Journal of Nursing Education

Responses of Baccalaureate and Graduate Programs to the Emergence of Choice in Nursing Accreditation

Janis P Bellack, PhD, RN, FAAN; Sherril B Gelmon, DrPH; Catherine L Thomsen

Abstract

ABSTRACT

Specialized accreditation in nursing is a widely recognized and respected hallmark of program quality. The advent of a second specialized accrediting agency for baccalaureate and higher degree programs in nursing prompted a survey of these programs to determine their choice of nursing accreditation agency, factors influencing their choice, their perceptions of the value added by nursing accreditation, and the difficulties encountered with the accreditation process. These study variables and the relationships between choice of accrediting agency and types of degree-granting nursing education programs offered by the institution, agency membership in the National League of Nursing (NLN) or the American Association of Colleges of Nursing (AACN), expected date of next accreditation vieit, geographic region, public versus private status, and type of institution (Carnegie classification) were analyzed. Findings revealed that nearly a quarter (24%) of respondents intend to continue with the NLN Accrediting Commission (NLNAC), whereas 30% indicated they have already switched to the Commission on Collegiate Nursing Education (CCNE) or intend to do so prior to their next accreditation cycle. However, nearly a quarter (24%) of respondents said they plan to be accredited by both agencies for the immediate future, and 21% indicated they are still undecided. Study findings suggest an end to single-source accreditation, and the beginning of a new market-oriented approach.

Abstract

ABSTRACT

Specialized accreditation in nursing is a widely recognized and respected hallmark of program quality. The advent of a second specialized accrediting agency for baccalaureate and higher degree programs in nursing prompted a survey of these programs to determine their choice of nursing accreditation agency, factors influencing their choice, their perceptions of the value added by nursing accreditation, and the difficulties encountered with the accreditation process. These study variables and the relationships between choice of accrediting agency and types of degree-granting nursing education programs offered by the institution, agency membership in the National League of Nursing (NLN) or the American Association of Colleges of Nursing (AACN), expected date of next accreditation vieit, geographic region, public versus private status, and type of institution (Carnegie classification) were analyzed. Findings revealed that nearly a quarter (24%) of respondents intend to continue with the NLN Accrediting Commission (NLNAC), whereas 30% indicated they have already switched to the Commission on Collegiate Nursing Education (CCNE) or intend to do so prior to their next accreditation cycle. However, nearly a quarter (24%) of respondents said they plan to be accredited by both agencies for the immediate future, and 21% indicated they are still undecided. Study findings suggest an end to single-source accreditation, and the beginning of a new market-oriented approach.

Accreditation is a widely recognized and respected hallmark of educational program quality in the United Stetes, having been an established fixture of United Stetes higher education since the early part of the 20th century. Accreditation is the act of certifying as meeting official requirements or providing with credentials (Braham, 1995) and assures the public that an educational program has met specified standards of excellence. Specialized accreditation assures these standards of excellence have been achieved by programs that provide professional preparation hi such fields as nursing, medicine, law, and architecture.

From 1T52 to 1998, the National League for Nursing (NLN) served as the sole accrediting agency for all levels of nursing education programe. In 1998, the American Association of Colleges of Nursing (AACN) created its own agency, the Commission on Collegiate Nursing Education (CCNE), for the specific purpose of accrediting baccalaureate and higher degree nursing education programs. The advent of a second accrediting agency in nursing created an opportunity for baccalaureate and higher degree programs to choose between accrediting agencies.

Consequently, a study was undertaken to determine patterns of choice of nursing accreditation agency among United States baccalaureate and higher degree programs, including factors that influenced schools' choices, their perceptions of the value added by nursing accreditation, and the difficulties they encountered with the accreditation process. The study also examined the relationship between choice of accrediting agency and types of degreegranting nursing education programs offered by the institution, agency membership in NLN or AACN, expected date of next accreditation visit, geographic region, public versus private status, and type of institution by Carnegie classification (Boyer, 1994).

The context and history of accreditation provides a useful backdrop for understanding the significance of this historical event (i.e., the creation of a second accrediting agency within a single health professions discipline) as welt as the role of accreditation in higher education in general and in nursing education in particular.

PURPOSES OF ACCREDITATION

The practice of accrediting programs of higher education emerged initially as a way to certify program quality to public and private supporters, prospective students, and employers of a program's graduates. Perhaps most significant at thia time in history, accreditation bestows direct benefits on the accredited institutions and programs, giving them access to federal funds, ensuring their eligibility for private grants and awards, and facilitating the professional marketability and educational mobility of their graduates. Specialized accreditation also may help individual educational programs secure their equitable share of resources within their home institutions. The process of accreditation also stimulates programs to engage in periodic self-study as a basis for continuing program improvement. Finally, specialized accreditation is a signal of public accountability because it is sought voluntarily and, in the caae of nursing, demonstrates a program's desire to exceed the minimum standards required by its state board of nursing.

In some states, such as South Carolina which uses a system of performance measures to allocate funds to higher education, accreditation of professional programs is a mandated performance indicator (Trombley, 1998). If specialized programs for which accreditation is available are not accredited, colleges and universities in states such as South Carolina lose points and dollars when competing for their share of the state's annual allocation to higher education.

HISTORICAL CONTEXT

The Unites States* system of accreditation grew out of a broader movement to provide structure and form to the educational process and the professions, which began at the end of the 19th century and formally took hold in the early part of the 20th century. Early guiding principles affirmed that only one specialized accrediting agency would be recognized in a particular field of study, to limit competition and duplication of effort.

In the post-war period, the United Stetes witnessed phenomenal growth in federal financing for higher education. During the 1950s there also was a dramatic increase in federally financed research (Ruzek, O1NeU, & Williard, 1993). In the 1960s, there was similar growth in fiscal support for a wide variety of education and health care expansion, with substantial benefits accruing to those health professions education programs accredited by a nationally recognized accrediting agency. The traditional sole source approach to accreditation and regulation of professional education created a situation in which the consequences for not securing accreditation from the only available accrediting agency for a particular profession were seen as- and very well could be- catastrophic. Without specialized accreditation, programs risked loss of the best and brightest students as well as access to federal and foundation funds for student support, advanced training programs, and special projects.

The single-source operating principle held true for specialized accreditation in the health professions until very recently when nursing became the first health profession to offer baccalaureate and higher degree nursing education programs a choice between two agencies that provide essentially the same accreditation services.

ACCREDITATION IN NURSING

Accreditation of nursing programs began prior to World War II, evolving from earlier efforts to standardize nursing curricula as a means of ensuring their quality. In 1952, tbe newly formed NLN assumed accreditation functions for nursing education, becoming the first nursing education organization to gain recognition by the United States Department of Education (then part of the United States Department of Health, Education, and Welfare) as nursing education's official accrediting body. Since 1952, the NLN has served as the sole specialized accrediting agency for practical, diploma, associate, and until very recently, baccalaureate and higher degree programs in nursing. Membership in the NLN is open to both individual nurses and non-nurses as well as agencies, the vast majority of which are nursing education programs (practical through graduate).

Although several accrediting agencies emerged over the ensuing years to accredit subspecialty programs in nurse midwifery, nurse anesthesia, and nursing continuing education, it was not until 19% that another agency formally expressed an intent to explore the possibility of becoming a second recognized accrediting body for baccalaureate and graduate degree-granting nursing education programs. That year, tbe AACN appointed a task force to examine the fiscal, professional, regulatory, and statutory aspects of specialized accreditation and what role, if any, the AACN should play in the accreditation of baccalaureate and graduate nursing programs (AACN, 1996). The AACN, established in the mid-1970s, is an organization of baccalaureate and graduate nursing education programs, with a membership of more than 500. Each member school is officially represented by its nursing dean or director, and membership is restricted to this group.

The AACN task force subsequently recommended the association pursue the development of a new alliance model that would bring the general and subspecialty accrediting bodies together in alliance with the AACN as a way to coordinate specialized accreditation in nursing and address the rapid proliferation of graduate-level nurse practitioner programs occurring at the time (AACN, 1997al. Perhaps more significantly, the taak force also proposed the AACN establish its own accrediting arm for the sole purpose of accrediting baccalaureate and graduate nursing education programs.

The AACN1S venture into accreditation came at a time when the NLN was encountering serious difficulties with the United States Department of Education (DOE).* The Higher Education Act (HEA) of 1992 had mandated a new set of criteria by which the DOE would grant recognition to accrediting agencies. Although the NLN had been continuously recognized by the DOE since 1952, in 1995 the DOE cited the NLN for failing to fully comply with the new requirements. The DOE deferred continued recognition to give the NLN time to show it was putting forth serious effort and acting in good faith to come into compliance (NLN, 1996). In the spring of 1996, the DOE concluded the NLN was still not in full compliance with 11 of the 77 required criteria, 5 of which were related to new regulatory standards the DOE had imposed on accrediting agencies as a result of the 1992 HEA.

Subsequently, the NLN presented a plan and specific timetables for achieving full compliance within 6 months. Nevertheless, the DOE staff recommended to the Department's National Advisory Committee on Institutional Quality and Integrity (NACIQI) that the NLN1S continued recognition be withdrawn, and the NACIQI concurred. The NLN immediately filed an appeal. In December 1996, the United States Secretary of Education upheld the NLN1S appeal and again deferred its petition for 6 months, with a requested progress report to be submitted in March 1997.

In the meantime, the NLN had moved to create a separate and independent accrediting commission, and the new NLN Accrediting Commission (NLNAC) formally began operations in January 1997. Concomitantly, the NLN Board of Governors resolved through the NLNAC to reaffirm its focus on accreditation as the central service of the organization and acknowledged the NLNAC as the nursing profession's foremost accréditer for all educational programs at all levels of nursing (Ryan, 1997).

The NLNAC submitted its required progress report in March 1997, and in June the NACIQI recommended deferral for 18 months of the NLNAC's petition for continued recognition and stipulated the NLNAC submit two progress reports. The NLNAC's new petition for continued recognition was submitted in June 1998 for review by the NACIQI at its fall 1998 meeting. The NLNAC petition was reviewed by the NACIQI in late 1998. The committee recommended to the Secretary of the DOE that the NLNAC be given continued recognition for 3 years, which the Secretary is expected to support.

Meanwhile, an AACN steering committee was appointed UT late 1996 to plan for the association's new accrediting entity and proposed alliance. Subsequently, the Commission on Collegiate Nursing Education (CCNE) was officially formed, and its first Board of Commissioners was elected in January 1998- The CCNE developed and approved standards and procedures for accreditation of baccalaureate and graduate education programs, which took effect in early 1998, and began conducting site visits in the fall of 1998. The CCNE will be eligible for initial recognition by the DOE after completion of its first cycle of accreditation in the spring of 1999.

One other factor is important in setting the context for the study reported here. The criteria and procedures for the two accrediting bodies are essentially similar. Both include standards related to mission and governance, faculty, students, curriculum, resources, and program outcomes. Each agency's procedures outline the processes for application, program self-study and review, program evaluator training and evaluation, accreditation decisions, appeal, and review of complaints (AACN, 1997b, 1997c; NLNAC, 1997a, 1997b).

NATIONAL TASK FORCE ON HEALTH PROFESSIONS EDUCATION ACCREDITATION

The advent of a second accrediting agency for baccalaureate and graduate nursing education just happened to occur at approximately the same time a special task force to examine accreditation in the health professions was convened by the Center for the Health Professions at the University of California, San Francisco. The Center is an outgrowth of the Pew Health Professions Commission, widely recognized for its work and seminal reports on preparing the health care workforce to meet the changing needs of the American health care system (O1NeU, 1993; Pew Health Professions Commission, 1995; Shugars, O7NeU, & Bader, 1991). The Commission has repeatedly called for reform of the current system of specialized accreditation to one more responsive to the changing health care environment and whose oversight and processes are linked more closely with the health care delivery system and consumers. In 1996, with support from the Commission, the Center created an interdisciplinary task force to examine health professions accreditation and make recommendations for its reform and improvement. The Task Force on Accreditation of Health Professions Education will deliver ite final report in early 1999.

Table

TABLE 1Profila of Respondent Institutions

TABLE 1

Profila of Respondent Institutions

The presence of two specialized accrediting agencies for baccalaureate and graduate nursing education programs provided an unforeseen opportunity to gather information concerning choice of accrediting agency and rationale for choosing between the two agencies, to learn more regarding the current climate for nursing accreditation given this historic change, and to inform the Task Force's broader deliberations. Therefore, a survey of deans and directors of baccalaureate and graduate nursing education programs was conducted in late 1997.

METHODOLOGY

A total of 620 baccalaureate and higher degree nursing education programs were surveyed. Mailing labels were obtained from the NLN for all nursing education programs that were members of the NLN*s Council of Baccalaureate and Higher Degree Programs. (At the time the survey was administered, the AACN1S accrediting body had not yet begun accrediting nursing programs. Therefore, it was decided that the NLN1S list of accredited programs was the best source.)

A four-page, 12-item survey questionnaire was developed by the research team. Items were designed to collect information to answer the research questions (e.g., types of nursing education programs offered, year of next accreditation cycle, type of institution). Items to assess perceived value of accreditation and difficulties encountered in the accreditation process were developed from reports in the literature and the work-to-date of the Center's Task Force on Accreditation of Health Professions Education. The survey and a cover letter were mailed to the full sample, with an assurance of confidentiality and a request to fax the completed survey to the Center for the Health Professions. Surveys were coded for follow-up purposes. A reminder letter and second copy of the survey were mailed 1 month later to nonrespondents. Return of a completed survey was considered consent to participate.

A total of 480 completed, usable surveys were returned, for a response rate of 77%. There was no significant difference in response rates between baccalaureateonly programs and those offering graduate degrees.

FINDINGS

A profile of respondent institutions is shown in Table 1. The distribution of respondents by degree(s) offered, agency membershipis), region of the country, public versus private status, and Carnegie classification of institutional type was essentially representative of the fall sample. All but 9 of the 480 respondents (98%) offered the baccalaureate degree, while nearly three fifths (E7%) offered the master's degree. Only 16% of the respondent institutions also offered the associate degree in nursing, and 13% offered the doctoral degree. These proportions are approximately equivalent to the population of United States baccalaureate and higher degree programs. Respondents were divided almost equally between public and private institutions, which also is true of the general population of colleges and universities. At the time of the survey, slightly more than three quarters (77%) of the respondents' schools belonged as agency members to both the AACN and NLN.

Patterò« of Choice of Accrediting Agency

Table 2 depicts respondents' choices of accrediting agency. Nearly one quarter (24%) expressed their intent to continue with the NLN-NLNAC, whereas 30% indicated they had already switched to the AACN-CCNE or intend to do so prior to their next accreditation cycle. However, nearly one quarter (24%) of respondents indicated they plan to be accredited by both agencies for the immediate future, and 21% indicated they are still undecided. Thus, nearly half had not made a definitive choice between the two agencies at the time of the study.

Choice of accrediting agency was associated with levels of degree programs offered. Schools oSiering graduate degree programs were more likely to have selected the CCNE (38%) or both the CCNE and the NLNAC (27%). One third (32%) of the schools that do not offer graduate degrees selected the NLNAC, with another 27% of these schools etili undecided. More than half the programs offering the doctoral degree selected the CCNE as the accrediting agency of choice, while one quarter of such programs reported plans to be accredited by both agencies for the immediate future.

Institutional Carnegie classification was associated with choice of accrediting agency as well, with those programs located in Research I or II (including academic health centers) and Doctoral I or II institutions most likely to choose the CCNE or both agencies. Programs in Master's I or II institutions were distributed evenly in choice of agency- 27% selected the NLNAC, 26% were undecided, 25% selected the CCNE, and 23% selected both. Programs in Baccalaureate I or II institutions were more likely to select the NLNAC (31%), with fairly equal numbers (22% to 24%) choosing the remaining options.

Nearly all (96%) of the programs that indicated a desire to be accredited by both the CCNE and the NLNAC belonged to both the AACN and the NLN. Relatively more of the programs that selected the NLNAC (35%) and those that remained undecided (28%) were members of the NLN only, while 18% of those that selected the CCNE were members of the AACN only.

Findings also revealed a preference for the CCNE among programs in public institutions- 36% versus 24% which selected the NLNAC, with 20% selecting both. Respondents in private institutions were distributed fairly evenly among options- 29% selected both, 25% selected the NLNAC, and 23% selected the CCNE.

Chi-square analysis of the relationships between choice of accrediting agency and programmatic and institutional variables revealed the following statistically significant (p < .001) findings:

* Schools offering master's degree programs were significantly more likely to have selected the CCNE or both the CCNE and the NLNAC.

* Schools offering the doctoral degree were significantly more likely to have selected the CCNE as the accrediting agency of choice.

* Programs located in Research I or II (including academic health centers) and Doctoral I or II institutions were significantly more likely to have chosen the CCNE or both agencies. Programs in Baccalaureate I or II institutions were significantly more likely to have selected the NLNAC.

Table

TABLE 2Intended Choice of Accrediting Agency

TABLE 2

Intended Choice of Accrediting Agency

* Schools holding agency membership in both the AACN and the NLN were significantly more likely to have chosen to he accredited by both the NLNAC and the CCNE. Schools belonging only to the NLN were significantly more likely to have selected the NLNAC as the accrediting agency of choice or to remain undecided. Schools that are agency members of only the AACN were significantly more likely to have selected the CCNE.

* Programs located in public institutions were slightly, but still significantly, more likely to have selected the CCNE. There was no significant association with choice of accrediting agency for programs in private institutions.

The relationship between choice of accrediting agency and timing of a respondent's accreditation cycle also was significant but difficult to interpret because of changes in agency, different review cycles for undergraduate and graduate programs, and plans to add or drop particular degree offerings. A Pearson's correlation was used to test for association between the number of years since the last accreditation cycle and choice of accrediting agency. Although all correlations were significant at the .001 level (two-tailed t test), the clearest association was between choice of agency and tuning of the next or most recent accreditation cycle (initial or continuing). Those programs with a longer span of time until their next accreditation cycle were most likely to be undecided, while those approaching upcoming reaccreditation were most likely to have made a choice of accrediting agency, with the strongest relationship in favor of choosing the NLNAC.

Reasons for Choice of Accrediting Agency

Respondents gave a variety of reasons for their stated choice of accrediting agency (Table 3). Two fifths (40%) indicated they prefer to be accredited by an agency that accredits only baccalaureate and higher degree programs. Nearly that number (38%) identified the AACN1S proposed alliance model for accreditation as a key factor in their choice of accrediting agency. These reasons are compatible with the AACN-CCNE's intent to limit its accreditation services to such programs and to develop an alliance of the various nursing accrediting and credentialing associations.

Table

TABLE 3Reasons Given for Intended Choice of Accrediting Agency

TABLE 3

Reasons Given for Intended Choice of Accrediting Agency

Approximately one third of respondents, respectively, indicated their desire to wait and see (34%), cost (33%), the NLN's positive history and track record in accreditation (32%), and, conversely, the NLN's problems with the United States DOE (31%) as reasons for their stated choice of accrediting agency. Only 14% of respondents identified a desire to be accredited by an agency that accredits all levels of nursing programs, nearly the same percentage of respondents (16%) whose institutions also offer the associate degree. Only 8% expressed a desire to be accredited by both agencies despite the fact that 24% indicated they intend to be accredited by both the NLNNLNAC and the AACN-CCNE for the immediate future. Such written comments as "Plan to evaluate which is most time and cost effective and most flexible," "Need more information to decide," "Temporarily both but will decide in 2000," "Waiting for Department of Education decision on AACN," and "Depends on AACN expectations" provide further explanation of this seeming discrepancy.

The association between choice of accrediting agency and reasons given for the choice was statistically significant at the .001 level (two-tailed f test) for all variables. Programs that selected the CCNE were more likely to cite the wish to be accredited by an agency that accredits only baccalaureate and higher degree programs as a significant factor in their decision, while more than 40% of the programs indicating a desire to be accredited by both agencies cited this same factor as important in making their decision. Several respondents noted their desire to promote the philosophy of the baccalaureate degree as the minimum entry credential for professional nursing practice as an important factor in choosing the CCNE. Programs that selected the NLNAC almost never cited the desire to be accredited by an agency that solely accredits baccalaureate and higher degree programs as a factor in their decision.

The AACN's proposed alliance model for accreditation also was related significantly to choice of the CCNE, with 74% of those that selected the CCNE citing this factor as important. Schools opting to be accredited by both agencies were slightly more likely to cite the AACN's proposed alliance model as a factor in their decision. This factor was more significant than level of degree programs offered by those schools. More than half (54%) of those that chose the CCNE cited the NLN's problems with the DOE as a factor in their choice, as did more than one third (38%) of those that chose both agencies. The desire to be accredited by an agency that accredits all levels of nursing programs was cited most often as a factor in the decision of those that chose the NLNAC, yet only 43% of this group reported it was an important factor (i.e., one of their top three reasons). The NLN's positive history and track record in accreditation was more important to those selecting the NLNAC (65%) but also was reported as significant by those choosing both agencies and those remaining undecided (27% and 29%, respectively).

Cost also was a significant factor in agency choice. More than half (51%) of those selecting the NLNAC and those that were undecided (52%) cited cost as a factor. On the other hand, continuous improvement and flexibility of accreditation criteria each were associated more often with choosing the CCNE (50% and 41%, respectively). Continuous improvement also was mentioned as an important factor by approximately 20% of those which selected the NLNAC or both agencies. Finally, respondents that selected the NLNAC or were undecided were relatively more likely to cite clarity of the agency's accreditation criteria as a factor (40% and 30%, respectively).

Perceived Benefits and Difficulties of Accreditation

Respondents also were queried on their perceptions of the value added by nursing accreditation as well as the difficulties encountered with the process of specialized accreditation in nursing. Table 4 delineates perceived benefits. Clearly, the recognition and prestige that accreditation confers as a hallmark of program excellence and adherence to high standards, and the professional marketability and educational mobility it affords program graduates, were cited by respondents as the most important reasons they value accreditation, with 71% and 67%, respectively, indicating these as perceived benefits. Other important reasons included the opportunity to engage in periodic self-study as a basis for program improvement (56%) and demonstrating accountability to flinders, consumers, and the public (43%). Peer review and consultation, leverage for an equitable share of institutional resources, and entitlement to federal funds were not included among the top three benefits by the vast majority of respondents. Two respondents cited eligibility for the armed services nursing corps as a perceived benefit.

Table

TABLE 4Perceived Benefits of Accreditation: Number and Percent of Respondents Who Ranked Each Item In Top Three

TABLE 4

Perceived Benefits of Accreditation: Number and Percent of Respondents Who Ranked Each Item In Top Three

Table

TABLE 5Perceived Difficulties of Accreditation: Number and Percent of Respondents Who Ranked Each Item in Top Three

TABLE 5

Perceived Difficulties of Accreditation: Number and Percent of Respondents Who Ranked Each Item in Top Three

With respect to the greatest difficulties encountered with specialized accreditation of their nursing program(s), almost 90% listed cost, in time and in human and fiscal resources, as the most significant problem (Table 5). Cost was identified almost twice as often as any other factor. Nearly half (46%) cited inconsistent interpretation of accreditation criteria. Less than one third ranked any of the remaining difficulties among the top three problems. Additional problems cited included lack of timely and accurate information from the accrediting agency (n = 8), unclear or changing criteria (n = 3), and computerized reporting (n = 2).

DISCUSSION

To set the context for the discussion of findings, several points need to be highlighted. First, the survey was conducted between November 1997 and January 1998. The CCNE deadline for applying for preliminary approval without an initial application fee was December 1997, Some respondents that indicated they had not made a choice may have subsequently done so in favor of the CCNE. The CCNE reported in early 1998 that 322 schools had submitted applications for preliminary approval (AACN, 1998a). Because schools that applied by December 1997 were not required to pay a fee for preliminary approval, this figure may or may not be representative of the schools that will ultimately choose the CCNE as their sole accrediting agency.

It also must be noted that the findings reflect that at the time of the survey, the NLNAC was the only recognized accrediting agency for nursing education and that the CCNE had not yet begun its initial cycle of site visits. The newness of the CCNE coupled with a nursing program's need to sustain its recognized NLNAC accreditation would likely have influenced respondents' choices. Nevertheless, the response of the nursing education community to realignment of its accreditation process, as revealed by the findings of this survey, was somewhat surprising. During the first year of an option to change, fully one fourth of the respondents indicated they had elected to be overseen solely by a new and as yet untested accrediting agency. This shows substantial dissatisfaction with the status quo. Another one quarter of respondents indicated a wish to be regulated by both accrediting agencies for the immediate future, most likely a temporary choice until these programs decide which agency best meets their perceived needs. Cost ultimately may drive programs to choose a single nursing accrediting agency. Recent postings to the AACN-CCNE's Web site say this: "We are concerned that giving it [NLNAC accreditation] up too early might harm us in some way. One of the problems is that our State Board and several of the laws concerning school nurses specify NLN accreditation. We. ..cannot afford two different accreditations," and "Supporting AACN is important, but no one at a school like ours can afford two accrediterà" (AACN, 1998b).

The atudy findings reflect a situation in which the traditional regulatory approach to accreditation is showing signs of strain. If the single provider of this service had been operating effectively and satisfactorily for the consumers (i.e., nursing schools), then one would expect there to be little if any interest in switching to a new agency. In this particular case, a significant level of demand for the alternative has made itself evident.

At the same time, these developments may be less a reflection of dissatisfaction with the ways in which the NLN has conducted the accreditation process than a much larger movement just now emerging. The current situation in the nursing profession may herald the end of single-source accreditation with its regulatory approach, and the beginning of a new market-oriented approach to accreditation services for health professions programs. In the steady-state environment of health care and health professions education of the past 5 decades, a single agency approach to accreditation worked because programs did not perceive a need for substantial redirection and renewal. Accreditation easily accommodated the limited demands placed on it in such an era. However, in the emerging health care system, health professions education programs are facing pressing new challenges that require them to be more responsive and flexible than ever before. In such an environment, programs are more likely to value help in achieving nimbleness and adaptability in the face of change and will be less concerned with how closely they adhere to established regulations and guidelines.

The survey findings point to some of these changes. When asked to identify the most important benefits of accreditation, the top three responses- the only ones to garner more than 50%- were those emphasizing the new realities facing programs: public recognition, professional marketability, and self-examination for improvement. A long-standing rationale for accreditation (i.e., public accountability) was fourth. Are nursing education programs now viewing accreditors as potential resources for helping the programs achieve recognition, engage in self-study, and enhance professional marketability of their graduates? If so, they will look for ways to secure these services and give their business to those agencies that can provide them (O'Neil, 1997). Of course, the reverse also is true; if they do not perceive accreditors as being able to provide significant assistance with programmatic change and improvement, they may seek it elsewhere.

What are these services and resources nursing programs may look to accreditors to provide? As the survey results demonstrate, nursing education programs are viewing accreditation as one aspect of a system of selfassessment and continuous improvement, an act of "intentional improvement" (Gelmon, 1997). Accreditors may be especially well-positioned to assist schools to anticipate and adapt to new challenges and opportunities as they arise and could become a resource to schools for skill building for continuous improvement and change management. They also may function as a clearinghouse for information on best practices and provide more programmatic consultation than has previously been their orientation. These roles would enable accreditors to play a more integral role in improvement efforts in nursing education.

Thus, the time for a single professional overseer (acra-editor) of nursing and other health professions education programs may be disappearing and, in fact, may be irrelevant when schools need to respond rapidly to changing health care and higher education environments. Accreditors now must operate in a market system, much like the programs they accredit. The opportunity for choice in accreditation places accreditors in the position of competing for business, presumably enhancing their customer focus and responsiveness and increasing the emphasis on delivering unified accreditation services at the most reasonable cost for the value.

What are the services nursing education programs need and should demand for accreditation to be relevant and add value? This study's findings show the greatest perceived values added by specialized accreditation are not federal fund entitlement, response to accountability demands of external groups, or leverage for institutional resources. Instead, the greatest perceived benefits are program excellence (and recognition for such), marketability and mobility of a school's graduates in the market, and continuous improvement of an educational program's services and products. The study findings also suggest the nursing education community, as reflected by the responses of its academic leaders, is ready for accreditation to offer more than it does presently. Time will tell if nursing education's accreditors are able to respond with new and expanded services to meet the needs and demands of current nursing education programs and their faculty and students.

This survey's findings also revealed that cost - in time, people, and money- is overwhelmingly the greatest difficulty schools face. Accreditation must move to become less costly. Nursing education programs cannot continue to commit the substantial resources they now invest in accreditation, especially in this time of decreasing resources for higher education, market pressures from the health care delivery system, and rapid social change.

CONCLUSION

Specialized accreditation in nursing education offers an opportunity to demonstrate the potential advantages and disadvantages of a market approach. An important question is whether educational programs will be better served by a choice of accrediting agency than by the traditional monopoly of a single agency.

It is too early to tell what the result of having two accrediting agencies for baccalaureate and higher degree educational programs will be, but it is clear the nursing profession is focusing its attention on putting in place a system of educational assessment and recognition designed to meet evolving societal demands, emphasize assessment and improvement of program quality, and ensure programs continue to have some form of credential to assure the public of the nursing profession's commitment to educational quality. This should serve to enhance and advance the profession, and the relevance and competence of its future graduates.

Both the NLNAC and the CCNE have expressed a commitment to continuous improvement and to promoting high-quality nursing education. To achieve this, it will be necessary to streamline the accreditation process, eliminating much of the current focus on compliance, while strengthening the roles of self-assessment, consultation, and continuous improvement. The existence of two accrediting agencies for baccalaureate and higher degree nursing education offers a living laboratory" to monitor the dual accrediting agency experience. It affords the profession, and the higher education accreditation community, an opportunity to determine if competition between two accrediting agencies will create further fragmentation or ultimately will stimulate improved and expanded accreditation services that are more responsive to the changing health, higher education, and social environments.

REFERENCES

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TABLE 1

Profila of Respondent Institutions

TABLE 2

Intended Choice of Accrediting Agency

TABLE 3

Reasons Given for Intended Choice of Accrediting Agency

TABLE 4

Perceived Benefits of Accreditation: Number and Percent of Respondents Who Ranked Each Item In Top Three

TABLE 5

Perceived Difficulties of Accreditation: Number and Percent of Respondents Who Ranked Each Item in Top Three

10.3928/0148-4834-19990201-04

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