Returning to Normal! ACEN’s First Post-Covid In-Person Self-Study Forum

Is your nursing program preparing for a site visit? The ACEN recommends that nursing program faculty and leaders attend a Self-Study Forum within two years prior to your program’s upcoming site visit. The forum is a 1.5-day workshop that provides attendees the opportunity to become more familiar with the ACEN Standards and Criteria and become comfortable with the idea of composing a Self-Study Report as required by the upcoming site visit. Participants receive 10 CEs.

The Self-Study Form on November 1‒2, 2021 in Houston, TX will be the first in-person event the ACEN has hosted since the start of the COVID-19 pandemic in March 2020. According to the ACEN’s Chief Executive Officer, Marsal Stoll, the ACEN is working closely with the host location “to protect the safety of attendees. The hotel agreed to follow all the COVID-19 safety practices/guidelines hotel-wide issued by the CDC or Marriott Corporation, whichever are more restrictive at the time of the event.”

You can learn more about the Self-Study Forum and register here.

ACEN Substantive Changes – April 2021

Notification of Substantive Change Actions
April 2021

Board of Commissioners Actions

The following publicly available information is provided by the Accreditation Commission for Education in Nursing (ACEN) concerning actions taken on April 9, 2021, by the ACEN Board of Commissioners related to substantive changes. Commission staff will not speculate on what decision might be made by the ACEN Board of Commissioners the next time a program is reviewed. For additional information regarding ACEN accreditation process, access the Accreditation Manual at

Access the ACEN 2017 Standards and Criteria by program type:

The Board of Commissioners approved the substantive change report for the following programs:

  • Bryant & Stratton College – Akron (Practical) Akron, OH related to a decline in licensure examination pass rates.
  • Jersey College – Largo (Associate) Largo, FL related to the implementation of distance education of 50% or greater.
  • Jersey College – Tampa (Associate) Tampa, FL related to the implementation of distance education of 50% or greater.
  • Jersey College – Teterboro (Associate) Teterboro, NJ related to the implementation of distance education of 50% or greater.
  • Santa Fe College (Associate) Gainesville, FL related to the implementation of distance education of 50% or greater.

The Board of Commissioners approved the substantive change report and authorized a focused visit for the following programs:

  • Americore Health/St. Alexius Hospital, Inc. (Diploma) St. Louis, MO related to a change in ownership and relocation.
  • Delaware State University (Baccalaureate) Dover, DE related to the acquisition of the ACEN-accredited master’s and baccalaureate nursing programs from Wesley College.
  • UPMC Jameson (Diploma) Newcastle, PA related to the implementation of the UPMC Hamot branch campus.

The Board of Commissioners approved the substantive change report and requested a written report about the status of the implementation of the substantive change for the following programs:

  • None

The Board of Commissioners approved the substantive change report and removed the requirement for a focused visit for the following programs:

  • None

The Board of Commissioners denied the substantive change report and authorized a focused visit for the following programs:

  • None

The Board of Commissioners denied the substantive change report for the following programs:

  • None


Continuing Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in compliance with all Accreditation Standards.

Continuing Accreditation with Conditions: A measure imposed by the ACEN Board of Commissioners following the determination of non-compliance with one (1) or two (2) Accreditation Standards. Next review and follow-up action(s) are determined by the Board of Commissioners.

Continuing Accreditation with Warning: A measure imposed by the ACEN Board of Commissioners following the determination of non-compliance with three (3) or more Accreditation Standards. Next review and follow-up action(s) are determined by the Board of Commissioners.

Continuing Accreditation for Good Cause: A measure imposed by the ACEN Board of Commissioners following the determination that a nursing program has not remedied deficiencies at the conclusion of its maximum monitoring period and the program has (a) has demonstrated significant recent accomplishments in addressing ; (b) has documented that it has the potential to remedy all deficiencies within the extended period as defined by the Commission; that is, that the program provides evidence which makes it reasonable for the Commission to determine it will remedy all deficiencies within the extended time defined by the Commission; and (c) provides assurance to the Commission that it is not aware of any other reasons, other than those identified by the Commission, why the nursing program could not be continued for good cause.

Denied Initial Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in non-compliance with one or more Accreditation Standard.

Denied Continuing Accreditation: A determination by the ACEN Board of Commissioners that a nursing program on conditions, warning, or for good cause is found to be in continued non-compliance with any Accreditation Standard. Thereafter the nursing program is removed from the listings of accredited programs.

Focused Visit: A site visit authorized by the ACEN Board of Commissioners to review significant accreditation-related information disclosed about a program as a result of:

A substantive change;

Information revealed about a program between periods of scheduled review;

Information received from the governing organization’s accrediting body related to an adverse action;

Information received from the program’s state regulatory agency for nursing related to a change in its status;

Information revealed by a program during the Evaluation Review Panel process;

Information received from the U.S. Department of Education regarding a program’s compliance responsibilities under Title IV of the Higher Education Act such as information related to a program’s most recent student loan default rates, the results of financial or compliance audits, program reviews, and any other information that may be provided by the U.S. Department of Education.

Follow-up Report: A report prepared by a program addressing the Standard(s) for which the nursing program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.

Initial Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in compliance with all Accreditation Standards.

Remove the Conditions Status and Grant Continuing Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in compliance with the Accreditation Standard(s) that the program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.

Remove the for Good Cause Status and Grant Continuing Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in compliance with the Accreditation Standards that the program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.

Remove the Warning Status and Grant Continuing Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in compliance with the Accreditation Standard(s) that the program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.

See ACEN 2017 Standards and Criteria
Clinical Doctorate/DNP Specialist Certificate
Master’s/Post-Master’s Certificate

Substantive Change Report: A report submitted by an accredited program informing the ACEN of a significant modification or expansion of the nature and scope of a nursing program and/or nursing education unit.

The Accreditation Commission for Education in Nursing (ACEN) and the Organization for Associate Degree Nursing (OADN) Coordinate Efforts To Support Nursing Education’s Role In Vaccine Strategy.

ATLANTA, GA -The Accreditation Commission for Education in Nursing (ACEN) and the Organization for Associate Degree Nursing (OADN) are strategically collaborating to assist the nationwide COVID-19 vaccination effort. Together, the organizations will advocate for an increased role for nursing education programs in the vaccine rollout to help meet the goals set forth by the Biden Administration. Through this collaboration, the ACEN and OADN will disseminate information and approaches that can assist nursing programs in identifying how students and nursing faculty can safely and effectively support vaccination education and efforts in their communities. ACEN accredited programs and OADN member schools can be found in every state, as well as U.S. territories and abroad, and these programs are poised to assist in the scaling of vaccine delivery.

The ACEN and OADN strongly encourage nursing programs to actively identify how they can support vaccine delivery in their communities. For full engagement in the vaccine effort, our organizations urge nursing students and faculty to receive the COVID-19 vaccine as soon as it is available to them.

“OADN believes that nursing education programs have an important role to play in the unprecedented effort to vaccinate the entire population. Nursing students and faculty have expertise and skills that should be engaged to safely accelerate the vaccine rollout,” said Donna Meyer, Chief Executive Officer of OADN. “The Biden Administration’s National Strategy for the COVID-19 Response and Pandemic Preparedness encourages states leveraging practical and registered nursing students to surge their vaccinator workforce. OADN and the ACEN believe that this one important strategy towards achieving the Administration’s vaccination goals and ensuring vaccine equity.”

“The ACEN is dedicated to ensuring the highest standards in nursing education. Our broad community of over 1200 accredited nursing education programs is well-prepared to help the nation meet the herculean task of wide-scale vaccination, while simultaneously continuing to prepare the nursing workforce for the future. The ACEN supports students participating in the COVID immunization efforts, as these efforts could be considered Clinical/Practicum Learning Experiences as defined in the ACEN Glossary. Nursing program engagement in the vaccination effort can take many forms, including vaccine administration, patient education, community outreach, and contact tracing, among others,” said Marsal Stoll, Chief Executive Officer for the ACEN. “In a letter to the nursing administrators of ACEN accredited programs on February 1, 2021, the ACEN shared how the Georgia Department of Health is engaging nursing students and faculty to support mass vaccination sites in the state. We encourage all stakeholders to consider this strategy, which includes just in time training and memoranda of understanding, when developing an approach in your state or area.”

“The Department of Veterans Affairs (VA) has stipulated that clinical trainees, including nursing students, can be trained and utilized as vaccinators at VA vaccine administration sites. Local nursing program deans and directors are encouraged to reach out to local VA nursing leadership to identify the best way to get involved. We will also continue to closely monitor the Biden Administration’s vaccination policies and regulations. This includes any amendments made by the U.S. Department of Health and Human Services to the Declaration under the Public Readiness and Emergency Preparedness Act (PREP Act),” continued Stoll.

“Additionally, the National Student Response Network (NSRN), an interprofessional collaborative of health professions students, is seeking nursing student volunteers for various roles in mass vaccination. Students interested in volunteering are encouraged to contact their regional or state coordinator,” noted Meyer.

“On the vaccine education front, the American Nurses Association is developing a coordinated vaccination messaging campaign which will provide COVID-19 vaccine information, encourage all nurses to be vaccinated, and promote vaccine education and uptake by consumers,” added Meyer. “OADN is participating in the development of this messaging campaign and will be sharing the communication tools and related resources once they are completed.”

The ACEN and OADN have joined the COVID-19 Vaccine Education and Equity Project which aims to promote equitable access to authorized and approved vaccines through equitable access to information and dialogue. The Project will foster dialogues to address and reduce vaccine skepticism, with the goal to promote equitable vaccine distribution and improved health outcomes for communities hit hardest by COVID-19.

Nursing education programs are encouraged to share how they are supporting the mass vaccination effort; please, share your stories here.  Continue to follow the ACEN’s COVID-19 News and Announcements and OADN’s COVID-19 Resources for more information and further developments.

About the Accreditation Commission for Education in Nursing (ACEN)

ACEN supports the interests of nursing education, nursing practice, and the public by the functions of accreditation. Accreditation is a peer-review, self-regulatory process by which non-governmental associations recognize educational institutions or programs that have been found to meet or exceed standards and criteria for educational quality for all levels of nursing education and transition-to-practice programs located in the United States, U.S. Territories, and internationally.  

About the Organization of Associate Degree Nursing (OADN)

OADN is the national voice and a pivotal resource for community college nursing education and the associate degree pathway. We work to expand networks that promote leadership, collaboration, and advocacy to further enrich nursing education and the communities we serve. Online at

New Leadership Offerings at OADN


By Mary Dickow, MPA, FAAN | Director of Strategic Initiatives | Organization for Associate Degree Nursing (OADN)
Bridges, Volume XIII – Issue 4, November 2019

At the 2019 Convention, OADN worked in partnership with the ACEN to deliver a full-day session entitled Be the Leader You Would Follow: Essentials for Great Leadership in Nursing. That session drew enormous interest from nurse educators attracted to this full-day, interactive experience. It provided the participants the opportunity to work on personal leadership development plans as well as to gain valuable tools and resources to take back to their programs to address real-time solutions. Other sessions offered on Professional Identity in Nursing and Critical Conversations were two of the highest attended breakout sessions, targeting important issues for nurse educators. OADN remains committed to staying engaged with the leadership pulse by paying attention to the current trends that affect nursing education and contributing to the success of nurse educators.

OADN understands the challenges and hurdles nurse educators face every day. With a goal to prepare them with the tools to address these challenges, OADN is planning to offer new leadership development opportunities to identify solutions. An exciting leadership development track is in the works for the 2020 Convention with topics such as mentoring, goal setting, and succession planning. As the only national nursing organization representing ADN programs, we have a responsibility to offer a strong leadership platform for new directors and faculty aspiring to lead. Everything OADN does to better prepare nurse educators is a reflection on the students and the communities surrounding the many community colleges across the nation. OADN is ready now more than ever to contribute to the knowledge and skills necessary to achieve the vision of creating healthier communities—one nurse leader at a time.

Working with national leaders such as the ACEN, OADN is in the process of developing webinars and pop-up sessions on hot topics in leadership to offer throughout the year. In addition, OADN is exploring ways to incorporate what was gained from the recent membership survey to demonstrate a commitment to taking what nurse educators say they need, then creating valuable content to address those needs. As OADN continues to grow, it is essential to acknowledge the importance of growing and mentoring new leaders while providing unique opportunities for the more seasoned leaders as well. OADN is committed to developing successful nurse leaders with a vision for 2020 and beyond!

Top 10 Ways to Get or Keep Your Faculty Engaged


By Suzette Farmer, PhD, RN | Director | ACEN
Bridges, Volume XIII – Issue 4, November 2019

Ever wondered how to engage faculty in the accreditation process? Read this article to see the Top 10 strategies for engaging faculty and ensuring program success during your next accreditation site visit!


Live accreditation every day—be visit-ready all the time. Create a culture where accreditation is not a dirty word!! For example, use ACEN terminology during meetings…make accreditation processes “normal” and familiar in your daily work as a nurse educator.


Appreciate and acknowledge how accreditation can help you be a better faculty member and a better program. As you become more familiar with the Standards and Criteria, you will recognize how curriculum (Standard 4) flows into outcomes (Standard 6); and soon, you will see how the ACEN’s emphasis on student learning and the end-of-program student learning outcomes can help you be a better and more effective nurse educator.


Use the Standards and Criteria as a framework for orienting new faculty. Don’t wait to introduce new faculty to accreditation and the ACEN Standards and Criteria. Once again, the emphasis on faculty qualifications and development, students and student learning, resources needed for program development and maintenance, the development and delivery of a curriculum designed to help graduates practice in a contemporary environment, and a focus on the achievement of end-of-program student learning outcomes and program outcomes will provide new nurse educators with a framework that will support them throughout their career in nursing education.


Keep it simple, don’t overthink the accreditation process. The Standards and Criteria are simply statements of good educational and academic practice. The Standards and Criteria are designed to help programs achieve and maintain quality…they are indicators of quality as determined by your nurse faculty peers. A program that is in compliance with the Standards and Criteria is not jumping through hoops; they are intentionally doing the “right thing” for their students and the profession!


Consider taking advantage of optional services offered by the ACEN, such a being an Observer on a site visit team or taking advantage of an Advisory Review. These optional services can help you be more familiar with the accreditation process and the activities of the site visit team (Observer); or, they can help you and your faculty develop a deeper understanding of selected Standards within the specific context of your program (Advisory Review).


Share accountability for maintaining accreditation readiness. The nurse administrator is not an island. When the work of accreditation is distributed among the faculty, everyone—including the students—benefits. Sharing accountability helps ensure the program is always ready for a visit, and it can help minimize the chaos that sometimes occurs before an accreditation visit. It also provides a means for faculty to provide service to the program and develop leadership skills!


Develop knowledge about and understanding of the Standards and Criteria. Don’t believe “urban legends” about accreditation—find out for yourself! Many people believe things about accreditation that simply are not true, such as the myth that you have to have a graduating class before you can be accredited (which isn’t true). Study the Standards and Criteria, review ACEN policies, and ask questions! The ACEN is here to be your supportive partner in the accreditation journey.


Nurse administrators should listen to faculty and be open to their ideas, learn to appreciate their creativity, and be willing to take a few risks when faculty suggest new ways of doing things. If we want to prepare our students for a dynamic healthcare environment, we need to be willing to make our nursing education programs more dynamic and move beyond “the way we’ve always done it” mentality. Don’t be afraid to try new approaches and be sure to give them some time to work! Celebrate innovation.


Encourage faculty to become peer evaluators for the ACEN and provide support for them to participate in site visits. Being a peer evaluator is an effective way to increase knowledge of the Standards and Criteria, learn from peers serving with you on the site visit team, and learn from the programs you visit. Dr. Sharon Beasley’s article will provide you more information about how becoming a peer evaluator benefits the program and the individual faculty member.


Send faculty members to an ACEN Self-Study Forum! Self-Study Forums are held 2‒3 times a year in locations across the country. It’s an opportunity for attendees to interact with other nurse educators and the ACEN Directors….all while developing a deeper understanding of the Standards and Criteria. We hope to see you soon!

Living the ACEN Accreditation Process


By Sharon Beasley, PhD, RN, CNE | Director | ACEN
Bridges, Volume XIII – Issue 4, November 2019

Dr. Suzette Farmer’s Bridges article, Top 10 Ways to Engage Faculty in the Accreditation Process (2019) , provided techniques to engage faculty in the preparation for and maintenance of ACEN accreditation. As a corollary to Dr. Farmer’s article, Living the ACEN Accreditation Process outlines key definitions inherent in the four-step ACEN accreditation process, and the faculty’s opportunities to participate in various steps of the accreditation process. Let’s start with a review of definitions necessary to understand each step of the process.

Definitions and the Four-Step Process

1. The Self-Study Report (SSR) is a written document addressing the program’s self-evaluation regarding its compliance with the ACEN accreditation Standards and Criteria (2017 ACEN Guidelines for the Self-Study Report). The SSR is evidence that is evaluated by peer evaluators in each level of review; therefore, it should be written clearly and accurately.

2. The site visit team is a group of peer evaluators (educators and clinicians who are eligible to volunteer as described in ACEN’s Peer Evaluator Selection Criteria), who are knowledgeable about various program types, appropriate curricula, common practices, and trends in nursing education and practice. The peer evaluators on the site visit team provide an onsite review inclusive of interviews, observations, tours, and a review of exhibits. At the conclusion of the site visit, the peer evaluators complete a Site Visit Report (SVR) documenting their findings and a recommendation for accreditation.

3. The Evaluation Review Panel (ERP) is a group of peer evaluators who are appointed by the ACEN Board of Commissioners (BOC) to conduct its own independent analysis regarding the extent to which the program meets the ACEN Standards. The ERP represents peer evaluators from programs similar to the programs reviewed and clinicians from various geographic regions. At the conclusion of ERP deliberations, these peer evaluators offer their independent recommendation to the BOC based on the program’s SSR and the findings from the peer evaluators on the site visit team.

4. The BOC is responsible for making all accreditation decisions, and the Commissioners are elected by the nurse administrators from ACEN-accredited programs. Additionally, this 17-member Board is responsible for ensuring consistency in the application of the Standards and Criteria among all programs within each cycle. The Board reviews each program’s SSR, the SVR and recommendation, the ERP recommendation, any additional information if applicable, and renders an accreditation decision.

All of these terms are commonly used in the ACEN realm of accreditation. Notably, all of the definitions are steps within the accreditation process. The four steps in the process are the:

  • Submission of the Self-Study Report;
  • Site Visit;
  • Evaluation Review Panel’s recommendation; and
  • Board of Commissioners’ accreditation decision.

The first step in the accreditation process is the perfect opportunity for faculty to become familiar with the ACEN accreditation process from the faculty/program’s perspective. The remaining three steps provide additional opportunities for participation within the ACEN accreditation review process. However, the three remaining steps require faculty to become ACEN peer evaluators – what a wonderful opportunity! Thus, living the ACEN accreditation process relies on the volunteer efforts of peer evaluators.

Why Are Peer Evaluators Needed?

The ACEN is recognized by the U.S. Department of Education (USDE) and the Council for Higher Education Accreditation (CHEA) to accredit all levels of nursing programs (i.e., clinical doctorate/doctorate in nursing practice specialist certificate, master’s/post-master’s certificate, baccalaureate, associate, diploma, and practical). Therefore, peer evaluators are needed for all program types and three (i.e., site visit, ERP, and BOC) of four levels of review. Eligibility to serve as a peer evaluator requires a minimum of a graduate degree in nursing. However, to serve on a team that reviews a graduate program, peer evaluators serving as a nurse educator must have a master’s degree in nursing and an earned doctorate degree from a regionally accredited college/university. To serve on a team that reviews an undergraduate program, peer evaluators serving as a nurse educator must have a master’s degree in nursing. A nurse clinician must have a minimum of a graduate degree in nursing to review any program type (2019 ACEN Accreditation Manual, Section 1 General Information, pp. 21–22). Further, the process to become a peer evaluator is seamless and includes submission of a letter of interest, a curriculum vitae, and a letter of recommendation. All documents must be submitted through our Nominate a Peer Evaluator portal located on the ACEN website.


Peer review is the core of the ACEN accreditation review process. The ACEN is fortunate to work with nearly 650 volunteer peer evaluators who ensure integrity of the accreditation review process by evaluating programs in three of four levels of the process. During each level of review, peer evaluators provide expertise from their current and past experiences in nursing education and practice. Peer evaluators offer their personal time and expertise to the nursing profession through their rigorous review of nursing programs. Serving as a peer evaluator is personally fulfilling and an altruistic act of serving a community of nursing students, educators, and clinicians. Yet, two of the most practical benefits are a broader and deeper understanding of the ACEN Standards and Criteria and exposure to various practices in nursing education. “…one of the most fulfilling attributes of the peer evaluator role is the opportunity to lend an expert voice to the accreditation review process and ultimately the quality of nursing education” (Beasley, Farmer, Ard, Nunn-Ellison, 2019).

How To Get Faculty Involved


By Wade Forehand, PhD, DNP, RN-BC, CNE | Director and Professor | Troy University School of Nursing
Bridges, Volume XIII – Issue 4, November 2019

The Accreditation Commission for Education in Nursing (ACEN) accreditation process intends to enhance quality improvement in nursing education through peer-review process. Achieving accreditation signifies that a school or university has been found to meet or exceed standards and criteria for educational quality. The accreditation process at any level is both a daunting and an arduous task for nurse administrators and faculty alike. Whether you are preparing for initial accreditation, a continuing accreditation review, or simply trying to incorporate the ACEN Standards and Criteria more into your daily practices, it is needed for the program’s betterment and livelihood. The focus of this column is to offer some very casual and practical advice from one nurse administrator to other administrators—or to faculty looking to embrace the accreditation process more confidently.

I would like to begin by sharing a little about my university, the nursing programs that we offer, and myself. Presently, I have the honor of serving as the Director of Nursing for the Troy University School of Nursing (SON) in Troy, Alabama. Troy’s SON offers programs at all levels including ASN, BSN, RN-to-BSN, MSN, Post-MSN Certificates, and the DNP. Our pre-licensure ASN and BSN programs are offered in a traditional face-to-face format on three different campus sites. Our RN-to-BSN, MSN, Post-MSN Certificates, and DNP programs are offered as distance education delivered online. I mention all of this in order to relay the complexity and diversity of the different degree offerings that we have at Troy University—to help you compare it to your own program. In terms of size, Troy University has approximately 17,000 students enrolled either on-campus or online. The SON has approximately 600 students enrolled. In respect to myself, I would say that I am a relatively new nurse administrator. I was appointed to my position two years ago in 2017. My background includes experience in teaching BSN and graduate students at the MSN- and DNP-levels. I have over seven years of experience in nursing education and fourteen years of nursing experience. I am also a Certified Nurse Educator through the National League of Nursing.

When I accepted the nurse administrator role in 2017, the SON was actively preparing for a continuing accreditation visit of our BSN and MSN programs, which was scheduled in for Spring 2019. Needless to say, I felt a great sense of responsibility to ensure that our site visit would go as smoothly as possible. Some of the strategies and activities that we implemented as a SON not only prepared us for the site visit, but also engaged all faculty in the process. Approximately three years ahead of our scheduled visit, we initiated a timeline and series of efforts that would carry our program through the entire continuing accreditation process. We intentionally wanted to build a schedule that would lead to a successful visit. In offering advice to others, I would first highly recommend that you consider strategically when to start preparing for your visit. A three-year preparation process has served our school well over the years. Getting faculty buy-in and support the preparation process was essential.

Faculty must be involved in the preparation and execution of the visit. Faculty and support staff are the cornerstone of a program’s success, and therefore must be instrumental in preparing the Self-Study Report (as required by the ACEN). Most probably know, but the Self-Study Report is a self-evaluation regarding compliance with the ACEN Accreditation Standards. This report in essence tells the story of the nursing program. The way that Troy University sought to engage faculty was to have them active in the planning process from day one. One of the early steps that we took was to create a schedule to ensure that all faculty in both programs being reviewed were able to attend one of the live ACEN Self-Study Forums. These forums, provided by the ACEN Directors, are offered throughout the year in a variety of locations. Forums provide faculty with an opportunity to dive deeper into the current ACEN Standards and Criteria. The forums are in a workshop format, and consist of a day-and-a-half activity where faculty prepare for a site visit. We intentionally started early in arranging for faculty to attend the Self-Study Forums to ensure that all faculty members would have an opportunity to attend and have background knowledge about the preparation for the visit. These Forums, along with the formation of committees and a timeline, helped jumpstart the effort to initiate the process. It was expected that all full-time faculty would play a role in writing the Self-Study Report and gathering documents of evidence concerning accreditation. I found it to be important to establish a culture within the school that both valued faculty input in the process and relayed the importance that each member plays in the success of continued accreditation.

Another point of advice that I would recommend in getting faculty involved is to harness the strengths that individual faculty members may have. It is important to consider what role best fits an individual faculty member. In other words, if someone’s strong suit is writing, then have that person play a role in writing or editing sections of the Self-Study Report. Another faculty member may be efficient and organized at compiling information for evidence. The overall goal is a successful visit. Take into consideration your team, their strengths, and their weaknesses as you put together committees and assignments for the visit preparation. I would also encourage nurse administrators to look at their faculty for expertise with the ACEN. Many programs will find that they have faculty that have served as peer evaluators or have played larger roles within ACEN. Challenge these individuals to be leaders in the preparation effort. Also, encourage faculty to consider becoming peer evaluators. The ACEN review process from the team perspective provides a wealth of knowledge when it comes to contributing to one’s own nursing program. I make it a priority to encourage faculty to be involved with the ACEN. In fact, Troy has many faculty members that are peer evaluators, team chairs, serve on the Evaluation Review Panel, and have held positions on the ACEN Board of Commissioners. Regardless of the role, experience with the ACEN is an invaluable asset for the nursing program.

Lastly, I would offer that the nurse administrator should set the team up for success in preparing for the visit. Make sure that you take into account the work that is involved with the visit. It may be necessary to consider work releases from your typical teaching or faculty duties. Remember a successful visit is the end result, and thus preparing is important. This is just as important as it is to make sure that the day-to-day operations continue. By forming committees and spreading the workload out among the faculty, you help to prevent the burden from falling on any single person. I also encourage nurse administrators to remain active in the overall process. Make sure to attend faculty meetings and committee meetings to talk about efforts and the progress that is being made. Moreover, set firm deadlines for progress and stick to those deadlines to ensure that progress is always being made.

In conclusion, I hope that this friendly advice may be helpful as you or your program engage in a deeper understanding of the accreditation process.

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!

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!

The ACEN Cares

The ACEN Cares

ATLANTA, Dec. 5, 2017 – It is that time of year again when giving back to the communities surrounding us is weighing on our minds. As a nursing organization, the ACEN has giving back on its mind year-round.

Each year, the ACEN team participates in an out-of-office excursion to help promote teamwork as well as inner-office collaboration and growth. This year, we chose to give back to the greater Atlanta area by providing a Career Day to students in Dr. Jeannette Francis-Ferris’s Health Sciences Courses at South Cobb High School in Austell, Georgia. Professional staff, our executive team, and our administrative team shared experiences, including our educational backgrounds and what led us to the ACEN. Students engaged in conversation and questions with our team and showed a thirst for knowledge. Before leaving the high school, members of the ACEN “editing team” assisted students in writing résumés for entrance into their desired college programs.

As the year progressed, members of the ACEN family were affected by natural disasters, resulting in damage to nursing programs in Texas, Florida, Puerto Rico, and the U.S. Virgin Islands. Many of our programs were flooded and without power, some even without drinkable water or access to food. In an attempt to help our programs, as family does in a time of need, the ACEN enacted Policy #6 Delay/Advancement of Accreditation Visit, which allowed programs affected by the hurricanes to postpone upcoming site visits and allowed programs to submit reports outside of pre-established timeframes. Additionally, the ACEN has partnered with four non-profit organizations to encourage monetary donations to the communities hardest hit. Partnerships include the Neighborhood Health Clinic in Collier County, Florida, which was one of the worst hit areas in Florida after Hurricane Irma and home to many people below the poverty line; the Hispanic Foundation, which is the leader in the nation’s Latino non-profit organization with the objective to aid Puerto Rico in its long road to recovery; the Rebuild Texas Fund, which is a combined effort of the Michael & Susan Dell Foundation and the OneStar Fund to provide areas of need and long-term recovery from Hurricane Harvey in Texas; and the Community Foundation of the Virgin Islands, which supports the current and long-term needs of proceeds to their designated efforts. Recovery in these areas is ongoing, and these organizations are still accepting donations.

Finally, each year during the holiday season, the ACEN offers its support to one local homeless shelter. This year, the ACEN is working with the Covenant House: Helping Children and Youth. As the name suggests, Covenant House is a homeless shelter for teens and young adults. These individuals come from a variety of backgrounds, including abuse victims, those kicked out of their homes, those who have aged out of foster care, and victims of human trafficking; but all have one thing in common: they have nowhere else to go, especially during the holidays. So, to help make the season bright, the ACEN has organized an in-office gift drive and will be delivering the gifts mid-December.

While it is important to remember to give in the winter months, it is a great feeling to be part of an organization that gives year-round. The ACEN believes in helping the community that serves as our home, as well as our family of programs. As the holidays come and go, the ACEN wishes everyone good tidings for the year ahead.

Season’s Greetings!