Expiration Date: December 31, 2001. No CE credit will be given after this date.

Table of Contents Abstract and Objectives Introduction Article #1: "Licensure, Certification, and Accreditation" Licensure Certification Accreditation Summary Article #2: "Issues of Accreditation: A Dean's Perspective" Role Needs Recommendations for Accrediting Schools of Nursing Summary Article #3: "Accreditation for the Future: A Director's Perspective" Questions for Tomorrow New Dimensions for Tomorrow's Care Systems Important Questions Suggestions for Change Summary References The deadline for completion of this module is Dec. 31, 2000. Abstract Note: This independent study module encompasses several articles from one issue of the Online Journal of Issues in Nursing. "Licensure, Certification, and Accreditation" by Barbara Stevens Barnum, RN, PhD, FAAN This article provides an historical overview of the three major ways that nursing regulates the profession, its members, and their performance, i.e., licensure, certification, and accreditation. Each type of regulation mechanism is described and differences between them are explained. Current issues related to accreditation of schools of nursing are outlined. "Issues of Accreditation: A Dean's Perspective" by Mary S. Collins, PhD, RN In response to Dr. Barnum's article ["Licensure, Certification and Accreditation"], this article gives a dean's perspective on accreditation of schools of nursing. Although accreditation can be an anxiety producing event, the position is taken that accreditation is needed to promote consistently high standards in nursing education. Further, accreditation must become an integral part of the daily functioning of the academic institution rather than an episodic event to result in overall continuous program improvement. "Accreditation for the Future: A Director's Perspective" by Sheila A. Ryan, PhD, RN, FAAN In response to Dr. Barnum's article, this article provides another view on licensure, certification, and accreditation. Current and future issues are outlined, discussed, and relevant questions are addressed. The issues involved in accreditation will not be resolved with simplistic competition; rather, the issues demand a response bigger than current practices. Objectives Describe the purpose of licensure, certification, and accreditation. Analyze the need for accrediting schools of nursing. Introduction By Sister Rosemary Donley, PhD, RN FAAN Professor of Nursing The Catholic University of America Article originally published August 28, 1997 OJIN probes the sensitive and important issue of accreditation of schools of nursing. Dr. Barnum rightly places accreditation within a paradigm that includes licensure and certification. She also offers vital distinctions about purpose (assure safety versus assure quality) and scope (individual versus institutional). The discussants, Dr. Collins and Dr. Ryan, place accreditation in the context of a social agenda of cost containment, managed care, and accountability in higher education and health care. As they lay out their conceptual grid, I am reminded of an old McDonald's commercial where a father comforts a preschool child who is feeling displaced by a new baby. The dad reminds the little boy that he has been around the block several times. Dr. Barnum speaks of this experience factor especially around licensure as identifying "hot" or "wedge" issues. In the decade of the nineties, accreditation has assumed center stage. It is hot! There is concern about the value of accreditation. There is debate about whether accreditation should be public or a private sector endeavor. There are efforts to relate accreditation to quality assurance, reimbursement, eligibility for financial aid, academic progression, or comparative advantage in the student, patient, or job market. Some commentators explain the loss of confidence in accreditations as another sign that twentieth century structures are collapsing under their own weight. Modern writers insist that accreditation should not be driven by process (credentials of accreditors or faculty, the format of the curriculum, or admissions and progression standards). They argue that it is the end, the product or the outcome that counts. Cognizant of these debates, Dr. Ryan asks what needs to be "done to" accreditation so that it fits into a technological or information society? Dr. Collins wants marketplace accountability. She asks whether accreditation as we know it meets the standards of efficiency or cost containment? If health and education become commercial enterprises, I wonder how the "customer" — the patient, the employer, or the student will sort through the hype and select the school or the health care environment that is best for them. Will private accreditation become a consumer's guide to quality health care and professional education? "Licensure, Certification, and Accreditation" By Barbara Stevens Barnum, RN, PhD, FAAN Article originally published August 13, 1997 Introduction There are three major ways we regulate our profession, its members, and their performance — namely, licensure, certification, and accreditation. The differences among these processes can be confusing. They have different purposes, unique philosophies, and diverse legal standings. Licensure Let's begin with licensure. A registered nurse (RN) or licensed practical nurse (LPN) — sometimes called a licensed vocational nurse — is individually licensed in a particular by testing that validates she/he has acquired the basic knowledge required for safe practice. Licensure does not purport to do more than that. The philosophy is one of protecting the client, public, from harm. This testing aims to eliminate those not qualified for minimal safe performance; it does not recognize exceptional performance (although the test is scored). A nurse must be licensed in a state in order to work as an RN or LPN (barring special circumstances not to be elaborated here). The exams for these two levels are separate and distinct, as are the qualifications that must be completed before a candidate sit for the test. Licensure in general is a granted to the states, not the federal government. Of course, nursing has conveniently gotten around this fact by, among other things, creating the Council of State Boards of Nursing. This body has allowed for national uniformity in testing and related criteria (between and among states) whiletechnically skirting the fact that each state is legally free to write its own licensure rules and examinations. This coordination has meant that a nurse could move from New Hampshire to Tennessee without the trauma faced, for example, by a lawyer making the same move. As a nurse who is old enough to remember the early insanities of each state having different requirements, I appreciate these efforts. I remember, for example, classmates who moved (even in my earlier days nurses were peripatetic), yet couldn't sit for licensure in the new state because their school program had offered 1,040 hours of psychiatric nursing instead of the 1,250 hours required in the new state. (Don't hold me to the hours, but the type of problem was typical.) The solution to such problems wasn't easy: the nurse would have to find some school willing to take him or her as a part-time student for more experience in the area judged inadequate. It was a numbers game of ultimate frustration that our present system avoids. Historically, there have been few "hot" issues concerning licensure, at least since licensure became a fact. There always have been, of course, various arguments concerning what crimes and misdemeanors can cost one a license, as well as issues of who should or should not serve on the administrative boards. On the national scene, however, there have been few historical proposals to change who gets licensed for what. RN licensure was well established in each state when I graduated and started working (circa 1958), but I can remember when there were still "waivered" LPNs, that is, people who worked as practical nurses but had not had the requisite education. As always happens in a situation of upgrading (in this case to licensure), there has to be some accommodation for those who getcaught in the middle of such an historical change. So the waivered LPNs were given their licenses by the grandfathering mechanism. Employers, of course, knew who had earned the license and who was waivered, and sometimes waivered LPNs were payed less, and not all institutions hired them. The Lysaught report (1981) by the National Commission for the Study of Nursing and Nursing Education, sponsored by the Kellogg Foundation, was another (almost) challenge to licensure. Lysaught and the Commission recommended two separate licenses, one in acute, one in distributive care. The Commission thought that nursing had grown too big for a single license (by this they meant that the total content of nursing had expanded beyond what could be contained in a single curriculum). The nursing profession decided to pass on that one, although the report looks more interesting now that we're in an era when much nursing delivery is moving out of acute, episodic care into what Lysaught called distributive care. The next big fluff concerning licensure was — and still is twenty years later — the proposal to make two RN licenses, one for 2-year nurses and one for 4-year degree-holding nurses, with the latter credential bearing the label, "professional." This licensure change never came about for many reasons, one of which was the rigidity of the proposers who did not want to waiver in as "professionals," nurses who didn't then hold the 4-year credential. Ironically, if there had been a little more accommodation, by now most of those waivered RNs would be retired and the issue would be finished. Instead, we are still arguing the same issue in our professional organizations. No profession in the history of this nation, incidentally, has managed to bootstrap its credentials without using the waivering mechanism. I don't know why the advocates of "no waivering" thought nursing could be different. Anyone who can count could tell that the 2-license plan would not happen without waivering, as long as nurses without the 4-year degree outnumbered those with it. Another perennial issue is that of institutional licensure. This proposal recommends that an institution be allowed to create its own job descriptions and license employees for them. The proposition has always been fought tooth and nail by nurses. (Not surprisingly, the proposal never suggests that institutional licensure apply to physicians, only to nurses and "lower level" personnel.) Fortunately, we live in an era when people no longer trust the beneficence of institutions, so perhaps institutional licensure as an issue is dead for a while. The newest issue is that of licensure for the nurse practitioner, an issue which is steadily being settled, one state at a time, with a few states still being controlled by medical interests that hope to stop or restrain the inevitable nurse practitioner tide. (On this issue, don't move to California.) But, once again, because licensure is a state's right, the licensure requirements differ from state to state. Will we ever have a Council of State Boards of Nurse Practitioners? Who knows. On the whole, because of our contrived uniformity from state to state, basic licensure (for RNS and LPNs) is relatively simple. This will be true until some state decides to lead a change, probably that of dividing RN licensure into two or more separate licenses (e.g., acute versus episodic,baccalaureate versus other, or some new proposal on the scene). As to issues, the practitioner license is evolving, at different speeds and with different rules, from state to state; but essentially, the movement has been toward giving practitioners more extensive authority and more power to work independently of physicians. Some states, such as New Jersey, extend relatively comprehensive powers to all advanced practice nurses (clinical nurse specialists and nurse practitioners). Certification Nurse certification, like licensure for RNs, involves individual testing, in this case testifying to status achieved by a nurse in some given specialty. If licensure has its eye on minimal performance, certification is oriented toward the other end of the spectrum, testifying to the nurse's achievement of a special competence. Most certification programs are limited to nurses but there are some certification programs open to health or human services professionals from diverse fields. Almost all graduates of nursing master's specialty programs (especially practitioner programs), want the status afforded by certification. However, unlike licensure, it is up to the individual to decide whether or not to take a certification exam. Although many jobs may only be open to nurses holding desired certifications, the certification process is voluntary. Certification programs in nursing have grown like Topsy, (I count over 30 of them without even working at it), mostly through individual specialty organizations but now through ANA and the American Nurses Credentialing Center as well. Many, but not all, of the certification programs are designed for nurse practitioners; some are open to clinical nurse specialists as well. Many certifications involve "broad" specialties, in areas such as midwifery, anesthesia, orthopaedics, and oncology. Other certificate programs are very narrow, such as those in areas of enterostomal care and intravenous therapy. For a long time, this country ignored the British system, which relied heavily on the certification process. Of course the British system often used certification in lieu of academic credentials, and our system has not gone that direction. The certificate has become very important but it is more likely to be combined with higher education than substituted for the lack thereof. Most major certification programs today require graduation from a related academic program (usually master's level) before allowing the candidate to sit for the certification examination. There are, however exceptions to this rule. Narrow certifications, like intravenous therapy, obviously don't comprise the core of specialty master's programs. Some few certification programs prefer to employ the principle of testing only for knowledge acquired. These programs measure what the candidate knows rather than where and how the knowledge was acquired. We are in the throes of a love affair with certification in this country, and virtually every RN has a string of (possibly) inexplicable certification initials following her signature. As specialty nursing has replaced general nursing, certification has become a powerful card in the competition for jobs. Issues in certification chiefly involve quality control and who has the right to certify in a given area. In some cases, nurses may choose among certifying agencies. More interesting is the overall question of when will it all stop? How many specialties will emerge? How many will the market support? Should there be any overall policy regulating certification? At present, certification serves as a good check on the quality of nurse practitioner programs, among which there is still much (if unacknowledged) quality differential. Accreditation Accreditation, unlike the RN/LPN testing in licensure and RN certification, evaluates and judges institutions rather than individuals. Most accreditation programs testify to the institution's achievement, rather than merely guaranteeing safety. Accreditation, like nurse certification, is voluntary — but not quite. For example, if a service institution wants to collect Medicaid bills, it will have to have accreditation. Hence, while accreditation is "voluntary," an institution might go broke for the privilege of not volunteering. Similarly, in nursing master's education, most programs will not admit a nurse who graduated from an unaccredited program, even if the program was licensed by the state. In nursing practice, we have long been familiar with Joint Commission on Accreditation of Hospitals, later revised to Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the change corresponding to the broadening of the accrediting target from merely hospitals to other health care delivery systems. In nursing, our chief accrediting body over the years has been the National League for Nursing (NLN). The NLN parent organization accredits (through independent arms) both home health organizations under the Community Health Accreditation Program (CHAP) and nursing education through the NLN Accrediting Commission (NAC). We'll look at the home health accreditation process first. Acquiring of deemed status for this new accrediting function brought NLN into direct competition with JCAHO (there is no monopoly on the coveted deemed status). JCAHO's deemed status allowed them to accredit home health care programs long before the NLN developed itscompetitor, CHAP. The League's argument for creating the competitive organ was that a nursing organization was better prepared to do this sort of accreditation than an organization in which nursing held little clout, certainly true of JCAHO, which has always preserved power (in the form of full membership) in the hands of physicians and administrators — in spite of active participation of nurses atlower levels of JCAHO. After a long struggle, NLN (or technically, the independent arm) achieved deemed status. The competition between the two organizations (CHAP and JCAHO) was inevitable, but JCAHO is now recognizing CHAP accreditation for home health care components in integrated systems that come under the JCAHO purview. The longer-standing function of accrediting nursing education organizations has been one of the NLN's chief reasons for being. The accreditation program covers all bases, accrediting programs for licensed practice nurses, diploma nurses, baccalaureate and master's level graduates. (There has been a power struggle for years concerning whether or not doctoral nursing programs should also be accredited. This issue, which has merits on both sides, has not yet been resolved.) Recently NLN was dealt a blow when its deemed status as an accrediting agency for nursing education was threatened by the granting agency, the Department of Education (DOE). Part of NLN's effort to meet the objectives required by DOE in order to retain deemed status has involved creating the separate arm, the NLN Accrediting Commission (NLNAC). Just as NLN offered JCAHO competition in home health accreditation, so the American Association of Colleges of Nursing (AACN) the organization of deans of baccalaureate and higher schools of nursing, has determined to offer NLN competition in the accreditation game. For decades, various members of AACN had proposed creating an accreditation service, and it was predictable that the group would take this period of NLN vulnerability as the time to propose its own accrediting process. AACN's present proposal for a "collaborative" accreditation process may end up threatening many or all of NLN's accrediting programs, not merely the baccalaureate and higher degree components. On the other hand, there is also talk about a cooperative venture between the two organizations, so time will tell what actually emerges. All these moves by the various organizations are typical of a health care environment like today's, that is, one run primarily by competition. Issues in nursing education accreditation run the gamut from: "Do we really need it?" to "Does it have to take so much time and energy?" Ironically, it is often the more sophisticated programs (those most likely to pass with flying colors) that see the accreditation processes as redundant. For these programs, the process may be measured only by the lost opportunity costs of faculty and administrative time put into the extensive requirements of preparing a self-report. (AACN claims that shortening the process will be one of its chief aims.) On the other hand, some smaller or newer programs need the clout (or threat) of accreditation requirements to gain resources from the home institution. Early in its professional development, nursing schools were well served by the accreditation process. It provided sound guidelines and clout with the home institutions; it weeded out failing programs that needed to be closed. In the present era, however, many schools of nursing are feeling over-regulated. State evaluation for nursing programs, general collegiate evaluation, and NLN evaluation together consume a heavy dose of scarce time of deans and faculties. Cost and time are big factors in an era of down-sizing — a phenomenon that education has not escaped. Backing away from the politics, one can ask the perfectly justifiable question of whether nursing still needs and profits from a specialized professional evaluation apart from state evaluation and academic accreditation of the home institution in which the nursing program is housed. The answer might lie in a careful assessment of what is gained collectively through accreditation at this time. One measure might be some study of the actual, contemporary changes that have taken place in nursing programs due to NLN accreditation. Nitty-gritty measures would serve to answer this question, items like: how many schools actually got bigger budgets, more nursing library books, or more faculty lines in order to meet accreditation standards? It would be interesting to have cost/benefit studies balancing what was gained versus what was lost in dean and faculty time for report preparation. Whether school accreditation be under NLN or AACN, the question remains: Do we still benefit from a separate professional education accreditation process? Has the era of professional accreditation passed? Has accreditation been superseded by a focus on individual certification? Summary To date, we have relied on licensure, certification, and accreditation to maintain standards for the nursing profession (in practice and in education), both for the public and for the profession. What are your thoughts? "Issues of Accreditation: A Dean's Perspective" By Mary S. Collins, PhD, RN Article originally published August 13, 1997 Introduction It is redundant to mention that health care, delivery of services, and the educational preparation of health care professionals is in transition. Chaos, perhaps, is a better term. Professional nursing embraced President Clinton's activities to transform the present health care system. Congress and the President could not agree on a comprehensive plan and the Health Security Act of 1993 died in Congress. What we are left with is one component of health care delivery, specifically, managed care, fueling the pervasive changes in health care. The rapidly changing nature of health care certainly affects the planning and implementation of educational programs in nursing. Contemporary issues in nursing education include that of accreditation. Just as the practice area is changing through managed care, nursing education and its accrediting bodies are changing. Nursing education has been forced to enter discussions regarding the role of and need for accreditation and to make recommendations related to accreditation in current and future aspects of its existence. Role As a dean charged with the leadership of a school of nursing, I have had the opportunity to look at the real role of accreditation. One of the questions often asked is: "Do we need accreditation in the health care arena of today?" The answer is that we do. We need accreditation to promote consistently high standards in nursing education. The ultimate goal of any nursing program, I believe, is to prepare the highest quality of graduate for practice today and tomorrow. Every activity, course, admission decision, clinical site selection, and evaluation is driven by that goal. Accreditation has to be a measure of quality. In the dynamic state of nursing education today, accreditation must act as illumination to help programs move forward in sustaining current quality programs, developing new relevant programs, and creating an environment which promotes positive trends in nursing education. It needs to be a measure above the regulatory requirements of minimum standards. Too often today, we are caught up in fads and fancy phrases which can get someone's attention but have little substance. We must move away from fads to focus our attention on the effective trends happening in health care and nursing education. As a profession, nursing has the responsibility for its own definition and self-governance. Certainly, states play a role in the regulation of nursing. Because preparation of quality professionals across programs and states is essential, accreditation is also needed. Schools of nursing are aided by standards of practice of specialty groups but consistency across jurisdictions helps to develop a strong practice workforce. I look to an accrediting agency to focus on quality, performance outcomes, and identification of practice knowledge and content which are consistent across programs. Accreditation should set forth expectations of program performance above minimums set by states. Consistency across colleges and universities, as well as states, is a very important issue at the moment. At the same time it is worthwhile to note that consistency does not mean identical. We do not need a cookie cutter approach to program planning. Rather, we need a set of substantive guidelines which when implemented serve to produce a quality product. It is the very nature of American higher education to be different and often unique. Differing missions, philosophies, and student bodies serve to offer variety. Prospective students can chose from the broadest selection of higher education in the world. Students choosing nursing need to know that those programs accredited by a national nursing accrediting agency will offer a program which meets or exceeds standards considered appropriate by a body of nursing peers. Criteria and standards need to drive the designation of accreditation, not politics and relationships. Because there is such a specific set of measurable outcomes, performance standards and professional behaviors, a specialty accrediting agency within nursing is needed. Although regional agencies may be used in concert with nursing accreditation agencies, it is not enough to use only regional accrediting agencies that focus on entire colleges or universities. A nursing accrediting agency is also required. Needs Dr. Barnum has given us an excellent overview of the collective processes that control the preparation and practice of nursing in her article, Licensure, Certification, and Accreditation. Separate and distinct regulations, some mandated and others "elective," drive the parameters of nursing education. There is often an interrelationship between and among the regulatory bodies governing nursing education. State boards of nursing regulate nursing as they approve and monitor programs of nursing so that they meet minimum standards of education. Programs of nursing ultimately prepare graduates of programs to practice in state jurisdictions. Graduates obtain licensure after qualifying through NCLEX examination. Renewal/approval of nursing programs by state boards is based on annual reports, NCLEX examination results, self study, survey visits, or other criteria established by the board. State boards give the nursing program the opportunity to open its doors, to function, and to offer a program which meets minimum requirements to prepare graduates for safe practice. If we have state regulatory bodies that monitor nursing education programs, why is there a need for an accrediting agency? It is because regulatory bodies differ from state to state. Their focus is on meeting minimum criteria for program delivery. Minimum standards vary from state to state. Although most states use the state board to regulate and approve nursing programs (National Council of State Boards of Nursing, June 1997), there are in fact four distinct methods of approval and monitoring of programs in states and jurisdictions. New York State is an example of a jurisdiction where a state agency other than the State Board for Nursing approves and monitors nursing programs; Mississippi and Puerto Rico do the same. This can lead to fragmentation of regulation oversight and may ultimately have an influence on the quality of nursing programs in the state. New York State has had an additional stress on the regulation and quality management of its nursing programs. Philosophical changes in the role of the government brought on by a new Republican governor, along with severe economic conditions and large decreases in the state budget, have severely impeded the ability of the state agency to regulate nursing programs. This can be seen in the mediocre performance of graduates on the NCLEX examination. Concerns about the quality of graduates extends to the quality of nursing practice and also the quality of students entering graduate programs of nursing. The consumer or student also has a right to expect a certain level of quality and preparation in nursing programs. Since there is such a variety of methods of approval by states, consistency is not assured. The standards of an accrediting agency need to be higher than minimal requirements. Another example illustrating the need for an accreditation agency that demands more than minimal standards includes the increasing number of programs preparing graduate level nurse practitioners. The explosion in the number of these programs is directly related to managed care and the focus on primary care. Some programs have started with little or no resources, limited faculty expertise, limited experience with graduate program development, and no knowledge of graduate program evaluation. Students flock to nurse practitioner programs as they see a future secure job situation. New York State's experience certainly mirrors this experience. In the last 5 to 10 years, the number of registered nurse practitioner programs has grown from 15 to 40. The State Education Department does not require national certification or testing of any type to receive certification to become a nurse practitioner. By virtue of completion of a state registered nurse practitioner program in New York State, a graduate becomes certified as an NP. Nursing educators all over the country are concerned about the evaluation of quality standards for advanced practice. The recent activities of the National Council of State Boards to develop a national nurse practitioner licensing and/or certifying examination directs attention to the concern over consistent competencies across jurisdictions. Debate on this issue has focused on the need for second licensure or advanced certification instead of examining the root of the problem — identifiable, consistent competencies validated across programs and jurisdictions. Competencies must be defined and enacted by each program. Concern that programs have not included these competencies have some suggesting legislative mandate to insure a minimum standard of competency. Although there is a need for an accrediting body, in addition to state regulating agencies, resources needed to implement accreditation activities must be considered. The human capital necessary for the preparation of documents, analysis of materials and production costs are enormous. The accreditation process must include data instruments and collection processes which are labor efficient. These instruments must be able to be used over time so that a profile of the program and/or school emerges clearly. In the past accreditation activities were seen in a rather episodic context. One of the first questions a prospective faculty member asks when interviewing for a position is "when was the last time you had a site visit?" and "when will the next site visit be made?" Faculty often gauge the type of work that will be asked of them based on the answer to those two questions. Accreditation to faculty means a set of laborious activities, including reports, meetings, review of programs, and sometimes changes in curricula. Depending on the size of the program, the faculty member may have a small or very substantive role in activities that continue for one or two years. Accreditation activities are seen as very labor intensive and the time detracts from other aspects of the faculty role including time for scholarly activity. The amount of time and commitment made to accreditation activities are often not reflected in promotion and tenure decisions at colleges and universities. As an administrator, I try to balance the need for school and university service activities and professional/faculty development activities essential to faculty retention and promotion. Recommendations for Accrediting Schools of Nursing The role of accreditation in the future is many fold. It defines standards of quality in nursing education programs. To refer only to clinical practice standards and then deduce what is needed for nursing education is backward. Colleagues in nursing practice must be a part of the discussions along with faculty who represent the variety of nursing programs today. Potential standards must be debated in a wide arena of nursing educators and then build to consensus. A fine example of this process is the development of two Essentials Documents, one for undergraduate education and one for graduate education which were created by task forces of American Association of Colleges of Nursing. Although not defined as standards of quality, these documents serve as guidelines for curriculum development. There also needs to be a variety of methods to build documents, standards and/or guidelines for quality nursing programs. Criteria for evaluation would follow from these documents. Today many nursing programs focus on the criteria for evaluation and plan accreditation activities around them. That seems to me to be also backward. Ongoing communication through meetings, conferences, workshops, town meetings, and a variety of Internet communication technologies will serve to produce, by the accrediting agency, the widest understanding of a definition of program quality. Along with extensive communication with nursing educators, an infrastructure needs to be put in place that supports this type of activity. Beginning, developing, and expanding programs of nursing in this changing health care environment is a dynamic process. Finally with the expansion in the number of graduate programs, particularly nurse practitioner programs, it is important to cooperate with specialty and role-related organizations when developing and evaluating programs. Cooperation among organizations which can build to an alliance of interest groups can help nursing programs build and develop programs without redundancy, loss of resources, or confusion of disparate standards. Indeed efficiency, efficacy, and clarity of purpose will flow from consistent quality indices. Summary In the past when I have thought about accreditation activities, I was reminded of the Alan Arkin film "The Russians Are Coming, The Russians Are Coming." Anxiety and concern over the production of a document called the self study only led to a visit by real people. As they approached the school, anxiety led to panic and the most unusual activities from cleaning, straightening, and power dressing to concern, self-doubt, and feelings of inadequacies emerged. It was the fear of the unknown that led to a sense of confusion and conflicting messages. Accreditation is needed. However, accreditation must become an integral part of the daily functioning of the program or school, not an episodic event. It is justifiable use of resources when it leads to overall continuous program improvement. By incorporating quality standards of nursing education into ongoing activities, a seamless, continuous development of the program and/or school exists. I believe this is attainable and will contribute to quality nursing education. I support nursing education accreditation and applaud recent efforts to establish a relevant, contemporary and accountable organization to support college and university nursing programs. "Accreditation for the Future: A Director's Perspective" By Sheila A. Ryan, PhD, RN, FAAN Article originally published August 20, 1997 Introduction Dr. Barnum raises several compelling issues in her piece on "Licensure, Certification, and Accreditation" while positing questions as to their future relevance to the profession as they stand today. Licensure, she asserts, is a state regulatory function to guarantee the "MINIMUM" safety of the entering professional. I always thought rather simplistically about these events as: licensure tests minimum safety for the entering professional; credentialing measures advanced knowledge and skills; accreditation verifies the program's quality and integrity to prepare the student appropriately and according to national standards. Questions for Tomorrow Two interesting sets of questions for future relevance include: Will we continue to require measures for quality to produce minimum or advanced competency? Are there other measures we should be considering? The answer to this set of questions of course will be "absolutely." Fifty years ago, outcome measures were not understood. Quality improvement has brought them to the fore. Nursing and other disciplines will need to successfully complete competency examinations in one's practice discipline (beyond the counting of curriculum inputs or process). Who will be the regulatory agent of accountability? the state? the federal government? the professions? the public stakeholders? And should the processes of licensure, accreditation and credentialing be linked in order to improve accountability? Actually, Barnum makes a case that states really are serving in this capacity nominally. The licensure exam is already national; the passing score is national; and states recognize reciprocity with each other across state boundaries now. States serve primarily as a register of record. As competency outcome measures for individuals become the norm, states may actually have a role to play in sanctioning schools within their state boundaries who do not meet or "produce" these competencies. They could impose additional requirements or practice restrictions as well for the graduate who cannot demonstrate minimum competency in all other desired areas. Barnum describes the "hot issue" around licensure as the proposed variety of new licensures suggested, but never approved, especially around entry to practice. This difference has been hampered, she says, by the rigidity associated with waivering or grandfathering of present RNs. I'm convinced, as Barnum, that this change will not be reached by consensus without grandfathering as long as associate degree and diploma nurses outnumber the baccalaureates for entry positions, as they will surely continue to do through several decades. With the massive reforms in health care delivery and market forces in search of efficient and productive quality outcomes, employers care more for needed competencies than the breed, hybrid, degree or credential. Lindeman recently asserted the entry to practice as the single most divisive "wedge" issue for the profession. My sense is that the "entry" issue will soon be replaced with the next "hot issue": models of workforce patterns and differential practice abilities across and within disciplines. The professional entry has changed over time, with added complexity and knowledge, and will likely continue to do so. More importantly will be the issue of how each discipline's preparation, including differential levels within the nursing profession, contribute uniquely and efficiently to the productive workforce team. What do you think? Changes in health reform, driven by financial pressures for efficient practice with respectable outcomes, will drive the profession to new levels of differential practice, preparation and competence. Licensure, accreditation and credentialing processes should be collaboratively transformed and linked to accommodate this differentiation. Most agree that the marketplace is forcing us to think differently about tomorrow's practice and to re-engineer how we prepare nurses for these new and emerging ways of practice. Along with these changes will come the cessation of our stale obsession with counting content and process based on disease models of caretaking for institutionalized sick individuals. Outcome measures of competency for different levels of practice with different populations will be the new day ... for licensure, accreditation and credentialing. New Dimensions for Tomorrow's Care Systems I attend many interdisciplinary meetings where nursing is considered essential for these new practice futures, albeit needing new knowledge in new dimensions of tomorrow's care systems. Such areas for role expansion include genetics counseling, grade school health curriculum modules, more ethics in response to more technology, financial outcome analysis and information management, just to name a few. However, these changes are slow in coming as faculties are not engaged in these practice demands nor are they "prepared" in these areas. The resulting burden is a faculty being pushed to add yet more to the curriculum in areas their own practice does not use or understand. Accreditation, consequently, becomes the peer review gatekeeper or scapegoat against such pressure. How can we mobilize healthy change among our faculties and use the licensure, accreditation and credentialing processes to help in these expanding knowledge areas and new roles for the profession? Must faculty have formal expertise before offering expert content? Are there other ways of making these areas available to students? With Internet potential, for example, do all schools need localized expertise? Important Questions Accreditation is a process very much in challenge today over several issues. Recently, the Association for Academic Health Centers held a seminar to review such issues across disciplines and outlined the following concerns for all accreditation processes: Should the nature and control of the accreditation processes be voluntary and peer-reviewed as currently offered, or be managed by governmental regulatory controls? Should the responsibilities for the accreditation process be regional for institutions or specialized by discipline? federal or state in purview? institutional or program specific? Should accreditation site visitors be objective and representative of the discipline, including each specialized program being reviewed, or are they more representative of trade associations and membership agencies just trying to secure more resources for their own interests? What are the assurances that accreditation works? What quality measures should be evaluated? How are the public stakeholders and policy makers involved in and educated about accreditation? Should accreditation be the linkage to certification, licensure and students' financial aid and financial loan default? Each question could and should engage some healthy discussion; OJIN provides an excellent forum for such interchange. Let me start the process illustrating how one of the above questions could be addressed. One could ask, "Should accreditors and site visitors be from the specialized programs being reviewed?" This would imply that programs with baccalaureate, masters, primary care practitioners, nurse midwifery and nurse anesthesia would be peer-reviewed with faculty site visitors from each program type. Responses might include noting that in principle, such a strategy is reasoned. However, in practice, it is far too costly and risks the appearance of being too self-serving. What are the alternatives? Are on-site visits the only way to provide peer review? Accreditation site visitors' quality and representativeness is one of many issue that needs dialogue and discussion. Assurances for measuring the quality productivity of accreditation is another. What measures do you believe should be evaluated and documented as outcomes and accountability of the process? What stakeholder inputs would be necessary to ensure effective quality accreditation? What sanctions should be imposed for those that don't meet these quality measures? Most educators are confident that accreditation is still the primary measure of academic quality. It is further true that the proliferation of accrediting bodies add to institutional costs, and university presidents are questioning the cost/benefit ratio. Although most agree that institutional accreditation alone will not suffice to ensure quality, accreditation processes often are used as an excuse to limit innovation and experimentation, to protect discipline turf and to avoid interdisciplinary approaches to learning or to collaborative accreditation processes. How can these phenomena be avoided? Many agree that higher standards and better progress in American higher education over time has been the result of accreditation's peer review process. Others argue that with the reauthorization of the higher education act in 1992 and again in 1997, it may well be time for total system review and some re-engineering of this frustrating, complex, confusing and labor intensive higher education "quality" process. Suggestions for Change In a recent Chronicle of Higher Education article, Shattuck (1997) challenged today's higher education "quality" by suggesting colleges and universities have continually admitted ill-prepared high school graduates into gradually more diluted undergraduate programs (except science, math and engineering). As long as such "bloated systems of higher education" are dependent upon the tuition of increasing class sizes, colleges indirectly promote or at best maintain these soft standards of high school performance. He holds high schools responsible to conduct standardized tests for graduation requirements, and asks colleges and universities to raise their entrance requirements, proposing that "open admissions should become a thing of the past." Shattuck also suggests "accrediting agencies accommodate to present lax standards," adding they continue to perpetuate lax standards when they are "responsible to no one outside their profession they are charged to regulate" (p. B7). The Task Force on Accreditation of Health Professions Education of the Pew Charitable Trust was charged with the goal to improve the health professions' accreditation processes so that they better meet evolving societal needs. Specifically noted was the idea that accreditation should have a role in improving education for the health professions. Further, they support accreditation as a model for assessment and improvement and one that promotes interdisciplinary health professions' education, while minimizing duplication and waste, and enhancing flexibility and adaptability. Other suggestions for future improvement include moving from evaluation of standards (the inspection function) to assessing improvements and serving as a catalyst for the improvement process. This will require benchmarking with other performance outcomes from other schools. They also suggest public participation involving multiple stakeholders and evaluating the effectiveness of the accreditation value. My "desired future" accreditation process would have faculty, student and program data and information electronically submitted annually, trended for improvements over time and benchmarked with similar regional, public, private institutions that a school wishes to identify as its cohort schools. Then, teams of trained, paid faculty that could include someone from each program type would review the annual data and self-study for quality and improvement. No actual site visits need to occur unless suspicious information or other criteria as determined would suggest the need for random or scheduled visits. What advantages or disadvantages to this scenario does the audience envision? Imagine what we could learn from such national repositories of nursing data and information. Summary In summary, accreditation is a means to recognize an educational institution for standards that qualify the graduate for higher or more specialized education or for professional practice through a process of periodic self-examination and peer review that focuses on quality improvement. There is a renewed call for a balance of the interests of the institutions, the professions and the public. Reducing the proliferation, duplication and cost of accreditation will require new structures that can also increase effectiveness and quality outcomes. Reducing barriers to innovation among health professions education must be a priority. These issues are not unique to the nursing profession nor will they be resolved with a simplistic competition from a new agency (AACN). While competition may ultimately serve as a catalyst to stimulate transformation in the accreditation industry, collaboration of limited resources in an already too costly process would provide ample opportunities for emerging partnership models. Even collaboration would not in itself offer assurances for the quality improvement and accountability being called for from employers and the public. This issue demands a response bigger than current practices. The NLN continues to have public and employer membership representation; a commitment to improvement, and plans for improvement are underway to implement an integrated, automated, electronic information system. NLN delivers specialized nursing accreditation more effectively than state, institutional, or regional bodies or administrators can deliver, but must continue to do so with a more efficient, quality improvement approach. Barnum asks "What is gained (with accreditation) versus what is lost (without accreditation)?" With the massive health reform underway and the need for major transformation in the education of all health providers, health care employers, professionals and the public will need better measures of quality improvement in the preparation of the nation's practitioners for tomorrow ... through improved and responsive accreditation, licensure and credentialing. We can't afford to go without, especially now, nor should we transfer the process to other self-serving regulators. There are several improvements needed, and we should be about providing them. References "Licensure, Certification, and Accreditation" by Barbara Stevens Barnum, RN, PhD, FAAN Lysaught, J. P. (1981). Action in affirmation: Toward an unambiguous profession of nursing. New York: McGraw-Hill. "Issues of Accreditation: A Dean's Perspective" by Mary S. Collins, PhD, RN National Council of State Boards of Nursing. (June, 1997). Emerging Issues. Chicago. "Accreditation for the Future: A Director's Perspective" By Sheila A. Ryan, PhD, RN, FAAN Association for Academic Health Centers. (1997, Spring). Accreditation: Issues and options for the future. Presentation at the Spring Meeting of the Association for Academic Health Centers. Washington, D.C. Pew Charitable Trust, (1997, Spring). The Task Force on Accreditation of Health Professions. Presentation at the Meeting of the Center for Health Professions. University of California at San Francisco, CA. Shattuck, R. (1997). From school to college: we must end the conspiracy to lower standards. The Chronicle of Higher Education 43(45), B5-6. Lindeman, C. (1997). Isn't it Time? Nursing and Health Care: Perspectives 18(4), 173. © 1997 Online Journal of Issues in Nursing Originally published August, 1997 Previous: Return to table of contents Next: Take test

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