action Coalition.

Shari considers it an honor walk beside nursing faculty of WKCTC as they chose to teach those that will follow them into the nursing profession and will value the opportunity to do the same with the ACEN organization.

Scott Thigpen
(Nurse Educator)


Dr. Scott Thigpen, DNP, RN, MSN, CCRN is a Professor of Nursing at South Georgia State College (SGSC) in Douglas, GA. He has led the LPN-RN Bridge program, the ASN program and developed and implemented the RN-BSN program. Dr. Thigpen has served on the SGSC Academic Leadership Team and lead accreditation activities including three successful accreditation site visits for the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC) for the level change from a two-year to four-year college, campus consolidation, and the decennial accreditation as a new institution. He has led SACSCOC substantive changes for the BS in Nursing and the BS in Long-term Healthcare Management.

Dr. Thigpen holds an ASN from South Georgia State College, a BSN and MSN in Adult Health from Valdosta State University and the Doctorate of Nursing Practice from the Medical College of Georgia in Augusta, GA. He is a Certified Critical Care Nurse (CCRN) and a proud member of the American Association of Critical Care Nursing (AACN) where he has served as a speaker at the National Teaching Institute (NTI) for over ten years. He also served as an Endocrine content expert for the AACN Essentials of Critical Care Nursing Orientation Online (ECCO 3.0) which has been utilized by over 1100 nursing facilities in the United States and Canada to orient nurses to progressive care and critical care units. Dr. Thigpen has presented extensively on a variety of nursing and leadership topics throughout the Unites States and internationally in Australia, Canada and Mexico.

In the field of nursing regulation, Dr. Thigpen has served on the Georgia Board of Nursing (2003-2010), as Vice President, Nursing Education Representative, Legal/Discipline Cognizant, and Site Visitor. He represented Georgia as a delegate to the National Council of State Board of Nursing and has been an NCLEX-RN item reviewer.

At the Accreditation Commission for Education in Nursing (ACEN), Dr. Thigpen has attended Nurse Administrator Workshops, Self-Study Forums and Site Visitor Training. He was a member of the ACEN 2017 Standards and Criteria Revision Team and has enjoyed serving the profession as a site visitor and an evaluation review panel member. In his spare time, he enjoys working on the family farm and leading praise and worship at his church.

Lisa A. Young


Dr. Lisa A. Young DNP, APN, FNP-BC received her Doctor of Nursing Practice from the University of Iowa. Dr. Young received her Bachelors of Nursing, Master’s in Nursing and nurse practitioner training with a focus on community health nursing from Saint Xavier University.

Dr. Young is a board certified family nurse practitioner with over twenty years of experience. Dr. Young is currently the Director of the Wellness/Health Center and an Associate Professor in Nursing at Chicago State University. Her early graduate nursing research on nurse practitioners in nurse managed centers as a cost effective alternative to emergency departments led her to Chicago State University. During her tenure, she conceptualized, implemented, and developed the nurse managed center which serves the campus community. She has clinical oversight and operations of the health center and the Office of Student Health Insurance to ensure students have access to preventative and affordable health care. She has continued to maintain her clinical practice working in the Wellness/Health Center and within the retail industry continuing to serve those without access to affordable health care. Dr. Young served as Interim, Chairperson for the bachelor’s and masters of nursing program and as Interim Assistant Dean for the College of Health Sciences at Chicago State University. Dr. Young’s research interests include nurse managed centers, using assessment to address targeted violence, HIV prevention, health disparities among ethnic minorities. She has an active interest in health policy and nursing political advocacy.

Dr. Young is a member of several professional organizations which includes Sigma Theta Tau International, American Association of Nurse Practitioners, American Nurses Association, ANA-Illinois, American College Health Association, American Public Health Association, and the Illinois Society of Advanced Practice Nurses. She has contributed professionally as a peer evaluator for the Accrediting Commission for Education in Nursing (ACEN) as one of the initial clinician peer evaluators with over nineteen years of accreditation experience. Dr. Young has served as a national delegate for the United States Agency for International Development (USAID) on a USAID South African Area initiative and educational presentations and US delegate in China.

Dr. Young received her Doctor of Nursing Practice from the University of Iowa, her Bachelors and Master’s in Nursing and nurse practitioner training from Saint Xavier University.

Susan Zlotlow
(Public Member)


Susan Zlotlow, Ph.D. retired after more than 18 years as the Director of the Office of Program Consultation and Accreditation and an Associate Executive Director of the Education Directorate at the American Psychology Association. She received her undergraduate degree at the University of Rochester and her M.A. and Ph.D. in clinical psychology from the University of Connecticut. She also received an honorary doctoral degree from Palo Alto University. Dr. Zlotlow’s publication and presentation history includes articles on child development and socialization, teaching, and accreditation in psychology.

Dr. Zlotlow taught at Wheaton College (Massachusetts) and has taught undergraduate and graduate classes at the University of Maryland at College Park. She served as a consultant to the public-school system in Albuquerque, New Mexico as well as engaged in clinical practice in Albuquerque, New Mexico and inner-city Baltimore. Prior to working in accreditation, Dr. Zlotlow served as the Assistant Dean in the Graduate School at the University of Maryland, College Park working on internal and external grant funding, including the institutional IRB, research review committees, as well as committees focused on campus resources for graduate students and faculty.

In her more than 18 years in accreditation, Dr. Zlotlow served as the Chair of the External Recognition Issues Committee of the Association of Specialized and Professional Accreditors, a group of programmatic and specialized accreditors that met with members of the Department of Education and Congress on issues related to accreditation. She also represented that group as a negotiator in the 2007 negotiated rulemaking hearings on accreditation issues in the US Higher Education Act. She also served for two terms as a member of the Council on Higher Education Accreditation (CHEA) committee of Specialized/National Accreditation. Dr. Zlotlow served on the Sullivan Commission that reviewed how accreditation standards in health professions impact diversity of those professions. She has received awards for her service from the American Psychological Association, several training councils in psychology, as well as from the Association of Specialized and Professional Accreditors.



Debbie Rahn
(Nurse Educator)


Dr. Debbie Rahn, EdD, MSN, RN Director of the Reading Hospital School of Health Sciences (RHSHS), is a current member of the ACEN Board of Commissioners and is seeking reelection for a second term of service. While serving on the ACEN Board of Commissioners for the past few years, Dr. Rahn has served on the finance and substantive change committees, as well as serving as an ERP chair and a site visitor. In Dr. Rahn’s current position as Director of the School of Health Sciences, she is responsible for the leadership of multiple diploma and certificate programs including nursing (RN), medical imaging (MI), surgical technology (ST), clinical pastoral education (CPE), Medical Laboratory Science, Diagnostic Medical Sonography, phlebotomy, Emergency Medical Technician (EMT), Advanced EMT, and paramedic programs. Dr. Rahn is a graduate of RHSHS (Nursing Program), Penn State University (BSN), Villanova University (MSN in Nursing Education), and Drexel University (doctorate degree in Educational Leadership and Management with a focus in Higher Education). Dr. Rahn has provided leadership at the school to create dual admission programs for the Nursing, MI, and ST Programs whereby students are dually admitted to a local four year university, receive both a diploma from RHSHS and an associate degree from the university at the time of graduation, and then have the opportunity to seamlessly transition into the university’s BSN (nursing) or Bachelors of Health Sciences (MI, ST) programs. The role as Director of a School of Health Sciences requires that Dr. Rahn work with a variety of program accreditation agencies.

Dr. Rahn has held multiple roles in professional and academic settings including staff nurse, Assistant Head Nurse of an inpatient psychiatric setting, Nurse Manager of an inpatient oncology unit, nursing program faculty, curriculum coordinator, director of a nursing program, and her current role as Director of the School of Health Sciences. She was awarded two grants to increase the use of simulation pedagogy in nursing education. Dr. Rahn has held a variety of leadership roles especially in the areas of ethics, nursing education, and nursing research. Debbie Rahn is a founding member of the Berks Regional Nursing Research Alliance, a grassroots organization representing multiple academic and practice partners, and designed to engage nurses in research and evidence base practice in a geographic area void of a major academic research institution. Dr. Rahn has a long-standing interest in bio-ethics, and currently serves as the vice-chair of the Reading Health System Ethics Committee. One of Dr. Rahn’s research interests is in the role of nursing teamwork related to patient outcomes including nurse-sensitive patient outcomes. She has presented at a variety of local, regional and national conferences, and her research on Transformational Teamwork has been published in the Journal of Nursing Care Quality (JNCQ).

Dr. Rahn is a member of multiple professional organizations and has served the profession on state and national committees including Pennsylvania Coalition for the Advancement of Nursing Education (PCANE), Pennsylvania Academic Progression in Nursing (PAPIN), National Education Progression in Nursing Collaborative (NEPIN), Hospital Association of Pennsylvania task force on healthcare workforce, and was the former co-chair for the Pennsylvania Southeast II Regional Action Coalition, addressing recommendations related to nursing education from the Institute of Medicine’s The Future of Nursing: Leading Change, Advancing Health, (IOM, 2011).

Vivian Yates
(Nurse Educator)


Dr. Vivian Yates, Ph.D., RN has served as the Dean of Nursing at Cuyahoga Community College in Cleveland, Ohio since 2013. She is responsible for the management of a multi-campus nursing program that includes practical and associate degree nursing programs with traditional, LPN to RN, and accelerated tracks. Over 800 students are enrolled in the programs with 42 full-time faculty.

With over 35 years in the nursing profession, Dr. Yates has a background in clinical nursing, academia, nursing administration, and nursing program accreditation. Her clinical background is medical-surgical and psychiatric nursing, serving in both clinical and managerial positions in hospital settings. She has over 25 years of teaching and administrative experience in nursing education; teaching in baccalaureate, associate degree, and practical nursing programs. Her research background includes examining the various facets of cultural diversity in nursing and health care.

Dr. Yates has extensive experience in the area of nursing education accreditation. She served as the Associate Director for Program Accreditation Support for the Accrediting Commission for Education in Nursing (ACEN) in Atlanta, Georgia from 2009 – 2011. She began serving as a site visitor in 1997, and served on several Evaluation Review Panels from 2000 – 2009. She has served as a consultant for nursing programs across the country and has presented at national forums on nursing program accreditation.

Dr. Yates is a member of several national and state nursing organizations including the American Nurses Association, the National League for Nursing, the Ohio Council of Associate Degree Nursing Education Administrators, and the Organization for Associate Degree Nursing. She has served as vice-president and president of her local chapter of the Ohio Nurses Association. She is a member of several nursing advisory boards in northeast Ohio, and serves on the Board of Directors at University Hospitals in Cleveland.

Dr. Yates earned an associate’s degree in nursing at Lorain County Community College, a bachelor’s degree in nursing at the University of Akron, a master’s degree in nursing at Kent State University, and a PhD in education at the University of Akron.

Kathleen Zajic
(Nurse Educator)


Dr. Kathleen Zajic, EdD, MSN, RN is Professor of Nursing at the College of Saint Mary (CSM) in Omaha, Nebraska. In her 28 years at CSM, Dr. Zajic has served in many administrative and appointed roles including Professor of Nursing, Director of Undergraduate Nursing, Chair of Health Professions, and the Associate Dean of Health Professions. Her career path and roles have been diverse but Dr. Zajic has a passion for nursing education and finds her true home in the classroom and clinical settings. In addition, Dr. Zajic has assumed a variety of appointed and elected roles within the nursing program, division, and college-wide committees; including being elected by her peers to serve as Chair; Faculty Assembly Council.

Dr. Zajic earned her EdD (with an emphasis in Health Professions) from the College of Saint Mary, her MSN (with an emphasis in Community Health Nursing and Nursing Leadership and Management) from the University of Nebraska Medical Center, and her BSN from Creighton University. Dr. Zajic has expertise in curriculum design, program evaluation, leadership, and community health nursing. Dr. Zajic has also served as a consultant within and outside of nursing on curriculum development, design, implementation, program assessment, and an array of public health initiatives.

Dr. Zajic has served as an ACEN site visitor since 2013, ERP chair since 2018, and was a member of the ACEN Standards and Criteria for Transition to Practice Task Force from 2016-2018. Dr. Zajic was elected to the Board of Commissioners in 2016, serving as the Chair of the Substantive Change committee since 2017. Dr. Zajic is a member of several professional organizations including Sigma Theta Tau International, Gamma Pi Chapter, the National League of Nursing, and the National Association of Local Boards of Health. Dr. Zajic provides extensive community service, serving as past chair for the Pottawattamie County Board of Health, Saint Albert School system Wellness Initiative Committee, and the Visiting Nurse Association (VNA) Nurse-Family Advisory Board. When Dr. Zajic is not in the classroom or clinical area she can be found providing health care services to the underserved and vulnerable populations in the Omaha metropolitan area.


By Appointment to the Nominating Committee

Betty Damask-Bembenek
(Nurse Educator)


Dr. Betty Damask-Bembenek, EdD, MN, RN has 35 years of nursing experience in a variety of nursing healthcare settings and 20 years of experience as a nurse administrator and educator at several universities and community colleges in the western region of the U.S. Nursing has provided me with a diversity of many great experiences and nursing education is one of the most rewarding of all. The diversity of these experiences has enhanced my skill sets to create quality in nursing educational programs through structural empowerment and an inclusive environment for all stakeholders in a variety of settings.

Dr. Bembenek has been Director of Nursing Education at Colorado Mountain College since 2009, and serves as the Dean for the School of Nursing, Health Science and Public Safety. At Metro State University, she was part of the faculty for the BSN program. Dr. Bembenek served as nurse administrator and faculty member at Weber State University and Division Chair of Nursing and Health Sciences at Salt Lake Community College. Areas of teaching and clinical practice have included nursing administration, education, emergency and trauma services, medical/surgical, obstetrics, critical care and rural nursing.

Dr. Bembenek has actively participated as a program evaluator and evaluation review panel member for the Associate Degree Programs and the combined AD & BSN panels for the Accreditation Commission for Education in Nursing (ACEN) for several years. Serving on the Board of Commissioners for associate degree programs would be an honor and privilege to support continuous improvement for nursing education.

Education Background:

  • Doctoral of Education: Ed.D. in Organizational Leadership, Northcentral University, Prescott, Arizona
  • Master of Nursing: Management, University of Phoenix, College of Nursing, Salt Lake City, Utah
  • Bachelor of Science in Nursing, Marian College, Fond Du Lac, Wisconsin
  • Associate of Science in Nursing, North Central Technical College, Wausau, Wisconsin


Each Commissioner will serve a three-year term from October 1, 2019 through September 30, 2022. The exception is Shari Gholson, who will serve from October 1, 2019 through September 30, 2021. The two-year term has the same expectations as the three-year; it is meant as a one-time occurrence to expand the number of nurse educators on the board to a total of 11. The 17 Board of Commissioner represent the following roles: 11 nursing education representatives, 3 nursing service representatives, and 3 public representatives. This diversification ensures the ACEN Board of Commissioners are able to give balanced representation from across identified constituencies insofar as possible.

The Board of Commissioners is a governing board and has the authority of a governing board, which is (1) ensuring the financial resources of the ACEN such as setting the fee schedule, budget, and reviewing the audit; (2) setting policy such as the policies found in the Accreditation Manual and the Standards and Criteria; and (3) most importantly, having the sole authority to determine the accreditation status of nursing programs. Members of the Board of Commissioners also serve as Chairpersons at Evaluation Review Panels, guiding the panelists through discussions and asking for status recommendations. We are very excited to congratulate our new and returning members of the Board of Commissioners!

Clarify, Verify, Amplify


By Donna Meyer, MSN, RN, ANEF, FAADN  |  CEO  |  Organization for Associate Degree Nursing; And Cynthia Maskey, PhD, RN, CNE  |  Treasurer  |  Organization for Associate Degree Nursing
Bridges, Volume XIII – Issue 2, June 2019

As a nursing program prepares for an ACEN site visit, it is important to keep two things in mind. One, nursing program accreditation is an important subject for nurse educators in recognizing the importance of continuous quality improvement; two, be clear in the explanations of the information and let your light shine! Nurses are hard-working, organized, dynamic, and humble. Nurse educators and administrators, which comprise the Organization for Associate Degree Nursing’s (OADN’s) membership, achieve great things but too often do not take credit for their efforts and accomplishments. The peer evaluators will arrive in the ACEN mindset that their task is to CLARIFY, VERIFY, & AMPLIFY the information that your program has provided for them. Careful thought should be given as to how to assist in this task.

Full faculty involvement is imperative throughout the accreditation process. Faculty should be involved early in writing the Self-Study Report and, very importantly, helping to gather the evidence that supports what is written. Faculty and administrators should work together to review the documents for clarity. Documents should be viewed through the lens of an outside peer evaluator. This can be difficult when one is working within the program day-in and day-out, but an attempt should be made to make sure that information is comprehensive and, again, clear. Sometimes what makes perfect sense to someone working within a curriculum might take a little bit of explanation to someone unfamiliar.

Remember that the preparation for the site visit is the time to point out what makes the nursing program special, exceptional, and successful! Each program has unique challenges and achievements within their communities. Those should be noted and amplified. The site visit is the time to recognize areas where the program may need to do better, but also to celebrate those ongoing accomplishments and the needs met in the community.

OADN formed a partnership with the ACEN because we believe that “accreditation not only serves the public as a measure of quality for healthcare employers and academic partners of associate degree programs, but also is an assurance of quality educational standards applied to faculty, staff and students.” OADN believes in the quality of associate degree programs. The site visit is truly an opportunity to demonstrate all that your programs have to offer. Through individual program accreditation, we also take an important step in collectively recognizing the excellent nursing education delivered by associate degree nursing programs across our nation.

Five Tried and True Tips for a Successful Site Visit


By Susan Thornock, EdD, RN  |  Chair, Annie Taylor Dee School of Nursing  |  Weber State University
Bridges, Volume XIII – Issue 2, June 2019

Recent discussion with other healthcare programs in our Dumke College of Health Professions on the Weber State University Campus, in Ogden, UT led to comments laced with humor and expressions of sympathy when the topic of nursing accreditation was mentioned. Accreditation for our Annie Taylor Dee School of Nursing has become legendary at our mid-sized university.

Over the past 10 years, our Annie Taylor Dee School of Nursing has hosted peer evaluators several times—three were site visits and the others were focused visits for a new program, added location, or change of curriculum. We are beginning a Doctor of Nursing Practice program in Fall 2019 and will then be sure to have another visit within the next year or two. With each visit we learn something new, something to be applied to our continuing growth and progression in nursing education. Considering all that could be shared, and there are many tidbits, there are five main areas of focus that I would consider key to a successful visit.

Primary to everything else is to arm yourself, your faculty, and your campus administration with as much knowledge as possible. The ACEN makes this abundantly easy with a comprehensive website and open access to experts. There is always someone at the end of the telephone or readily available through email to respond to any questions. There is no question too stupid to ask, and you are always made to feel like you are brilliant and your questions are valid. Never hesitate to take advantage of this support. Becoming very familiar with the website and how to navigate through the information is crucial. This should always be the first source as almost all questions can be answered at this site.

Of equal importance is to create a team of faculty, make sure you include all faculty, and add students to that team. From my perspective as a chair, I consider this the biggest catapult to a successful site visit. Our site visit 10 years ago was one person trying to provide everything necessary for 40 faculty and several hundred students. The failure of that visit was due to the process, not the individual. Our most recent site visit had 60 staff and faculty armed with knowledge and with the expectation to be fully involved. The outcome of that visit was a successful visit, happy and engaged faculty, and a place on Maslow’s Hierarchy that could be nearing self-actualization.

The third suggestion to a successful outcome is to create your own experts. The best way to do this is to make sure all faculty are encouraged to become peer evaluators. Faculty that have been involved in a site visit as a peer evaluator are absolutely necessary in the refining process before the peer evaluators arrive, while they are there, and in the follow-up after everyone has gone home. Try not to disregard practical experience when it comes to accreditation. You can be assured that the ACEN will help with this endeavor and will welcome and train your faculty willing to become peer evaluators.

Fourth is finding your balance—what needs to be displayed or presented as opposed to what you want to present. There is some wisdom in understanding the difference in what the ACEN peer evaluators will want to see and what you might want to show them. An over-abundance of information, or information that is disorganized, will only confuse and frustrate your peer evaluators. A word of caution: if you are confused, they are too. A practice run with your faculty experts is always a good idea.

Last, it really does not matter how confident you feel, how well-prepared you think you are (or are not), your environment will be disrupted when your peer evaluators arrive. I am one to believe disruption does, in many instances, lead to good things. In my opinion, disruption is a cousin to the chaos theory, and with the right care, proper attention, and a good deal of teamwork, the outcome can help advance our desire to provide the best nursing education possible. That is after all, one of the objectives and a most desired outcome of the ACEN. Good luck with your next site visit!