The autonomy of nursing education is predicated upon its ability to have authority in the areas of faculty selection, course content, curriculum development, instructional processes, establishment of standards, and evaluation of performance. However, there are powers beyond the campus that impact upon and directly influence the policies and programs of higher education and its professional schools. One such power is the increasing number of agencies which oversee and sanction the processes of accreditation which is only one aspect of the phenomenon known as credentialing. The purpose of this paper is to present a philosophical and historical assessment of the impact of accreditation on curriculum development and to answer the question : is accreditation a threat to the control of curriculum?
How has the process of accreditation, which has as its origin the process of assuring public accountability and institutional integrity, become so complex and confounding to us as a discipline? Why is the issue of significance at this point in time when nursing already has a wellestablished and apparently effective system of accreditation?
There are no simple answers to these queries, and the problem cannot be confined solely to accreditation even though it is the issue central to the discussion. The concept of credentialing is the framework within which the issue lies. Accreditation in nursing is part of an entangling web woven together by approval, licensure, certification, registration, and academic preparation. Nursing is one of the most "credentialed" professions there is (Hinsvark, 1981) and, as a profession, it continues to proliferate the process by the creation of more certifying and accrediting agencies in the specialty areas of nursing. Even the National Council of State Boards of Nursing is raising the question, "Should state boards of nursing accredit nursing education programs?" (EUiott, 1983). It begins to b« apparent that the control of the curriculum, standard setting, institutional governance, and professional autonomy are all challenged by accreditation.
For purposes of this discussion, accreditation is defined as,". . . a system for recognizing educational institutions and professional programs affiliated with those institutions for a level of performance, integrity, and quality which entitles them to the confidence of the educational community and the public they serve" (American Council on Education, 1982). The National Commission on Accrediting recognized three types of institutional approval: regional accreditation, specialized or professional accreditation, state accreditation and state legal authority over regulating and approving schools.
To understand how accreditation could be viewed as a threat to curriculum development, it is necessary to review those historical events which have led to our present state. Societies at large have created some mechanism to regulate and set standards for the quality of education. In the United States this has been uniquely a function of voluntary organizations and individual states. Specialized accreditation had its start with the American Medical Association (AMA) which was formed in 1847 and began "grading" schools in 1875. This was a "loose" process until the Flexner report of 1910 which had a profound impact on many professional schools throughout the country (Carnegie Foundation for the Advancement of Teaching, 1982). By 1918 the American Dental Association began accrediting as did the American Bar Association in 1923. It is interesting to note that the accreditation of these three professions is and always has been a function of their respective professional organizations.
Nursing's emergence into specialized accreditation had a similar pattern but at a later point in time. In 1893 the American Society of Superintendents of Training Schools (ASSTS) was formed, "... to establish and maintain a universal standard of training" (Dooling, 1979). Two years later the ASSTS began to define standards for nursing education. In the same year, 1895, the North Central Association (NCA) was created to develop standards and publish a list of accredited colleges, thus, giving rise to regional accreditation. It became the model for the five other agencies which, with the NCA, comprise the six regional accrediting bodies for colleges and universities in the United States (Carnegie Foundation for Advancement of Teaching, 1982). The NCA published the first list of accredited colleges in 1913.
Between 1903 and 1912 state boards of nursing and nurse practice acte came into being, bringing with them mandatory regulating bodies and standard setting. In 1912 the National Organization for Public Health Nurses (NOPHN) was founded and the ASSTS became the National League for Nursing Education (NLNE) (Dooling, 1982X The NOPHN immediately began the accreditation of collegiate programs preparing public health nurses while the American Nurses' Association (ANA), which had been formed the year before, refrained from any attempts at accreditation of the profession.
The impetus for establishing a national system of nursing accreditation came in 1923 when the Goldmark report on Nursing and Nursing Education was published (Kalisch & Kalisch, 1978), Two years later, a committee on the grading of nursing schools was formed and functioned until 1937. The following year, the NLNE and the Conference of Catholic Schools of Nursing began accrediting (CCSN), thus, giving nursing three accrediting groups: the NOPHN, the NLNE and the CCSN. Ten years later, in 1948, the Brown report pointed to the need for a single national accrediting body (McCloskey, 1981) and so a National Nursing Accrediting Service was established to unify the process. In 1952 the newly formed National League for Nursing (NLN) became responsible for the accreditation of all basic programs in nursing.
The picture is net complete without a brief look at how the federal government began its involvement with accreditation. The Association of American Universities (AAU) was established in 1905, published a list of accredited institutions in 1914, initiated site visiting in 1923, and provided the only national system of accrediting until 1948 (Carnegie Foundation for the Advancement of Teaching, 1982). By 1952 the six regional associations had become a national network and a National Commission on Accrediting (NCA) was established. The awarding of federal monies for any type of training, education or research soon became dependent upon the approval of accreditation of such institutions. As a result of government influence, we now have several commissions who accredit the accrediting agencies. The U. S. Commissioner of Education began publishing a list of those agencies or associations approved by NCA in 1952. The first list had 28 names; 30 years later it had 64 (Carnegie Foundation for the Advancement of Teaching, 1982). Almost half of the agencies listed are directly related to the health professions!
What then, are the implications of accreditation for curriculum development in nursing? It is this author's belief that the process of voluntary and mandatory accreditation has become a threat to the integrity of professional nursing education. There is an insidious encroachment upon the establishment of academic standards, the organization and structure of curriculum, the actual content of programs, and the evaluation process. Institutional costs for membership in the specialized agencies are escalating as are the sheer number of agencies involved in accreditation. Faculty time and energy are shifted away from the primary goal of teaching when self-evaluation reports are in the process of being prepared. Curriculum revisions are frequently made to assure adherence to "guidelines" of the visiting agency, thus, leading to the phenomena Quiring and Gray, (1979) describe as "patching." Another major problem is the linkage now appearing between specialized accrediting agencies and occupational licensure by states.
To illustrate how all these factors interdigitate, let us look at Hypothetical School of Nursing (HSN). HSN is located in a state university and offers a baccalaureate and masters degree in nursing. The master's program has a nurse-midwifery, pediatrie nurse practitioner, and nurse-anesthetist component in addition to its regular offerings. HSN truly ascribes to ANA's Social Policy Statement, (1980, p. 21) that, "Specialization is a mark of the advancement of the nursing profession."
The state Nurse Practice Act requires that nurse-midwives and nurse anesthetists must be graduates of the American College of Nurse-Midwives (ACNM) or the American Association of Nurse Anesthetists (AANA) accredited programs in order to be licensed. The federal scholarship monies for students in these specialty areas require the same accreditation and HSN's federal research grant requires NLN accreditation of the school and regional accreditation of the university. The ACNM and AANA require given numbers of various experiences in clinical settings with specialized facilities both in terms of resources and patient caseloads. They also designate requirements for faculty who will teach in the program. The pediatrie nurse practitioner component was originally planned as an innovative post-baccalaureate certificate program, but the NLN said "no" it is a specialty area and, therefore, must be at the master's level.
All three specialized accrediting agencies and the federal and state governments had an impact on the curriculum development of HSN! As the Carnegie Report on Governance of Higher Education (1980) points out, such specialized accreditation, which is linked to state certification/licensure and federal allocation of money, has weakened the authority of the institution. It has exercised control over the curriculum.
The major argument against accreditation, that of governance, is also the principal warrant for it, Aydelotte (1983) speaks to this when stating,
IQ order to achieve a full professional status, an occupational group must exercise autonomy within its defined area of practice. Ib be accorded true professional status, a group must function autonomously in the formation of policy and in the control of its activity.
Accreditation has fostered excellence in postsecondary education through the development of guidelines for assessing educational effectiveness. The process, albeit time consuming, does encourage improvement through self-study and planning. The public perceives accreditation as evidence that an institution or profession has clearly defined and appropriate objectives which are fulfilled under optimal conditions in the learning environment and lead to the graduation of safe and competent practitioners of the profession. McCloskey (1981) believes accreditation has encouraged ongoing peer review by the faculty and staff of institutions as well as facilitated the transfer of students from one school to another. There can be no doubt that accreditation has provided a basis for determining eligibility for federal funds. It must be said that accreditation has helped legitimize nursing as a profession.
But what of the entangling web? Can institutions afford the costs of proliferating accrediting bodies with their demands to control curricula? Can we ignore our contract with society to be accountable? The ANA (1980, p. 7) answered these questions succinctly, "Self- regulation to assure quality in performance is at the heart of this relationship. It is the authentic hallmark of a true profession." It is obvious that nursing must claim and exercise its autonomy over the profession, but how it does so is in a state of flux. Outside powers continue to influence nursing. The latest report by the Institute of Medicine (1983) is a prime example of a Congressional mandate to have "outside" bodies determine what the needs are of nursing and nursing education.
It is this writerk position, based upon historical evidence, that accreditation is a threat to curriculum development. However, it is also placed in a position so that nursing and higher education can institute measures to overcome the negative aspects of the process and still assure accountability. Incorporation of specialized and regional accreditation would be the interim step. This would reduce costs, utilize existing mechanisms, and shorten the time factor for faculty involvement in multiple self-study reports. The final solution proposed incorporates the recommendations of the ANA's Committee for the Credentialing of Nursing which states "... it is imperative that reform in nursing credentialing be instituted in a timely and systematic manner" (ANA1 1979). It is time for more than just a new system for nursing. There is increasing involvement of consumers in health care policy and a mounting demand for accountability in the delivery of health care services. The widespread mobility of health care providers mandates a more efficient mechanism to assure society an equitable standard of professional performance in every community. It is time for a national credentialing center for the health professions. We need a form of governance which allows for a mechanism of control within each profession while sustaining a centralized system of unified planning, policy making, and action. This task is monumental but not impossible. But first, before any new approach can be tried, the question must be answered ... is accreditation a threat to curriculum development?
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