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).