Read NLNAC Accreditation Manual with Interpretive Guidelines by Program Type text version

2006 Edition Accreditation Manual with Interpretive Guidelines by Program Type for Postsecondary and Higher Degree Programs in Nursing

A publication of the National League for Nursing Accrediting Commission, Inc. This publication is organized in two sections: the first section contains the accreditation processes and procedures and Commission policies; the second section provides guidelines and specific documentation needed to show compliance for each nursing program type. Information provided in this publication is accurate as of August 1, 2006. Significant changes occurring between publications are reprinted in electronic media, print media, and on the NLNAC website.

NLNAC 61 Broadway-33rd Floor New York City, NY 10006 Phone: 800-669-1656 Ext.153 Fax: 212-812-0390 Web site: www.nlnac.org

© 2006 National League for Nursing Accrediting Commission, Inc. All Rights Reserved The trademarks NATIONAL LEAGUE FOR NURSING ACCREDITING COMMISSION and NLNAC are owned by the National League for Nursing, Inc., and are being used pursuant to license.

TABLE OF CONTENTS

SECTION I: ACCREDITATION MANUAL

I. INTRODUCTION Mission.......................................................................................... Purpose......................................................................................... Goals............................................................................................ Recognition ................................................................................. Benefits of Accreditation..................................................................... Philosophy of Accreditation................................................................ History of Nursing Accreditation........................................................... Products and Services......................................................................... Persons Responsible for Accreditation..................................................... II. THE COMMISSION Overall Structure of the Commission...................................................... Board of Commissioners.................................................................... Members of the Board of Commissioners................................................ NLNAC Organizational Structure.......................................................... III. ACCREDITATION STANDARDS AND CRITERIA FOR ACADEMIC QUALITY OF POSTSECONDARY AND HIGHER DEGREE PROGRAMS IN NURSING NLNAC Definition of Quality.............................................................. NLNAC Accreditation Standards.......................................................... Standards and Criteria.......................................................................... Planning for Systematic Program Evaluation (SPE)..................................... Elements for SPE including Assessment of Student Academic Achievement....... IV. ACCREDITATION PROCESSES AND PROCEDURES Planning for Accreditation.................................................................. Candidacy Process.................................................................. Initial Accreditation................................................................ Continuing Accreditation.......................................................... Accreditation of Programs within Multi-Campus Institution.................. Evaluation Process............................................................................ Staff Assistance/Mentoring.................................................................. Self-Study...................................................................................... Self-Study Report................................................................... Guidelines for Writing the Self Study............................................ Submitting the Self Study Report................................................. 18 18 19 19 20 21 21 21 22 22 24 12 13 14 16 17 9 9 10 11 1 1 1 2 3 4 5 7 8

Guidelines for Formatting the Self-Study Report.............................. The Site Visit.................................................................................. Multiple Nursing Programs Within an Institution.............................. Collaborative and Coordinated Site Visits with Other Agencies............. Length of Visit....................................................................... Assignment of Site Visit Team................................................... Appointment of Team Chairperson............................................... Responsibilities of the Team Chairperson....................................... Responsibilities of the Team Members........................................... Nursing Education Unit Responsibilities....................................... Visit Arrangements ................................................................ Agenda for the Visit................................................................ Sample Agenda for Accreditation Visit.......................................... Visiting Off-Site Campus(es)...................................................... The Site Visitors' Report.................................................................... The Report........................................................................... Staff Review.......................................................................... Evaluation Review Panel .................................................................. Assignments of the Evaluation Review Panel Members....................... Nursing Program Representative Attendance at the ERP Meeting.......... Evaluation Review Panel Procedures .......................................... Commission................................................................................... Summary Timeline for Evaluation Process................................................ Program Evaluators........................................................................... Eligibility for Selection as Program Evaluator.................................. Site Visitor............................................................................ Evaluation Review Panel Member............................................... Appeal Panel Member.............................................................. V. GENERAL POLICIES Policy #1: Conflict of Interest.............................................................. Ethical Imperatives.................................................................. Ethical Guidelines ................................................................. Confidentiality and Communications............................................ Disclosure Memorandum......................................................... Policy # 2: Representation on Evaluation Review Panels and Commission......... Clinician/Practitioner Representation............................................ Public Members..................................................................... Policy # 3: Eligibility for Accreditation................................................... Policy # 4: Types of Commission Actions on Applications for Accreditation...... Initial Accreditation................................................................ Continuing Accreditation......................................................... Accreditation with Condition or Warning Status................................ Follow-Up Report.................................................................. Follow-Up Visit and Report...................................................... Policy # 5: Notification of Commission Decisions...................................... The Program.......................................................................... Other Groups to be Informed ................................................... Information Provided the Secretary, US Department of Education..........

24 25 25 25 26 26 27 27 27 28 29 30 30 31 32 32 33 34 34 34 35 36 37 38 38 39 40 40

41 41 41 43 43 44 44 44 45 46 46 46 47 47 49 51 51 51 52

Policy # 6: Delay/Advancement of Continuing Accreditation Visit.................. Policy # 7: Withdrawal...................................................................... Voluntary Withdrawal from NLNAC Accreditation......................... NLNAC Withdrawal of Accreditation ........................................ Policy # 8: Opportunities for Third Party Comments on Programs Scheduled for Evaluation................................................................... Policy # 9: Public Disclosure About the Program ....................................... Policy # 10: Appeal Process................................................................ Decisions Eligible for Appeal..................................................... Notice of Appeal.................................................................... Appointment of an Appeal Panel................................................. Procedures for Governing the Appeal Process.................................. Documents for the Hearing........................................................ The Hearing......................................................................... The Decision........................................................................ Policy # 11: Public Notice of Proposed Policy Changes............................... Policy # 12: Records on File ............................................................ VI. MONITORING POLICIES AND PROCEDURES Policy # 13: Interim Report (NOT IN EFFECT)......................................... Policy # 14: Reporting Substantive Changes ................................................ Substantive Change................................................................. Change in Ownership............................................................... Additional Location.................................................................. Policy # 15: Distance Education .......................................................... Definition of Distance Education................................................. Considerations for Implementing Distance Education......................... Policy # 16: Program Closing................................................................ Closing an Accredited Program ................................................. Preparation of Closing Report..................................................... Policy # 17: State Board of Nursing Approval............................................ Policy # 18: Accreditation Status of the Governing Organization.................... Policy # 19: Focused Visit................................................................... Policy # 20: Complaints Against an Accredited Program.............................. Policy # 21: Complaints Against the National League for Nursing Accrediting Commission.................................................................... Policy # 22: Program Accreditation Status in Relation to State and Other Accrediting Agency Actions................................................. Policy # 23: Public Notice of Proposed New or Revised Standards and Criteria.................................................................... Policy # 24: Assessment of The Adequacy of Standards and Criteria, NLNAC Process, and Practices........................................................ The Process of Review............................................................. Aspects of the Review.............................................................. Reliability of NLNAC Processes................................................ Communications and Broad Consultation Practices........................... Planned Use of Data Analysis..................................................... Evaluation of Site Visit............................................................. Annual Report......................................................................

53 53 53 53 54 54 55 55 55 55 55 56 56 56 57 57

58 58 58 60 60 61 61 61 63 63 63 65 65 65 65 67 68 69 69 69 69 70 70 70 70 71

NLNAC Ongoing Systematic Program of Review What Will Be Evaluated: NLNAC Standards And Criteria...................................... NLNAC Processes...................................................... NLNAC Communications And Broad Consultation...............

72 73 74

SECTION II: INTERPRETIVE GUIDELINES BY PROGRAM TYPE

GENERAL INFORMATION Introduction................................................................................... Directions for Use............................................................................ Glossary for Interpretive Guidelines....................................................... Differentiated Education: Creating What Must Be .................................... Core Competencies ­ Adapted By NLNAC.............................................. References References for Core Competencies.................................................... References for Standards................................................................ Guidelines for Preparing the List of Individuals and Groups Interviewed........ Guidelines for Preparing the Categories of Documents Reviewed................ MASTER'S DEGREE NURSING PROGRAMS

(Including Post-Master's Certificate)

75 75 76 82 84 87 87 88 89

Standard I: Mission and Governance...................................................... Standard II: Faculty.......................................................................... Standard III: Students........................................................................ Standard IV: Curriculum and Instruction.................................................. Standard V: Resources....................................................................... Standard VI: Integrity........................................................................ Standard VII: Educational Effectiveness .................................................. BACCALAUREATE DEGREE NURSING PROGRAMS Standard I: Mission and Governance...................................................... Standard II: Faculty.......................................................................... Standard III: Students........................................................................ Standard IV: Curriculum and Instruction.................................................. Standard V: Resources....................................................................... Standard VII: Integrity....................................................................... Standard VI: Educational Effectiveness ................................................. ASSOCIATE DEGREE NURSING PROGRAMS Standard I: Mission and Governance...................................................... Standard II: Faculty ........................................................................ Standard III: Students ...................................................................... Standard IV: Curriculum and Instruction.................................................. Standard V: Resources....................................................................... Standard VI: Integrity........................................................................ Standard VII: Educational Effectiveness ..................................................

91 93 95 97 99 101 103

105 107 109 111 113 115 117

119 121 123 125 128 130 132

DIPLOMA NURSING PROGRAMS Standard I: Mission and Governance...................................................... Standard II: Faculty.......................................................................... Standard III: Students........................................................................ Standard IV: Curriculum and Instruction.................................................. Standard V: Resources....................................................................... Standard VI: Integrity........................................................................ Standard VII: Educational Effectiveness................................................... PRACTICAL NURSING PROGRAMS Standard I: Mission and Governance...................................................... Standard II: Faculty.......................................................................... Standard III: Students........................................................................ Standard IV: Curriculum and Instruction.................................................. Standard V: Resources ..................................................................... Standard VI: Integrity....................................................................... Standard VII: Educational Effectiveness................................................... 147 149 151 153 155 157 159 133 135 137 139 141 143 145

I. INTRODUCTION

MISSION The National League for Nursing Accrediting Commission (NLNAC) supports the interests of nursing education, nursing practice, and the public by the functions of accreditation. Accreditation is a voluntary, self-regulatory process by which non-governmental associations recognize educational institutions or programs that have been found to meet or exceed standards and criteria for educational quality. Accreditation also assists in the further improvement of the institutions or programs as related to resources invested, processes followed, and results achieved. The monitoring of certificate, diploma, and degree offerings is tied closely to state examination and licensing rules and to the oversight of preparation for work in the profession.

PURPOSE To provide specialized accreditation for programs of nursing education, both postsecondary and higher degree, which offer either a certificate, a diploma, or a recognized professional degree (Master's, Baccalaureate, Associate, Diploma, and Practical Nursing).

GOALS The goals of NLNAC are to: · Promulgate a common core of standards and criteria for the accreditation of nursing programs · Strengthen educational quality through assistance to associated nursing education units by evaluation processes, functions, publications, and research · Advocate self-regulation in nursing education · Promote peer review · Foster educational equity, access, opportunity, mobility, and preparation for employment based upon type of nursing education · Serve as gatekeeper to Title IV-HEA programs for which NLNAC is the accrediting agency. (These include some practical nursing and all hospital diploma programs eligible to participate in programs administered by the U.S. Department of Education or other federal agencies.)

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RECOGNITION The National League for Nursing Accrediting Commission is recognized as the accrediting body for all types of nursing education by: · · · · · · · · · United States Department of Education (USDOE) United States Uniformed Nursing Services (USUNS) Veterans Health Administration, Department of Veteran Affairs (VHA) National Council of State Boards of Nursing (NCSBN) State Boards of Nurse Examiners (SBNE) Council for Higher Education Accreditation (CHEA) Association of Specialized and Professional Accreditors (ASPA) Pan American Health Organization (PAHO) U.S. Department of Health and Human Services, Bureau of Health Professions, Division of Nursing (USHHS) · National Certification Corporation for the Obstetric, Gynecologic and Neonatal Nursing Specialties (NCC) · Employers National, regional, and specialized accreditors that provide oversight in regard to federal funding eligibility must be reviewed by the United States Department of Education (USDOE) to ensure that the accrediting body meets specific standards established by Congress. The United States Secretary of Education is charged with review of accrediting bodies and providing recognition to those accrediting agencies that meet the Secretary's criteria. Students in institutions or programs accredited by a USDOE recognized agency are eligible for federal financial aid assistance and other needed resources. NLNAC also meets the recognition standards of The Council for Higher Education Accreditation (CHEA). CHEA, a non-governmental organization, recognizes regional, specialized, and professional accrediting bodies to ensure quality, accountability, and improvement in higher education. Additionally, NCC has added NLNAC accreditation as an eligibility requirement for individuals seeking advanced practice certification.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-I: Introduction

BENEFITS OF ACCREDITATION NLNAC accreditation is a voluntary peer review process to enhance quality improvement in nursing education. Accreditation: · Provides recognition that a nursing education program has been evaluated and periodically re-evaluated by a qualified, independent group of respected and competent peers who have found it to be meeting appropriate postsecondary and higher educational purposes in a satisfactory manner; · Assures professional development opportunity and validation for faculty; · Is a gateway to licensure and eligibility for entitlement programs; · Identifies areas needing development; · Fosters ongoing, self-examination, re-evaluation, and focus on the future; · Aids in student recruitment and retention; · Assists employers seeking graduates who are competent nurses; · Facilitates career and education decision-making; · Promotes professional and educational mobility of program graduates; · Enables student eligibility for funding support from federal and state agencies, and foundations for those programs that do not have regional or national accreditation; and · Fulfills the NCC eligibility requirement for applicants seeking advanced certification.

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PHILOSOPHY OF ACCREDITATION The NLNAC accreditation program is founded on the belief that specialized accreditation contributes to the centrality of nursing for the public good and provides for the maintenance and enhancement of educational quality through continuous self-assessment, planning, and improvement. Accreditation indicates to the general public and to the educational community that a nursing program has clear and appropriate educational objectives and is working to achieve these objectives. Emphasis is placed upon the total nursing program and its compliance with established standards and criteria in the context of its mission/philosophy as well as current and future nursing practice. Accrediting agencies share responsibility with faculty and clinicians for the development of accreditation standards, criteria, policies, and procedures for participation in accreditation and review of accreditation processes. NLNAC supports the continuation and strengthening of voluntary specialized accreditation by peers as a principal means of public accountability and ongoing improvement. Specialized accreditation sets standards for programs and ensures, through the self-study process and accreditation review, the promotion of effective education and program improvement. Since the nursing education unit analysis is closely related to the governing organization itself, NLNAC activities will, when possible, be coordinated with other officially recognized regional and specialized accrediting bodies. Standards and criteria for accreditation, materials that document compliance, and policies and procedures are based on principles widely accepted and tested in general and professional education. All those involved in the process must be aware of current developments in education and nursing; the effectiveness of the current standards, criteria, policies, and procedures; and the evidence of need for change. A systematic ongoing review of all components of the accreditation process is essential to ensure an up-to-date, reliable, and valid accrediting process.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-I: Introduction

HISTORY OF NURSING ACCREDITATION 1893 The American Society of Superintendents of Training Schools for Nurses, forerunner of the National League for Nursing, was founded for the purpose of establishing and maintaining a universal standard of training for nurses. National League of Nursing Education published Standard of Curriculum for Schools of Nursing. Accrediting activities in nursing education were begun by many different organizations. National League of Nursing Education published A Curriculum Guide for Schools of Nursing, the last of its type by the organization. National League of Nursing Education initiated accreditation for programs of nursing education for registered nursing. The formation of National Nursing Accrediting Service unifying accreditation activities in nursing. It was discontinued in 1952 when accreditation activities were consolidated under the National League for Nursing. The U.S. Department of Education recognized the National League for Nursing and included it on the initial list of recognized accrediting agencies. NLN (later NLNAC), has been continually recognized by the U.S. Department of Education since this date. The NLN Board of Directors established a policy charging each educational council with the responsibility for developing its own accreditation program. The program was conducted through the NLN three membership units: the Council of Baccalaureate and Higher Degree Programs; the Council of Diploma and Associate Degree Programs; (the Diploma and Associate Degree Programs separated into two councils in 1965), and the Council of Practical Nursing Programs (1966). The accreditation program and services were administered by NLN professional staff. Federal funding for nursing education under the Nurse Training Act was contingent upon the compliance of schools of nursing with Title VI of the Civil Rights Act of 1964. Council on Postsecondary Accreditation (COPA) recognized the NLN Accreditation Program. Outcome criteria were incorporated into Standards and Criteria for all accredited programs. NLN Board of Governors approved the recommendation of the NLN Accreditation Committee to institute core standards and criteria. NLN Board of Governors approved establishment of an independent entity within the organization to be known as the National League for Nursing Accrediting Commission (NLNAC).

1917 1920 1937 1938 1949

1952

1958

1964 1977 1991 1995 1996

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HISTORY OF NURSING ACCREDITATION (continued) 1997 NLNAC began operations with sole authority and accountability for carrying out the responsibilities inherent in the accreditation processes. Fifteen Commissioners were appointed: nine nurse educators, three nursing service executives, and three public members. The Commissioners assumed responsibilities for the management, financial decisions, policy making, and general administration of the NLNAC. The peer review process was strengthened with the formation of program specific Evaluation Review Panels. 1998 NLNAC continued collaborative work with specialty organizations to strengthen application of standards for advanced practice nursing programs. Advanced practice nurses were invited to serve as clinicians on the site visit teams. The U.S. Department of Education Secretary renewed NLNAC recognition as a nationally recognized accrediting agency for nursing education. NLNAC received continuing recognition by the Council for Higher Education Accreditation (CHEA). NLNAC was incorporated as a subsidiary of the National League for Nursing. U.S. Department of Education renewed NLNAC recognition as a nationally recognized accrediting agency for nursing education.

1999 2000 2001 2002

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-I: Introduction

PRODUCTS AND SERVICES · Initial accreditation and continuing accreditation of approximately 200 nursing programs per year · Continuous monitoring of approximately 1300 programs per year · NLNAC Accreditation Manual with Interpretive Guidelines by Program Type for Postsecondary and Higher Degree Programs in Nursing o o o o o Master's Degree Programs in Nursing (Including Post-Master's Certificate) Baccalaureate Degree Programs in Nursing Associate Degree Programs in Nursing Diploma Programs in Nursing Practical Nursing Programs

· NLNAC Directory of Accredited Nursing Programs · Forums o o Self-Study Program Evaluator

· Candidacy/Mentoring · Report to Constituents o o Analysis of NLNAC Annual Reports Analysis of accreditation cycles

· NLNAC website: www.nlnac.org

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PERSONS RESPONSIBLE FOR ACCREDITATION Board of Commissioners Volunteer Program Evaluators Site Visitors (Nurse Educators and Clinicians) Evaluation Review Panelists Appeal Panelists

Professional Staff Title

Interim Executive Director Deputy Director Deputy Director

Name

John F. Garde, CRNA, MA, FAAN Carol Gilbert, PhD, RN Ngozi O. Nkongho, PhD, RN

Phone Ext.

451 407 465

Email

[email protected] [email protected] [email protected]

Administrative Staff Title

Director of Finance & Operations Administrator for Accounting & Information Systems Ricki DeSantis Joe Luis Ortiz

Name

Phone Ext.

362 493

Email

[email protected] [email protected]

Support Staff Title

Accreditation Specialist Manager of Information Systems & Web Design Accounting Specialist Special Assistant Administrative Assistant Anthony Bugay Alex Mariquit Jocelyn Pineda Yvonne Lopez Michael Philips

Name

Phone Ext.

261 247 319 409 114

Email

[email protected] [email protected] [email protected] [email protected] [email protected]

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-I: Introduction

II. THE COMMISSION

OVERALL STRUCTURE OF THE COMMISSION NLNAC is governed by a fifteen member Board of Commissioners who are elected by the members of NLN at the NLN annual meeting. The legal basis for the foundation and structure of the Commission is outlined in the Bylaws and the Articles of Incorporation. NLNAC is incorporated under the laws of the state of New York.

BOARD OF COMMISSIONERS · Nine (9) Commissioners are nurse educators representing NLNAC accredited programs, three (3) Commissioners represent the public, and three (3) Commissioners represent nursing service. · Commissioners are diversified and assure balanced representation from across identified constituencies insofar as possible. · No Governor, officer, or employee of the National League for Nursing or employee of NLNAC may serve as a Commissioner. · The Board of Commissioners sets accreditation policy and makes accreditation, administrative, budget, and policy decisions. · Commissioners serve as chairperson of the program specific evaluation review panels. · Decision of accreditation status is made by the Commissioners, based on review of program materials, the Site Visitors' Report, and the recommendation of the Evaluation Review Panel.

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MEMBERS OF THE BOARD OF COMMISSIONERS NURSE EDUCATORS:

Term 2003-2006 Patricia R. Forni, PhD, RN, FAAN Professor, College of Nursing University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma Ann B. Schlumberger, EdD, RN Chairperson and Professor Department of Nursing University of Arkansas at Little Rock Little Rock, Arkansas Phyllis Turner, PhD, RN Senior Researcher Bedford, Virginia Term 2004-2007 Sharon A. Denham, DSN, RN Professor, School of Nursing Ohio University Athens, Ohio Dala J. DeWitt, MS, RN Senior Director Nursing Education School of Nursing The Community Hospital Springfield, Ohio Maris A. Lown, MS, RN Director, Health Sciences Brookdale Community College Lincroft, New Jersey Term 2005-2008 Grace Newsome, EdD, APRN, BC, FNP Professor of Nursing, MS Coordinator North Georgia College & State University Dahlonega, Georgia Marilyn K. Smidt, MSN, RN Director of Nursing Programs Grand Rapids Community College Grand Rapids, Michigan Sharon Tanner, EdD, RN Associate VP for Instruction North Carolina Community College System Raleigh, North Carolina

NURSING EXECUTIVES:

Term 2003-2006 Patricia R. Messmer, PhD, RN, BC, FAAN Nurse Researcher Miami Children's Hospital Miami, Florida Term 2004-2007 Nancy Valentine, PhD, RN, MPH, FAAN, FNAP Senior Vice President/CNO Main Line Health Bryn Mawr, Pennsylvania Term 2005-2008 Diane L. Visencio, MPH, RN, BC, PHN Disaster Programs Manager Emergency Medical Services Ventura County Public Health Oxnard, California

PUBLIC MEMBERS:

Term 2003-2006 Robert E. Parilla, PhD Senior Consultant Academic Search Consultation Service President Emeritus - Montgomery College Gaithersburg, Maryland Term 2004-2007 Raymond S. Andrews, Jr., JD Trustee Donaghue Medical Research Foundation West Hartford, Connecticut Term 2005-2008 Howard L. Simmons, PhD Professor and Chairperson Department of Advanced Studies Leadership and Policy Morgan State University Baltimore, Maryland

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-II: Commission

NATIONAL LEAGUE FOR NURSING ACCREDITING COMMISSION ORGANIZATIONAL STRUCTURE

NLN Board of Governors

NLNAC Board of Commissioners

NLNAC Executive Director

Professional Staff

Administrative Staff

Program Evaluators

Support Staff

LEGEND: Cooperating Direct

NLNAC Accreditation Manual 2005 Edition

Section I-II: Commission

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III. ACCREDITATION STANDARDS AND CRITERIA FOR ACADEMIC QUALITY OF POSTSECONDARY AND HIGHER DEGREE PROGRAMS IN NURSING

NLNAC DEFINITION OF QUALITY The core values of accreditation emphasize learning, community, responsibility, integrity, value, quality, and continuous improvement through reflection and analysis. They require that the nursing program measures itself by exacting standards, honors high aspiration and achievement, and expects all persons associated with the program to recognize their responsibility to provide a supportive and humane environment in which people interact with each other in a spirit of cooperation, openness, and mutual respect. Accreditation standards are agreed upon rules to measure quantity, extent, value, and quality. Criteria are statements which identify the variables that need to be examined in evaluation of a standard. NLNAC criteria are presented to peer reviewers as statements that represent an accurate description of an accredited program. Peer review is a long established and effective component of program evaluation in education settings. In education, peer review is used to help determine which programs to accredit. Peer reviewers know the current thinking in the various program types, the curriculum rules and conventions, and are trained to identify program compliance with standards and criteria. Program specific expertise is preserved at the point of: criteria documentation; program evaluation conducted by peers from like programs at the time of the site visit; during evaluation review panel deliberations; and upon appeal. Quality in education ensures high levels of opportunity for student learning and student achievement. Accreditation is an affirmation of certain values central to thinking about postsecondary and higher education ­ appropriate mission, organizational structures, processes, and functions; resources aligned with core values; collegiality; and continuous self-improvement. NLNAC accredits all types of nursing education programs in a variety of postsecondary and higher education settings including vocational-technical agencies, hospitals, proprietary schools, professional schools, seminaries, colleges, universities, and other institutions which offer diplomas, certificates, and/or academic degrees.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-III: Standards & Criteria

NLNAC ACCREDITATION STANDARDS

I. Mission/Governance There are clear and publicly stated mission and/or philosophy and purposes appropriate to postsecondary or higher education in nursing. VII. Educational Effectiveness There is an identified plan for systematic evaluation including assessment of student academic achievement. II. Faculty There are qualified and credentialed faculty, appropriate to accomplish the nursing education unit purposes and strengthen its educational effectiveness.

VI. Integrity Integrity is evident in the practices and relationships of the nursing education unit.

III. Students The teaching and learning environment is conducive to student academic achievement.

V. Resources Resources are sufficient to accomplish the nursing education unit purposes.

IV. Curriculum and Instruction The curriculum is designed to accomplish its educational and related purposes.

Understanding Standards and Criteria in the Evaluation of Nursing Education Units The singular function of nursing is the improvement of the human condition. Each certificate, diploma, or degree has an identifiable, discrete set of specific outcomes. Postsecondary and higher education provide for the development of the learner's ability to think for oneself, master analytical problem solving, apply scientific knowledge, and make value judgments within the context of the specific program type. Thus, education requires a broad academic orientation and depth and breadth of intellectual skills translated into competencies so as to fulfill nursing's function in all types of nursing. Standards: agreed upon rules for the measurement of quantity, extent, value, and quality. Criteria: statements which identify the variables that need to be examined in evaluation of a standard.

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STANDARDS AND CRITERIA STANDARDS I. Mission & Governance There are clear and publicly stated mission and/or philosophy and purposes appropriate to postsecondary or higher education in nursing. CRITERIA 1. Mission and/or philosophy of the nursing education unit is congruent with that of the governing organization, or differences are justified by the nursing education unit purposes. 2. Faculty, administrators, and students participate in governance as defined by the governing organization and the nursing education unit. 3. Nursing education unit is administered by a nurse who is academically and experimentally qualified, and who has authority and responsibility for development and administration of the nursing education unit. 4. Policies of the nursing education unit are consistent with those of the governing organization, or differences are justified by the nursing education unit purposes. 5. Faculty members (full-time and part-time) are academically and experientially qualified, and maintain expertise in their areas of responsibility. 6. Number and utilization of full-time and part-time faculty meet the needs of the nursing education unit to fulfill its purposes. 7. Faculty performance is periodically evaluated to assure ongoing development and competence. 8. The collective talents of the faculty reflect scholarship through teaching, application, and the integration and discovery of knowledge as defined by the institution and the nursing education unit. 9. Student policies of the nursing education unit are congruent with those of the governing organization, publicly accessible, non-discriminatory, and consistently applied; differences are justified by the nursing education unit purposes. 10. Students have access to support services administered by qualified individuals that include, but are not limited to: health, counseling, academic advisement, career placement, and financial aid. 11. Policies concerned with educational and financial records are established and followed.

II. Faculty There are qualified and credentialed faculty, appropriate to accomplish the nursing education unit purposes and strengthen its educational effectiveness.

III. Students The teaching and learning environment is conducive to student academic achievement.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-III: Standards & Criteria

STANDARDS IV. Curriculum & Instruction The curriculum is designed to accomplish its educational and related purposes.

CRITERIA 12. Curriculum developed by nursing faculty flows from the nursing education unit philosophy/mission through an organizing framework into a logical progression of course outcomes and learning activities to achieve desired program objectives/outcomes. 13. Program design provides opportunity for students to achieve program objectives and acquire knowledge, skills, values, and competencies necessary for nursing practice. 14. Practice learning environments are selected and monitored by faculty and provide opportunities for a variety of learning options appropriate for contemporary nursing. 15. Fiscal resources are sufficient to support the nursing education unit purposes commensurate with the resources of the governing organization. 16. Program support services are sufficient for the operation of the nursing education unit. 17. Learning resources are comprehensive, current, developed with nursing faculty input, and accessible to faculty and students. 18. Physical facilities are appropriate to support the purposes of the nursing education unit. 19. Information about the program intended to inform the general public, prospective students, current students, employers and other interested parties, is current, accurate, clear, and consistent. 20. Complaints about the program are addressed and records are maintained and available for review. 21. Compliance with Higher Education Reauthorization Act Title IV eligibility and certification requirements is maintained. 22. There is a written plan for systematic program evaluation that is used for continuous program improvement. 23. Student academic achievement by program type is evaluated by: graduation rates, licensure/certification pass rates, job placement rates, and program satisfaction.

V. Resources Resources are sufficient to accomplish the nursing education unit purposes.

VI. Integrity Integrity is evident in the practices and relationships of the nursing education unit.

VII. Educational Effectiveness There is an identified plan for systematic evaluation including assessment of student academic achievement.

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PLANNING FOR SYSTEMATIC PROGRAM EVALUATION (SPE) Principles · · · · Systematic program evaluation involves the process of determining whether the various parts and the entire program are achieving its mission, goals, objectives, and outcomes. Multiple indicators are used to determine program effectiveness in the preparation of competent nurses. A central concern of accreditation is that the evaluation and assessment processes be directed toward achievement of program goals and result in program improvement on an ongoing basis. Programs develop overall evaluation plans unique to their own needs and interests as a means of coordinating outcomes with goals and objectives. They must select methods of assessment to generate data relevant to their individual outcomes, establish levels of achievement, and use the results for improving program quality. Program goals and objectives should be evaluated in terms of: o educational appropriateness; o relevance to constituent needs; o expectations of practitioners in the field; o relation to the program mission; and o relevance to the expectations of and responsibilities to the publics that nursing aims to serve.

·

NLNAC does not mandate specific evaluation techniques, procedures, or use of specific instruments for outcomes assessment by programs. NLNAC encourages programs to select assessment methods that are based upon the evaluation question being addressed within the context of their own evaluation. Program evaluation in this framework facilitates program revision and improvement, supports decisions regarding curriculum changes, and enhances approaches to teaching including selection of clinical and related experiences. It also allows the faculty and staff to address student perceptions about inconsistencies among what the faculty teach, observations made by students in practice, and the work place requirements that exist. Furthermore, it encourages program selfexamination as well as auditing of current policies and practices.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-III: Standards & Criteria

ELEMENTS FOR SYSTEMATIC PROGRAM EVALUATION INCLUDING ASSESSMENT OF STUDENT ACADEMIC ACHIEVEMENT

AREA ACTIVITY

The Plan: Component Levels of Achievement Frequency Assessment Methods Implementation of the Plan: Results of Data/Information Collection & Analysis Data/information collected as prescribed Data/information analyzed and aggregated Data/information trended Verification that evaluation findings are used in making decisions for program development, revision, and maintenance Identify specific components with Standards and Criteria Define expected levels of achievement for each component Establish time frames for assessment of all plan components Select and/or develop procedures, and/or instruments/tools to measure each component

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IV. ACCREDITATION PROCESSES AND PROCEDURES

PLANNING FOR ACCREDITATION Nursing education units considering accreditation should contact NLNAC to begin the Candidacy process. As part of this process, nursing education units will be assigned a member of the professional staff as their mentor. The mentoring service is provided to facilitate faculty selfreview and planning. The faculty of the program and administrative officers of the governing organization determine when the program is ready to apply for candidacy and initial evaluation. The decision should be based on an in-depth self-study of the program in relation to the NLNAC standards and criteria. When the NLNAC Commission grants accreditation to a program, all students who graduated during or after the accreditation cycle* during which the site visit was performed will be recognized as graduates of an accredited nursing program. *Fall Cycle: July 1 to December 31

Spring Cycle: January 1 to June 30

Candidacy process A nursing education unit seeking initial accreditation must apply for candidacy. Candidate status is granted after an NLNAC professional staff review of a nursing program's potential to achieve NLNAC accreditation. Programs must provide evidence of current State Board of Nursing approval and governing organization's accreditation/approval status (where appropriate). A program seeking accreditation completes an application for candidacy including paying the required fee. Candidate status does not guarantee that a program will achieve initial accreditation. Candidates may indicate the following to potential students and interested members of the public: "This nursing education program is a candidate for accreditation by the National League for Nursing Accrediting Commission." A program in candidacy must complete the accreditation process within 2 years (4 accreditation cycles). Procedure: Once eligibility for candidate status is established, programs will be asked to submit information addressing: · · · · Faculty academic and experiential qualifications;. The curriculum/program plan of study; Resources to deliver the program; and Catalog (where appropriate).

Detailed instructions (Candidacy: Guide for Presentation) will be provided to programs to assist in the preparation of materials.

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All materials submitted are reviewed by NLNAC professional staff. Applicants are notified within six (6) weeks if approved for Candidate status.

Initial Accreditation A governing organization that offers a program not previously accredited by the Commission initiates the process through its chief executive officer. The chief executive officer of the governing organization for the nursing education unit must authorize the NLNAC to conduct the accreditation process by submitting the official authorization form sent from the Commission. All programs seeking initial accreditation must first apply and be approved as a Candidate for accreditation. A nursing program may withdraw its initial accreditation and discontinue the process at any time, up to six weeks prior to the date of the site visit. Once the site visit occurs, the nursing program is not eligible to withdraw from the process.

Continuing Accreditation Planning for continued accreditation is an ongoing process. A program must be visited and reevaluated at specified intervals to ensure continuing compliance with the accreditation standards and criteria. The NLNAC staff notifies the program of a pending visit approximately one year in advance. Dates for the site visit are scheduled in consultation with the nurse administrator as the program must be in full operation during the visit. Once the site visit occurs, the nursing program is not eligible to withdraw from the process. Official authorization to conduct the NLNAC accreditation process is secured from the chief executive officer of the governing organization and the nurse administrator for the nursing education unit. The program will receive an authorization form from NLNAC approximately one year before the visit is to take place. If the nurse administrator of an NLNAC accredited program chooses to cancel the accreditation process, notification of cancellation must be submitted in writing to the Commission, which will then take formal action and remove the program from the official listings of the NLNAC accredited programs. If a program is notified about its need to comply with a Commission action and does not respond, the program will be removed from the official listings of NLNAC accredited programs by the Commission at its next scheduled meeting.

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Accreditation of Programs within Multi-Campus Institutions When a governing organization has multiple campuses and is accredited as one institution, the nursing education units may choose to seek NLNAC accreditation either as one unit or as separate units. If the nursing education units choose separate accreditation, all nursing education units offering the same program type must seek accreditation. The decision should be based on the following considerations: · The governing organization's regional accrediting agency policy on accrediting institutions with multiple campuses; (If the regional accrediting agency allows each campus of a multi-campus institution to have its own administrative structure and offer its own curriculum, the nursing education units may seek accreditation as separate entities.) The governing organization's governance and administrative structure; (If the governing organization offers separate curricula on each campus and has separate faculty and administrative structures to provide these curricula, the nursing education units may seek accreditation as separate units offering the same program type. If the nursing education units are run as a single unit with one administrative structure, faculty, and curriculum, the nursing education units should seek accreditation as a single program offered at multiple sites.) The State Board of Nursing policy on governing organizations with multiple campuses. (If the State Board of Nursing permits governing organizations with multiple campuses to offer separate nursing programs on each campus, all nursing education units may seek separate accreditations.)

·

·

If a governing organization with multiple campuses decides to seek separate NLNAC accreditation for each campus, each nursing education unit pays full annual accreditation fees and site visit fees as a separate entity. Each nursing education unit then seeks accreditation individually and submits its own self-study and has a separate visit, review process by the evaluation panel, and action by the Commission.

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EVALUATION PROCESS The NLNAC accreditation process includes the following steps: · · · · · · · · · Staff assistance and mentoring Program preparation of the Self-Study Report Team site visit for program evaluation by program specific site visitors Site Visitors' Report Staff review Evaluation Review Panel with program specific expertise Staff review and referral to the Commission Commission accreditation decision Appeal panel (when appropriate)

The NLNAC process for the evaluation of nursing education programs is a comprehensive fourstep process with the self-study as the first step. The second step is the site visit. In the third step, a peer evaluation review panel examines the reports written by and about the program. The final step is a review of the process and the decision on accreditation status by the NLNAC Board of Commissioners.

STAFF ASSISTANCE/MENTORING NLNAC professional staff is available to assist a program preparing for an accreditation visit in whatever way best meets the needs of the nursing faculty. Self-Study Forums are offered annually to provide content and framework for the process and details regarding the preparation of the Self-Study Report. While all programs seeking initial accreditation are expected to attend a forum, the forum is available to anyone planning accreditation review. Dates and locations are posted on the NLNAC website (www.nlnac.org). Programs applying for initial accreditation will be assigned an NLNAC professional staff member as a mentor once they have begun the candidacy process.

SELF-STUDY Programs applying for accreditation must prepare a self-study to demonstrate the extent to which the program meets the accreditation standards and criteria. The process of self-study represents the combined effort of the governing organization administrators, nursing education unit administrators, faculty, staff, students, and other individuals concerned with the nursing program. All those associated with the program should participate in the self-study process. Broad participation leads to an understanding of the total program.

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Self-Study Report The Self-Study Report is the primary document used by the site visit team, the evaluation review panels, and the Board of Commissioners to understand the nursing program. · The report must be based upon the NLNAC accreditation standards and criteria in effect at the time of the review. (Accreditation standards and criteria become effective on the Commission approval date. Programs scheduled for review within twelve months of revision of the standards and criteria may elect to use the current or the former version of the standards and criteria.) · Faculty and administrators are responsible for presenting evidence that clearly indicates how the standards and criteria are being met. Members of the site visit team will use the Self-Study Report in preparation for their visit to the program. Guidelines for Writing the Self -Study The Self-Study Report is written by the members of nursing education unit using the most recent edition of the NLNAC Accreditation Manual with Interpretative Guidelines by Program Type for Postsecondary and Higher Degree Programs in Nursing. The self-study document must include program history, context, and self-evaluation related to the standards and criteria as well as program plans for future development and improvement. Program specific presentations of the standards and criteria and a glossary can be found in the Interpretative Guidelines section of this document. There are four sections to the Self-Study Report: · · · · Section One - Executive Summary Section Two - Standards and Criteria: Mission & Governances, Faculty, Students, Curriculum & Instruction, Resources, Integrity Section Three - Standards and Criteria: Educational Effectiveness Section Four - Appendix

Section One: Executive Summary The Executive Summary is a brief (10-15 pages) presentation of the nursing education unit including a description of how the nursing program fits within the governing organization and the extent to which it is in compliance with the NLNAC Standards and Criteria. In addition to offering basic demographic information about the nursing education unit and the governing organization, the summary offers information describing the relationship between the nursing program and its institution and community. In addition, key evidence demonstrating how the program is in compliance with each of the Standards for accreditation should be presented in summary form. Finally, an analysis of the nursing education unit's strengths and areas needing improvement should be included. Content a) General Information: Program type(s) being reviewed, purpose(s) and dates of the visit; name and address of governing organization; name, credentials, and title of chief executive officer of governing organization; name of governing organization accrediting body and accreditation status (date of last review and action); name and address of nursing

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education unit; name, credentials, and title of nurse administrator of the nursing education unit; telephone, fax number, and email address of nurse administrator; name of the State Board of Nursing and approval status (date of last review and action); NLNAC standards and criteria used to prepare the Self-Study Report. b) Introduction: Overview of the nursing program in context by describing how it fits within the nursing education unit (if more than one program is offered) and how the nursing education unit fits within the governing organization and community; student population (number of full-time and part-time students by program type); and faculty cohort (number of fulltime and part-time by program type). c) History of the Nursing Education Unit: Year nursing program(s) was/were established; length of program(s) in credits and time; history of the nursing education unit; NLNAC accreditation history (include date of initial accreditation); clarification of differentiated education where more than one type of nursing program is offered; number of campuses or satellite sites offering the nursing program(s) and distance education offerings (if appropriate); other nursing accreditation (e.g. Council on Accreditation of Nurse Anesthetists, the American College of NurseMidwives Division of Accreditation). d) Summary of Standards and Criteria: Overview reflecting the major findings that demonstrate program compliance with each standard. e) Analysis and Summary of Strengths and Areas Needing Improvement: Conclusions with a listing of strengths, areas needing improvement, and future plans. Section Two: Standards I-VI and Criteria 1-21 Section Two provides the opportunity for the nursing education unit to demonstrate the extent to which the program being reviewed is in compliance with the Standards: Mission and Governance, Faculty, Students, Curriculum and Instruction, Resources, and Integrity. The Self-Study Report is expected to speak to each standard and its criteria addressing all of the items listed in the `Documentation confirms' subsection within the presentation. The use of the `Documentation confirms' items assures that the program has fully discussed all aspects of each criterion. The Interpretative Guidelines section of this document provides the `Documentation confirms' subsection for each criterion within each standard. The narrative presentation should be clear and succinct. Tables, graphs, and/or presentations of sections of the nursing education unit's evaluation plan may also be used as a means to simplify and organize information to demonstrate trends and changes over time. Suggestions of material/indicators and sample tables that may facilitate the presentation of each standard are offered in the Interpretative Guidelines section of the Manual. Nursing education units submitting one Self-Study Report for a multiple program visit are expected to address each program type offered, beginning with the basic program and progressing to the most advanced program, demonstrating the extent to which each is meeting the criteria. Faculty are expected to clearly differentiate between the educational programs offered.

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Section Three: Standard VII and Criteria 22-23 ­ Educational Effectiveness This section is a presentation of the nursing education unit's plan for systematic evaluation of the unit and the results of the ongoing assessment including the assessment of student academic achievement. In addition to the presentation of the plan, the narrative should address how findings related to all the standards have been used for program maintenance, revision, and development. When addressing criterion 23, the discussion should include the four achievement measures. Section Four: Appendix The appendix is for supplemental materials that support information discussed within the body of Self-Study Report.

Submitting the Self-Study Report To Each Member of the Site Visit Team: · · · One (1) paper copy of the Self-Study Report; One (1) electronic (CD or Diskette) copy of the Self-Study Report; and One (1) copy of the current catalog (paper, CD, or Diskette).

Materials should be shipped/mailed to each member of the site visit team; items must be received by the team members no less than six weeks prior to the date of the visit. To NLNAC: · · · · Six (6) paper copies of the Self-Study Report; Six (6) electronic (CD or Diskette) copies of the Self-Study Report; Six (6) copies (paper or electronic) of the current catalog; and One (1) copy of the Executive Summary (first section of the Self-Study Report) in a separate unbound folder.

All copies are to be sent to the National League for Nursing Accrediting Commission, 61 Broadway, 33rd Floor, New York, NY 10006. If the nursing education unit is having a multiple program visit, a complete set of the items listed above should be sent for each program being reviewed. The materials must be received in New York six weeks prior to the scheduled date of the site visit. The Self-Study Reports and catalogs become the property of NLNAC. Guidelines for Formatting the Self-Study Report Page Length: The Self-Study Report should be no more than 200 pages for a single program or 300 pages for a multiple program report, inclusive of the appendix, but excluding the written plan for systemic program evaluation. The report is to be typed front-to-back on standard white paper (8 ½ x 11 inches). The complete systematic program evaluation should be included in the SelfStudy Report.

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Margins: A margin of at least 1 inch should be allowed on the top, bottom, and right hand side of the page. 1 ½ inches on the left hand side of the page to allow for binding is usual. Typeface: The type is expected to be dark, clear, and readable with a font size of 11 or 12. Spacing and Pagination: The text should be 1½ to double-spacing. The pages should be numbered consecutively, inclusive of the whole presentation (text, appendices, etc.).

THE SITE VISIT The purpose of the accreditation visit is to evaluate the nursing education unit by clarifying, verifying, and amplifying program materials as presented in the Self-Study Report. Based on these data, the site visit team will make a recommendation relative to the accreditation status of the program(s). The visit is an essential part of the accreditation process. It gives the school an opportunity to demonstrate and highlight information presented in the Self-Study Report as well as provides for interaction among all concerned: administrators, faculty, students, staff, and site visitors. In addition, the on-site visit allows site visitors an opportunity to see the nursing program first-hand. The site visitors verify congruence between the Self-Study Report and the actual practices of the program so that the Evaluation Review Panel Members and Commissioners have a clear and complete understanding of the program. Multiple Nursing Programs within an Institution NLNAC encourages nursing education units offering more than one type of program (i.e. master's, baccalaureate, associate degree, diploma, and practical nursing programs) to request that all programs be reviewed for accreditation at the same time. The nursing education unit will prepare one self-study. NLNAC professional staff will work with the nurse administrator to establish one visit team whose recommendations for each program's accreditation status will be reviewed by the appropriate peer evaluation review panel. Collaborative and Coordinated Site Visits with Other Agency NLNAC welcomes the opportunity to cooperate with other accreditation and approval granting agencies. The goal is to increase efficiency and decrease faculty workload while maximizing outcomes. Two options are available: the Coordinated and the Collaborative Visit. To have either a Collaborative or Coordinated Visit, the nurse administrator initiates the process by making a request to NLNAC. The staff then works with the nurse education unit to achieve their goal. Collaborative Visit The Collaborative Site Visit involves the establishment of one site visit team that incorporates representatives from NLNAC and the other accreditation or approval agency. Using the standards and criteria from both agencies, the program prepares one self-study report. One agenda is established for the visit. At the conclusion of the site visit, the representatives of each

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agency on the visit team write individual reports that assess compliance with their respective standards and criteria or regulations. Recent examples of such collaboration have included site visits with the Council on Certification of Nurse Anesthetists and the American College of Nurse Midwives Division of Accreditation. Coordinated Visit The program prepares materials separately for each agency team. The two teams share an agenda and conduct a site visit that meets each agency's requirements. However, the representative from another agency is not a member of the NLNAC site visit team. The NLNAC team and the other representative may participate jointly in such activities as conferences with faculty, students, and other groups. Many of the activities of the NLNAC team and the representative will be carried out separately since the purposes of NLNAC accreditation may differ from those of other accrediting/approval bodies. The final analysis and conclusions of the NLNAC team is done exclusively by the team as is the NLNAC Exit Meeting. At the conclusion of the visit, each visit team develops an individual report that assesses compliance with their standards and criteria or regulations. Length of Visit Accreditation visits are usually scheduled for three days. However, the length depends on several factors including: size and complexity of the nursing education unit; geographical locations of the various resources used for student learning experiences; the number of nursing programs involved; and coordination of the visit with other agencies. Correspondences from NLNAC will indicate the inclusive dates of the visit. Assignment of Site Visit Team Each site visit is conducted by a team of nursing educators with program specific expertise and a clinician. A single program review visit team typically has three (3) members. When multiple programs are reviewed during a visit, the size of the team is adjusted to fit the review needs. The NLNAC staff will select a team and notify the nurse administrator in advance of the visit. The nurse administrator is invited to contact NLNAC staff if a possible conflict of interest is identified among team members. If a team member becomes ineligible or unable to serve, another site visitor with comparable qualifications will be appointed. NLNAC staff will assign site visitors considering their expertise with multiple program factors including but not limited to: · · · · · · · Program type; Size of program and governing organization; Carnegie classification; Setting (urban, suburban, and rural); State; and Governance of the governing organization (public, private, and religious). In addition, graduate programs offering advance practice nursing options will have at least one team member with current advanced practice certification.

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The evaluation team is made up of three or more members, depending upon the complexity of the setting and/or the diversity of educational programs to be visited. One member is designated as chairperson of the team. Appointment of Team Chairperson A site visitor is eligible to be a team chairperson for an accreditation visit once she/he has served in the role of team member a minimum of three times. The first time a site visitor assumes the role of team chairperson, an experienced chairperson who also serves as a team member will mentor the new chair. Responsibilities of the Team Chairperson The team chairperson assumes the following responsibilities: · Acts as official spokesperson for the team; · Coordinates the planning with the team members; · Conducts the team orientation session and subsequent team meetings and conferences; · Receives the electronic file from the nurse administrator listing: o information on all individuals and groups interviewed by the team o all documents made available in the "display room" · Allocates responsibilities for various activities to insure optimum utilization of team members and adequate coverage of all areas during the visit including interviews and conferences with key personnel on and off campus; · Requests additional information as necessary; · Notifies the nurse administrator of the arrival of the team and plans the time for the first meeting; · Conducts periodic conferences with the nurse administrator; · Arranges for the exit meeting with the nurse administrator and any persons the nurse administrator invites to be present; · Collates and edits the Site Visitor Report to assure completeness and clarity; · Sends the completed Site Visitor Report (electronically and CD/Diskette) to NLNAC within one week following the site visit; · Is available for telephone contact by the Evaluation Review Panel at the time of the program's review; (In the event that the team chair is not available at the time of review, a member of the site visit team will be contacted.) · Assumes the additional responsibilities stated under `Responsibilities of the Team Members.' Responsibilities of the Team Members The team member assumes the following responsibilities: When the NLNAC accreditation information packet is received, he/she reviews all contents of the packet including: · · Accreditation Manual with Interpretative Guidelines by Program Type for Postsecondary and Higher Degree Programs in Nursing; and Site visitor memo.

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When the materials from the school are received: · Reviews the Self-Study Report prior to arriving at the school; · Notes areas which need clarification or amplification; and · Develops a plan for verification. Upon arrival at the site: · Assumes responsibility to collect data cooperatively and make observations; · Contributes to the content and participates in the writing of the Site Visitors' Report; and · Participates in the exit meeting with the nurse administrator and any persons invited to be present. After the visit: · Retains a copy of the Self-Study Report, Catalog, Site Visitors' Report, and any other resource materials used/developed during the site visit until the Commission's decision is finalized; and · Reviews materials in preparation for contact by the Evaluation Review Panel. Nursing Education Unit Responsibilities · · · · · · Provides the team chair with an electronic file that lists the names, credentials, and titles of individuals and group members scheduled to be interviewed by the site visitors when the team arrives on site; (see Guidelines, p.88) Provides the team chair with an electronic file listing all documents available in the "display room" by defined category; (see Guidelines, p.89) Provides computers and printer(s) for the team to use throughout the visit; Establishes a room in which materials for the site visitors are assembled and the team can read and work during the period of the visit; Obtains any necessary written permissions required prior to the visit (i.e., review of records and visits to clinical agencies); Assembles the following materials in the site visit team work room: o o o o o o o o o o o o o o Annual reports to the chief administrator of the governing organization and to the Boards of Nursing Budgets Class and clinical schedules for the week of the visit Complete course outlines including samples of examinations and evaluation forms Faculty handbook Faculty vitae Minutes of faculty and committee meetings for the past two to three years Latest accrediting agency report and approval letter for the governing organization Results of standardized tests, National Council Licensing Examinations, and/or certification examinations Most recent State Board report(s) to the program and approval letter Samples of student and faculty projects Student handbook Clinical agency contracts Other materials the faculty deems essential to the site visitors' understanding of the nursing education unit and its program(s).

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These materials will be used during the visit and will be left with the nursing education unit upon the completion of the visit. Site visitors will ask to review records of faculty, students, and recent graduates. The student records include both academic and financial aid. These records will be reviewed in the offices where they are filed. Visit Arrangements Area Housing Responsibility Nursing Education Unit Site Visitor · Individual site visitors will pay for · Nurse administrator will make the hotel accommodations and be hotel reservations for the site reimbursed by NLNAC. visitors and notify each team member. · Each visitor is to have a separate hotel room in close proximity to each other; availability of restaurant facilities is essential. · The program is responsible for arrangements for transportation to and from the airport/hotel if inadequate transportation or great distance makes this necessary or desirable. · Any intra-visit travel expenses and arrangements are the responsibility of the program. · All persons traveling on NLNAC business are expected to use common carriers (tourist class or equivalent rates). · Reservations whether by air, bus, or train are to be reserved and purchased through the NLNAC designated travel representative at least six weeks in advance of the site visit. · Airline availabilities, transportation arrangements from airports, bus, or train stations is the responsibility of the site visitor. · A written request to use a personal automobile is required in advance of the visit. The site visitor will receive authorization. Reimbursement is based on current NLNAC policy. · Food during the visit is the responsibility of each reviewer and will be reimbursed by NLNAC after the visit based on current NLNAC policy. · NLNAC will bill the program according to the prevailing fee schedule prior to the accreditation visit. · Payment is expected prior to the visit, or the accreditation visit will be cancelled.

Travel

Food

Fees

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Agenda for the Visit A tentative agenda for the visit is prepared by the nursing education unit and sent to the site visit team chairperson along with a copy of the class and clinical laboratory schedules and the Technology Assessment Form at least six weeks prior to the scheduled visit. Activities usually planned to take place during the visit include: · Preliminary, interim, and closing meetings with the nurse administrator (and assistants); · Meeting with faculty; · Meetings with administrative officers of the institution; · Meeting with nursing students; · Meeting with the public for third party comments and review of written third party comments; · Meeting with nursing service personnel as appropriate; · Visits to appropriate facilities and resources; · Visits to selected clinical agencies to observe and meet with students; · Review of curricular and other materials prepared by the faculty; · Review of appropriate records of faculty, students, and recent graduates; · Request for additional data to clarify and amplify the self-study; and · Classroom and clinical observations. Sample Agenda for Accreditation Visit Day One · · · · · · · · · Welcome meeting with Nurse Administrator, Associates/Assistants, and available Faculty Conference with Nurse Administrator1 Conference with the Chief Executive Officer of the governing organization (~ 30 minutes2 ) Conference with other administrative persons of the institution (i.e., Academic Dean, Finance Officer ~ 30-60 minutes/person) Conference with support personnel (i.e., counseling, admissions officer, financial aid officer ~ 30-60 minutes/person or may be arranged as a group) Conference with Librarian and tour of library/learning resource center (~ 60 minutes) Meet with students (~ 60 minutes) Tour educational facilities Read materials in "display room"

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Day Two

· · · · · · · ·

Tour of clinical agencies3 Conference with Nursing Service Representatives (i.e., nurse administrators, nurse managers, graduates) Meet with Nursing Faculty (~ 2-3 hours) Observe classroom activities Conference with General Education Faculty (if appropriate) Review student faculty records Meet with members of the Public Read materials in "display room" Exit Meeting4

Day Three

·

1. The team chairperson will arrange to meet with the nurse administrator at the beginning and end of each day and periodically throughout the day. 2. Time frames are only provided as a guide. 3. Clinical units for selected visitation should have students present and prepared to meet with site visitors. It may be helpful for site visitors to have had the conference with the total faculty prior to visiting the clinical agencies. 4. Accreditation visit activities may overflow into the third day. Upon arrival at the site, the team meets to discuss the conduct of the visit. On the first day, site visitors meet with the nurse administrator to review the plans for the visit. Site visitors need to set time aside each day of the visit for reading essential materials and preparing and writing the Site Visitors' Report. Visiting Off-Site Campus(es) Programs with off-site campuses must discuss with the site visit team chairperson, prior to the visit, alternative methods for the visiting team to evaluate those campuses, as it is not required that all campuses be visited by the team (e.g., off-site faculty can visit the main campus, participate in the faculty meeting via a conference call, or campus facilities can be viewed through a slide show or video presentations).

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THE SITE VISITORS' REPORT The visit team chairperson is responsible for presenting a complete and well organized report to NLNAC one week after the conclusion of the site visit. Team members will provide the chairperson with comments and draft sections of the report. The Report The Site Visitors' Report includes verification of data, documentary statements, and additional descriptive material essential to a clear and concise picture of all aspects of the program. It includes the site visitors' statements of findings for each of the accreditation standards and criteria. The report also includes the team's recommendation(s) for the accreditation status of the program(s) reviewed. The report is intended to verify, clarify, and amplify the Self-Study Report of the nursing education unit. Site visitors review all materials on site and include comments about the materials under the appropriate standard within the Site Visitors' Report. Team chairpersons are asked not to attach documents since the information will be commented on within the body of the report. If the team chairperson believes that it is absolutely necessary to include a document to clarify an aspect of the program, it will become part of the Site Visitors' Report. The Site Visitors' Report is prepared in narrative format. The report is made up of four sections. 1. General Information Name, city, and state of governing organization and nursing education unit Name, credentials, and title of the chief executive officer and nurse administrator Name of governing organization accrediting body (date of last review and action) Telephone, fax number, and email address of nurse administrator Current State Board of Nursing approval status (date of last review and action) Current NLNAC accreditation status (date of last review and action) 2. Site Visit Information Name, credentials, title, affiliation, and address of the site visitors NLNAC Standards and Criteria used Program(s) demographics Third Party comments Persons/groups interviewed Documents reviewed

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3. Evaluation of Standards and Criteria For each standard, the report should include: · Statement of the standard and all criteria; · Commentary and Summary including strengths and notation as to program compliance with the standard; and · Areas needing development or evidence of non-compliance. 4. Recommendation The report concludes with the visit team's accreditation recommendation to the Commission (see Policy #4). Staff Review All Site Visitors' Reports are reviewed by the NLNAC professional staff. If questions arise, the team chairperson is contacted for clarification. A draft copy of the report is mailed to the nurse administrator of the nursing education unit for review and correction of "errors of fact" within eight weeks after the conclusion of the site visit. The completed Response Form must be received by NLNAC within two weeks after the nursing education unit receives the draft report. Substantive comments are shared with the team chairperson who then decides whether the report is to be changed. The corrected final report will become part of the permanent materials relating to the accreditation visit as will the Response Form submitted by the nurse administrator. The final report will be sent to the nurse administrator and the site visit team members prior to the Evaluation Review Panel meeting.

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EVALUATION REVIEW PANEL There are four standard peer Evaluation Review Panels (ERP) appointed by the Commission (Master's and Baccalaureate degree, Associate degree, Diploma, and Practical Nursing). The role of the ERP is to assure that the process of peer evaluation has been carried out according to the accreditation standards and criteria. The panelists review the findings of the visit team as presented in the Site Visitors' Report compared to the program self-study and catalog and make a recommendation for accreditation status to the Commission. The role of the Evaluation Review Panel is to validate the work of the site visitors and extend it by noting points of agreement and raising any questions where disagreement or a lack of clarity exists. In the latter case, site visitors are available by telephone during panel deliberations and may enter into discussion with the panel to assure an accurate understanding of the Site Visitors' Report. The aim is to promote a seamless review which has integrity and does justice to the program under review. The role of the professional staff is to facilitate the work of both review groups. Panelists do not conduct a de novo review of the program(s). Rather, they determine the adequacy of the evidence to support each standard and criterion. The purpose is to see that the standards and criteria are applied consistently across all programs reviewed by the panel. Finally, they make a recommendation to the Commission on the accreditation status of each program. Assignments of the Evaluation Review Panel Members To facilitate panel discussion, two or three panel members are assigned to review and present in the following manner: Presenter One The first presenter reviews the Self-Study Report, the Site Visitors' Report, the School Catalog, and the Response Form to the Site Visitors' Report, and presents an evaluation based on the information found in these documents. Presenter Two The second presenter focuses on the Site Visitors' Report while reviewing the Self-Study Report and the school catalog. An evaluation is presented based upon the analysis. The third presenter analyzes the materials and presents a short evaluation using the Site Visitors' Report as the primary document.

Presenter Three

Presenters are concerned with the evidence affirming that the Site Visitors' Report accurately reflects the status of the program in meeting the standards and criteria. The narrative reports discuss compliance with the standards, program strengths, and areas needing development. Nursing Program Representative Attendance at the Evaluation Review Panel Meeting The nurse administrator and whomever she/he invites may attend the Evaluation Review Panel deliberation about the program in person and/or by telephone conference. The attendees are observers during the presentation of the program, panel deliberations, and vote, and will not be asked to respond to questions or to clarify information. No documents relative to developments occurring after the site visit may be used during this deliberation. At the conclusion of the panel deliberations, the nurse administrator is invited to address the panel.

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Evaluation Review Panel Procedures Chair Panel Composition Voting Conflict of Interest A member of the NLNAC Board of Commissioners 8-25 Peer members Majority of members present A panel member does not participate when she/he: · served as a site visitor for the program being reviewed; · resides in the same state; and/or · served as a consultant or is otherwise associated with the program or institution. Approximately 20 minutes/program or 30-50 minutes/multiple programs · Presenter One: Introduction and presentation · Presenter Two: Additional information not stated by first presenter · Presenter Three: Additional information as needed (only if not previously stated) Information is presented by standard with each criterion addressed. The role of the panelist is to: verify information presented in the Site Visitors' Report; determine if the process has been carried out appropriately; and affirm that the site visitors have addressed all criteria. The panelists will identify program compliance with the standards, strengths (i.e., exemplary practices), and program areas needing development. Discussion The full panel considers the findings. Site visitors will be contacted by telephone if a question raised by a panel member needs further clarification. Recommendation: A motion and second are made to recommend the accreditation status of the program to the NLNAC Board of Commissioners. The motion is open for discussion by the members of the panel. The question is called and followed by a vote on the motion. Program Participation Once the deliberations are completed, the program representative(s) will be invited to address the panel.

Presentation

The goal of the peer evaluation process is to render an honest and fair recommendation to the Commission regarding the accreditation status of the program. A summary of the findings from the Evaluation Review Panel is forwarded to the Board of Commissioners.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-IV: Processes and Procedures

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COMMISSION The Commission has the sole authority to determine the accreditation status of applicant programs. The Commission, composed of experts in nursing education, administration, nursing service, and public members bases its decisions on the complete and consistent application of the accreditation standards and criteria within and across program types. The full Commission makes the final accreditation decision at its next regularly scheduled meeting. To assist the nursing program in future planning, a copy of the Summary of Deliberations of the Evaluation Review Panel is forwarded to the program along with the Commission decision letter. In all cases, the applicant will be given the rationale for any decision. In cases where accreditation is denied, the applicant has the opportunity to present their case in a full and impartial hearing before an independent Appeal Panel.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-IV: Processes & Procedures

SUMMARY TIMELINE FOR ACCREDITATION PROCESS

PROCESS COMPONENT Planning for Accreditation TIMELINE Candidate status is granted after a staff review of a nursing education program's potential to achieve NLNAC accreditation. A program in candidacy must seek initial accreditation within 2 years (4 accreditation cycles). Initial: One year in advance, official authorization from the chief executive to initiate the accreditation review is received by NLNAC. Continuing: One year in advance, NLNAC staff notifies the nursing education unit of a pending visit. Official authorization from the chief executive officer is received by NLNAC. The administrator of the nursing education unit sends one (1) paper and CD/Diskette copy of the Self-Study Report and one (1) paper or CD/Diskette copy of the current catalog to each of the site visit team members. These materials must be received six weeks prior to the scheduled date of the site visit. Six (6) paper and CD/Diskette copies of the Self-Study Report, six (6) paper or CD/Diskette copies of the current catalog, and one unbound copy of the Executive Summary (first section of the Self-Study Report). If the nursing education unit is having a multiple program visit, a complete set of the items listed above should be sent for each program being reviewed. The materials must be received in the NLNAC office six weeks prior to the scheduled date of the site visit. The Self-Study Reports and catalogs become the property of NLNAC. Fall Cycle: September ­ October/November Spring Cycle: January ­ March Team Chairperson: One week following the visit, the Site Visitors' Report is due at NLNAC. NLNAC Professional Staff: Within eight weeks after the site visit, a draft copy of the report is mailed to the nurse administrator to review for errors of fact. Nurse Administrator: Two weeks from receipt of draft report, the completed Response Form must be received by NLNAC. NLNAC: Prior to the Evaluation Review Panel meeting, a copy of the final Site Visitors' Report is sent to the nurse administrator and site visit team members. Spring Panel Meeting: June Fall Panel Meeting: January/February Spring Cycle: July Fall Cycle: February Nursing education unit will receive Commission decision and a copy of the ERP summary within 30 days of the Board of Commissioners meeting.

·

· · Self-Study Report ·

·

Site Visit Team Report

· · · · · ·

Evaluation Review Panel Commission Decision

· · · · ·

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-IV: Processes and Procedures

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PROGRAM EVALUATORS Program evaluators are site visitors, evaluation review panel members, and appeal panel members. They make recommendations to the Board of Commissioners. Program evaluators are knowledgeable about the current thinking within the various program types, appropriate curricula, conventions and current trends in healthcare, nursing education, and/or nursing practice. Eligibility for Selection as a Program Evaluator In order to be eligible as an NLNAC Program Evaluator, the individual must satisfy the following requirements: 1. Academic Credentials: Master's Degree Programs Baccalaureate Degree Programs Associate Degree Programs Diploma Programs Practical Nursing Programs Nurse Clinician 2. Experience: Nurse Educator Nurse Clinician 3. Knowledge of: Postsecondary and/or Higher education Curriculum and instruction Current issues in nursing education and practice Philosophy and processes of specialized accreditation 4. Expertise in: Communication Group dynamics Computer literacy Management Professional practice 5. Contributions in: Scholarship/Research Practice Community service Institutional service Professional service Full-time faculty appointment or administrator in an NLNAC accredited program* Clinical appointment in nursing practice Earned doctoral degree from a regionally accredited College/University and a Master's degree with a major in nursing Earned doctoral degree and a Master's degree with a major in nursing Master's degree with a major in nursing Master's degree with a major in nursing Master's degree with a major in nursing Master's degree with a major in nursing

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-IV: Processes & Procedures

* 1. Program evaluators must be from NLNAC accredited nursing programs. 2. Current program evaluators who have accepted a part-time faculty or administrative position or who have retired may continue to serve as program evaluators for up to three (3) years. Site Visitor Selection All site visitors are current faculty and/or administrators of NLNAC accredited programs or nurse clinicians and are selected through mechanisms and criteria established by the Commission. Individuals identified by staff, nominated by a colleague, or self-nominated must submit a letter of interest, current resume, and a letter of recommendation. After NLNAC staff review, selected individuals will be invited to become a site visitor and must attend the Program Evaluator Forum for orientation. Appointment Site visitors are eligible to serve for an indefinite period of time if they receive ongoing positive site visit performance evaluations and remain current with the accreditation process. Visitors remain current by attendance at the Program Evaluator Forums and regular participation in NLNAC accreditation activities. Continuing Eligibility A site visitor who: · retires may continue to serve up to three additional years if she/he remains current in nursing education and the accreditation process. · is no longer affiliated with a nursing education program or nursing service will be ineligible to continue as a site visitor. · takes a position in a nursing program not accredited by NLNAC will be ineligible to continue as a site visitor. Evaluation Site visitors are evaluated by the members of the site visit team and the nursing education unit following each site visit. Preparation In order to assure consistency in the application of the accreditation standards and criteria, site visitors are expected to attend one Program Evaluator Forum (conducted on an annual basis) every four years. Briefing sessions are conducted by telephone conference call for all site visitors prior to the assigned visit each accreditation cycle. Honorarium An honorarium will be provided to the site visitor after a visit is completed.

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Evaluation Review Panel Member Selection Evaluation review panel members and alternate panel members are program specific and are appointed by the NLNAC Board of Commissioners. The NLNAC professional staff reviews candidates based on information from current evaluation review panel members, site visitors, Commissioners, and accredited programs and recommends their names to the Commission. Evaluation review panel members and alternate panel members must be current site visitors of NLNAC accredited programs. Appointment Evaluation review panel members serve for a three-year term and may be appointed to a second consecutive term. Approximately one-third of the evaluation review panel member terms expire in any one year. Alternate evaluation review panel members may serve indefinitely. Panel vacancies are filled by program specific evaluators selected from the list of alternate panel members to complete the unexpired term. An evaluation review panel member who retires may serve out the existing term but will not be eligible for reappointment. Preparation Evaluation review panel members are expected to attend program evaluator forums. Prior to each ERP meeting, a briefing session is held to orient new panel members and update the continuing panel members. Appeal Panel Member Selection Appeal panel members must have knowledge and experience with the peer review process. The nurse educator members must be currently active in nursing education. Evaluation review panel members and Commissioners cannot serve as an appeal panel member. Appointment The Appeal Panel consists of individuals drawn from a NLNAC Commission approved list of the individuals qualified to serve as appeal panel members.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-IV: Processes & Procedures

V. GENERAL POLICIES POLICY #1: CONFLICT OF INTEREST Services as staff member, consultant, site visitor, evaluation review panel member, Commission member, or appeal panel member create situations which can cause conflicts of interest, prompt ethical questions, or raise issues regarding the objectivity and credibility of the accreditation process. The National League for Nursing Accrediting Commission has adopted the following rules to avoid such occurrences. Ethical Imperatives Site visitors, evaluation review panel members, Commissioners, appeal panel members, and staff will not participate in any decision-making capacity for a nursing education unit if they have: · · · · a close, active personal association with a program being considered for official action by the National League for Nursing Accrediting Commission. been on the faculty or staff, have been a student, or served as a consultant on accreditation matters. jointly authored research or literature, participated in a common consortium, or have special research involvement with current program faculty. served in evaluation roles regarding the same institution including membership on state visit teams, regional accreditation teams, or evaluation committees for boards of trustees or regents in the past five (5) years. been paid as a consultant, served as a commencement speaker, received an honorary degree, or otherwise profited or appeared to profit from service to the program. maintained close personal or professional relationships with individuals. a relative or former graduate advisees or advisors.

· · ·

Ethical Guidelines Responsibilities of Program Seeking Accreditation · · · It is the responsibility of each program to facilitate a thorough and objective appraisal of its education unit. Programs are allowed to veto site visitor team members if it can be demonstrated in writing that a potential conflict of interest exists. Any perceived inadequacies of the National League for Nursing Accrediting Commission procedures or processes should be reported by the program to the Executive Director at the time of the occurrence rather than withheld until after action has been taken.

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Responsibilities of Site Visitors, Commissioners, and Staff · Any Commissioner or evaluation review panel member who was a member of a site visit team for a program under consideration or is from the same state must absent her/himself from the Evaluation Review Panel or Commission discussion about the program. When the program of an evaluation review panel member is being considered for accreditation or appeal, the individual may not serve on the Evaluation Review Panel or Appeal Panel during that accreditation cycle. When a program of a Commissioner is being considered for accreditation or appeal, the Commissioner will absent her/himself from the portion of the Commission meeting agenda concerned with the evaluation of that program. Commissioners and program evaluators will be reminded of the confidentiality of all information pertaining to the review of applications and the need to avoid any actions that might give the appearance of a conflict of interest or could reasonably be perceived as affecting the reviewer's or Commissioner's objectivity. At each level of review, reviewers and staff are required to not accept membership on a team or to absent themselves from the room during the review of any application if their presence would constitute or appear to constitute a conflict of interest. To avoid the appearance of a conflict of interest, serving as a site visitor for a competing specialized accrediting agency shall preclude serving as site visitor or Commissioner for NLNAC. A site visitor or ERP member who has served in a similar capacity for a competing specialized accrediting agency may be eligible to serve as an NLNAC site visitor or ERP member after a period of two years has elapsed since the last review activity for the competing organization.

·

·

·

Actions to be avoided by the Program Evaluators and Commissioners · · · Advertising of one's status as a program evaluator, evaluation review panelist, Commissioner, or appeal panel member for the purpose of building a consulting clientele; Soliciting of consultation arrangements with programs preparing for accreditation review; Engaging in consultation to the extent that it results in conflict of interest including serving as a consultant to a program one has recently visited as a member of an accreditation site visit team; or. Implying definitive answers on NLNAC policies and procedures.

·

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-V: General Policies

Confidentiality and Communications · All elements of the NLNAC accreditation process (i.e., content of questions and answers, discussions, interpretations, and analyses) are to be treated in the most private and professional manner. Both ethical and legal considerations demand that information acquired through the accreditation process not be used for purposes other than accreditation matters unless permission is obtained from the program. Documents, reports, and other materials prepared by the program for NLNAC action should be treated as private documents in the absence of specific policies, which make clear the degree and extent of their exposure. NLNAC will release documents in response to a valid court order. All materials pertinent to the applications under review are privileged communications prepared for use by Commissioners, evaluators, and NLNAC staff and may not be shown or discussed elsewhere. Under no circumstances may a Commissioner, evaluator, or NLNAC staff advise deans, program directors, faculty, or anyone else of the Commission's decision or discuss the review proceedings. Except prior to and during the site visit or evaluation review panel meeting, there shall not be direct communication between evaluators and applicant institutions. Any need for additional information from institutions must be directed to the NLNAC Executive Director or appropriate Deputy Director who will handle all such communications.

·

·

·

·

Disclosure Memorandum CONFLICT OF INTEREST AND CONFIDENTIALITY STATEMENT (To be signed prior to each assignment or at each meeting; signed by staff annually) Site Visit Team Member, Evaluation Review Panel Member, Commissioner, Appeal Panel Member, and NLNAC Staff DATE: (Each NLNAC activity) I have received and read the statement on "Conflict of Interest." I understand that the aim is to avoid any actions, which may give the appearance that a conflict of interest exists. Thus, I will leave the room in cases where I believe I may have a conflict. Since it is sometimes difficult to decide these matters, I will ask questions should a suspected conflict arise. In addition, I understand that: (1) material furnished for review purposes and discussion during a site visit or review meeting is considered privileged information; (2) I will not vote on any program status in which I am in conflict* ; (3) I will not go on a site visit to a program in which I am in conflict**; and (4) I absent myself and do not participate in the discussion of, visit to, or vote on any program in which I, or to my knowledge, my spouse, relative, or close professional associate has an interest as an employee, consultant, officer, or in any other collaboration. *not applicable to site visit team members **not applicable to evaluation review panelists TO:

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-V: General Policies

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POLICY #2: REPRESENTATION ON EVALUATION REVIEW PANELS AND THE COMMISSION The evaluation, policy, and decision-making bodies of NLNAC are composed of educators, administrators, clinicians/practitioners, and members of the public. Clinician/Practitioner Representation "Practitioners" in nursing are defined by the State Boards of Nursing as all licensed nurses who work for pay. This also includes the registered nurse who provides or oversees services to people or communities. All are responsible and accountable for organizing, planning, assigning, and overseeing patient care. Master's prepared nurse clinicians whose primary place of employment is other than nursing education are included on site visit teams. The individual will have primary responsibility for verifying that the program prepares its students for contemporary nursing practice. Advanced Practice Nurses (APN) in the U.S. include the clinical nurse specialist, the nurse practitioner, the certified registered nurse anesthetist, and the certified nurse midwife. (NCSBN, 1992; AACN, 1996) Some nursing authorities would prefer to broaden the definition of APN to add the category of nurse administrator prepared at an advanced level, since this individual is essential for creating the environment for the practice of professional nursing. Master's prepared nurse clinicians who may also work as advanced practice nurses are eligible to serve as site visitors. Public Members Public members on the Board of Commissioners will have no connection to the discipline of nursing or to nursing education units. Individuals representing the public will not be: · · · An employee, member of the governing body, owner, or shareholder of, or consultant to a program that either is accredited by or has applied for accreditation by NLNAC; Affiliated with or associated with NLNAC or NLN; or A spouse, parent, child, or sibling of an individual identified in the above statements.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-V: General Policies

POLICY #3: ELIGIBILITY FOR ACCREDITATION A nursing education program is eligible for initial or continuing accreditation when the following conditions exist: · · The governing organization offering the program is legally authorized to grant the credential (degree, diploma, or certificate) to the program seeking accreditation. The governing organization offering the program and granting the credential is accredited or approved for candidacy by an appropriate agency. o If the program is administered by a college, university, or technical institution which is part of the system of higher education, and grants a diploma, certificate, associate, baccalaureate, or master's degree in nursing, then the governing organization must be accredited or hold candidacy by one of the following agencies: Middle States Association, New England Association, North Central Association, Northwest Association, Southern Association, Western Association; Accrediting Bureau of Health Education Schools; Accrediting Commission of Career Schools and Colleges of Technology; Accrediting Commission of the Distance Education and Training Council; New York State Education Department for Hospital Based Nursing Programs offering the Associate degree; and Joint Commission on Accreditation of Health Care Organization. If the program is administered by a hospital and grants a diploma, then the hospital must be approved by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) or the Healthcare Facilities Accreditation Program (HFAP) of the American Osteopathic Association. If the program is administered by a vocational school and grants a certificate, then the school must be approved by the appropriate state agency for vocational education. If the nursing education unit (school/college) is independent and has state approval to grant an associate, baccalaureate, or master's degree in nursing, then the school/college must be accredited or approved for candidacy by one of the following agencies: Middle States Association; New England Association; North Central Association; Northwest Association; Southern Association; Western Association; Accrediting Bureau of Health Education Schools (ABHES); Accrediting Commission of Career Schools and Colleges of Technology (ACCSCT); Accrediting Commission of the Distance Education and Training Council; or New York State Education Department (for Hospital Based Nursing Programs offering the Associate Degree).

o

o

o

·

The program must be currently approved without qualification by the state agency that has legal authority for education programs in nursing. This policy is not applicable to those programs in nursing over which a board of nursing has no jurisdiction (i.e., selected master's degree programs or programs admitting previously licensed nurses). The program has one class of students in the final semester or quarter at the time of the site visit or has graduates of the program.

·

When a governing organization has multiple campuses and is accredited as one institution, the nursing education units may choose to seek NLNAC accreditation as one unit or as separate units. If accreditation is sought as separate units, all nursing education units offering the same program type must be evaluated for accreditation for any one of them to be accredited. NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-V: General Policies

p.45

POLICY #4: TYPES OF COMMISSION ACTIONS ON APPLICATIONS FOR ACCREDITATION A nursing program is considered for initial or continuing accreditation by the NLNAC Commissioners when it demonstrates compliance with the standards of accreditation. Initial Accreditation Granted: Initial accreditation* of a nursing program is granted when the program demonstrates compliance with all NLNAC accreditation standards. Next review is in five (5) years. *Accreditation is effective as of the accreditation cycle in which the visit took place. Denied: Initial accreditation of a nursing program is denied when a program does not demonstrate compliance with all NLNAC accreditation standards. The program may reinitiate the accreditation process at any time. Continuing Accreditation Granted: · Continuing accreditation of a nursing program is granted when the program is in compliance with all accreditation standards. Next review in eight (8) years. · Continuing accreditation with conditions is granted when the program is found to be in non-compliance with one or two accreditation standards. Next review in two (2) years Master's, Baccalaureate, Associate, and Diploma Programs, and eighteen (18) months for Practical Nursing Programs (see p.47 for details). Continuing accreditation of a nursing program with warning is granted when the program is found to be in non-compliance with three or more of the accreditation standards. Next review (full site visit with Self-Study Report) in two (2) years Master's, Baccalaureate, Associate, and Diploma Programs, and eighteen (18) months for Practical Nursing Programs. Continuing accreditation of a nursing program with removal of condition status is granted when the program is found to be in compliance with all accreditation standards. Next review in six (6) years for the Master's, Baccalaureate, Associate, and Diploma Programs, and six and one half (61/2) years for Practical Nursing Programs. Continuing accreditation of a nursing program with a removal of warning status is granted when the program is found to be in compliance with all accreditation standards. Next review in eight (8) years.

·

·

·

Denied: · Continuing accreditation is denied when a program with conditions or warning status is reviewed and found to be in continued non-compliance with any accreditation standard. The program is removed from the listings of accredited programs. It may reinitiate the application process for initial accreditation at any time. NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-V: General Policies

p.46

Accreditation with Conditions or Warning Status · The Commission places conditions on a program's continuing accreditation when the program has been found to be in non-compliance with one or two accreditation standards. o The conditions include the Commission request for a Follow-Up Report or a FollowUp Report with a Follow-Up Visit within the specified period of time addressing the standard(s) with which the program has been found to be in non-compliance. The Follow-Up Report or Follow-Up Report and Follow-Up Visit Report, and ERP Summary will constitute the basis for Commission action. The action is to either accept the report, finding the program in compliance with all NLNAC standards, or not accept the report as the program remains in non-compliance. Programs in compliance will be granted continuing accreditation. Next review in six (6) years for Master's, Baccalaureate, Associate, and Diploma Programs, and six and one half (61/2) years for Practical Nursing Programs. Programs not in compliance with NLNAC standards will be denied continuing accreditation.

·

The Commission places an accredited program on warning status when the program has been found to be in non-compliance with three or more accreditation standards. o When a program has been placed on warning status, the Commission must request a new Self-Study Report with a revisit within the specified period of time. The new Self-Study, Site Visitors' Report, and ERP Summary will constitute the basis for the Commission action to remove the warning status and grant continuing accreditation for eight years, or to deny continuing accreditation and remove the program from the listings of accredited programs.

·

The maximum period for accreditation with conditions or warning status for Master's, Baccalaureate, Associate, and Diploma Programs is two (2) years from the Commission action. If full compliance with the accreditation standard(s) is not demonstrated within two years, continuing accreditation will be denied. The maximum period for accreditation with conditions or warning status for Practical Nursing Programs is eighteen (18) months from the Commission action. If full compliance with the accreditation standard(s) is not demonstrated within eighteen months, continuing accreditation will be denied.

·

Follow-Up Report Purpose: To provide the nursing education unit the opportunity to demonstrate paper compliance with one or two specific accreditation standard(s). Assignment Process: A Follow-Up Report may be recommended to the Commission by the site visit team, the ERP, or a Commissioner as part of the accreditation review when it is found that the nursing program is out of compliance with one or two of the NLNAC accreditation standards. The decision to assign a nursing education unit a Follow-Up Report is made by the Commission after review of the recommendation(s) and other documents associated with the accreditation review process.

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Review Process: Follow-Up Reports are reviewed by the ERP to establish whether the nursing education unit has demonstrated compliance with the identified one or two NLNAC Standards. The panel recommendation regarding compliance with the NLNAC Standard(s) is forwarded to the Commission for action. Based on the Follow-Up Report and the recommendation of the ERP, the decision regarding the accreditation status of the nursing program is made by the Commission. Decision Options: · Affirm continuing accreditation; the program is in compliance with all NLNAC standards. Next accreditation site visit in six (6) years for Master's, Baccalaureate, Associate, and Diploma Programs, and six and one half (61/2) years for Practical Nursing Programs; or · Deny continuing accreditation and remove the nursing program from the listings of accredited programs. The program is not in compliance with NLNAC Standard(s). Guidelines for Preparing the Follow-Up Report: (1) Organization The report is to be presented in two sections, Introduction and Presentation of the identified NLNAC Standard(s). (2) Content · Introduction o Name and address of the governing organization o Name, credentials, and title of the chief executive officer of the governing organization o Name of institutional accrediting body (date of last review and action taken) o Name and address of nursing education unit o Name, credentials, title, telephone number, fax number, and email address of the administrator of the nursing education unit o Name of State Board of Nursing (date of last review and action taken) o Date of most recent NLNAC accreditation visit and action taken o Year the nursing program was established o Total number of full-time and part-time faculty teaching in the specified nursing program A completed Faculty Profile Form (see Interpretive Guidelines) o Total number of full-time and part-time students currently enrolled in the specified nursing program o Length of program in semester or quarter credits, hours, or weeks · Presentation of the identified NLNAC Standard(s) o State the standard o State the evidence of non-compliance (from the Commission accreditation decision letter) o Offer a narrative addressing the current NLNAC interpretive guidelines for the entire standard with emphasis on the areas of non-compliance Address all criteria for the standard including the `Documentation confirms' sections

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-V: General Policies

If Standard IV Curriculum and Instruction is to be presented, include brief syllabi (2 pages) for all nursing courses. Also include clinical evaluation tool(s) with an explanation of the student evaluation process. Each course syllabus should include: o o o o o o o o Course title and description Total course hours (theory hours and, as appropriate, laboratory and/or clinical hours) Placement of course, number of times course is presented to each class, and the number of students enrolled at any one time Name(s), credentials and title(s) of faculty responsible for the course Course objectives Teaching methods and evaluation methods unique to the course A topical outline (for theory courses) Description of the sequential arrangement of the theoretical content and related major clinical and laboratory experiences, including a typical plan for the clinical and laboratory experiences; indicate the type of patient units and any other major agencies used (for clinical courses).

If Standard VII Educational Effectiveness is to be presented, include the entire program evaluation plan with outcome data/information for the past three (3) years. (3) Format · The number of text pages should not exceed fifty (50). · The appendix has no page limit. · The report should be typed on both sides of the page using 1½ or double-spacing, 1 inch margins, and bound securely. · All pages, including the appendices are to be numbered consecutively, and ordered according to a table of contents. · Each copy of the report should have a title page. · Confidential records (e.g., faculty transcripts, student records) should not be included without written permission. (4) Submission · Six (6) copies (paper and CD/Diskette) of the Follow-Up Report and six (6) copies (paper and CD/Diskette) of the current school catalog are to be sent to NLNAC on or before the date indicated in the NLNAC Board of Commission accreditation decision letter. · Submission dates o Reports due in the Fall must be submitted by November 1st. o Reports due in the Spring must be submitted by March 15th.

Follow-Up Visit and Report Purpose: To verify compliance with the specified accreditation standard(s). When a Follow-Up Visit is required in conjunction with a Follow-Up Report, the visit will be made by a program evaluator from a similar program type and one NLNAC professional staff.

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Follow-Up Visit Report: The report, which is to be written by the peer evaluator and NLNAC staff member, includes verification of data, documentary statements, and descriptive material pertinent to the entire standard(s). The report is prepared in narrative format comprised of four (4) sections: General Information; Introduction; Evaluation by standard in which the program was found to be in noncompliance; and Recommendation. (1) General Information Name, city, and state of governing organization and nursing education unit Name, credentials, and title of the chief executive officer and nurse administrator Name of governing organization accrediting body (date of last review and action) Telephone, fax number, and email address of nurse administrator Current State Board of Nursing approval status (date of last review and action) Current NLNAC accreditation status (date of last review and action) (2) Introduction Name, credentials, title, affiliation, and address of program evaluator NLNAC Standards and Criteria used Program(s) demographics Persons/groups interviewed Documents reviewed Summary of findings (3) Evaluation of Standards and Criteria For each standard in which the program was found to be in non-compliance, the report should include: · Statement of the standard and all criteria; · Commentary and Summary including strengths and notation as to program compliance with the entire standard; and · Areas needing development or evidence of non-compliance. (4) Recommendation The report concludes with an accreditation recommendation to the Commission. Options include: Accept the Follow-Up Report and the Follow-Up Visit Report affirming the next accreditation visit; or Deny continuing accreditation.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-V: General Policies

POLICY #5: NOTIFICATION OF COMMISSION DECISIONS An applicant for accreditation (initial or continuing) explicitly agrees that if accreditation is granted, all records pertaining to that program may be made available to the Secretary, U.S. Department of Education and the state licensing agency, as appropriate. The Commission will submit to the Secretary of Education information regarding a program's compliance with federal student aid program requirements if the Secretary requests such information, or the Commission believes that the program is failing to meet its Title IV responsibilities, or is involved in fraud and abuse with respect to its activities. Prior to submission of information, the program will be provided an opportunity to comment on Commission findings. Within 60 days of a final negative action, the Commission will make available to the Secretary of Education, appropriate state and recognized accrediting agencies, and the public (upon request), a brief statement summarizing the reasons for the negative action determination and the comments, if any, made by the program with regard to the Commission decision. The Program Within 30 days of the Commission meeting, NLNAC staff will send written notification of the Commission action to the nurse administrator, chief executive officer of the governing organization, the site visit team, ERP members, and the Secretary, U.S. Department of Education. The letter to the nurse administrator and chief executive officer will also include any strengths and areas needing development identified by the Commission and a copy of the ERP Summary. Other Groups to be Informed · · · · · · · State Boards of Nursing DOE Case Management Teams Regional Accrediting Associations State Departments of Education (as applicable) Council of Higher Education Accreditation (CHEA) Higher Education Publications, Inc. The Public

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Information Provided the Secretary, U.S. Department of Education The following information will be reported to the Secretary at the same time it is reported to the nursing education unit. Time for Submission Report Category Final Accreditation Decision · Initial Accreditation o Granted o Denied, with reasons · Continuing Accreditation o Granted without restriction o Granted with Condition o Granted with Warning Status o Denial, with reasons · Outcome of Appeal, with reasons · Withdrawal Summary of Major Accreditation Activities Directory of Accredited Programs Substantive Changes · All Accredited Programs · Title IV Participants Complaints · Against Accredited Programs · Against NLNAC Title IV Participant Compliance · Comprehensive Loan Repayment Plan · Default Rates · Adverse Financial or Compliance Audits Fraud or Abuse Proposed Changes: (which alter the scope of recognition or compliance with requirements) · Policy · Procedures · Standards and Criteria Legend

M=Master's Degree, B=Baccalaureate Degree, A=Associate Degree, D=Diploma, P=Practical Nursing

Other Within 30 Days of the February, July and November Commission meetings

Annually March

Programs Affected By Requirements M B A D P X X X X X

March September March aggregated March aggregated Within 30 days of review March aggregated

X X X

X X X

X X X

X X X

X X X

Within 30 days of review

X

X

X

X

X

X

X

X

X

X

As Necessary

3 years

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-V: General Policies

POLICY #6: DELAY/ADVANCEMENT OF CONTINUING ACCREDITATION VISIT The nurse administrator of the programs(s) may formally request a delay or rescheduling of a visit for continuing accreditation. The NLNAC Executive Director makes the decision to grant or deny the request based on the reason(s) provided. The time frame considered for a visit delay is six months (one accreditation cycle). Delays are not granted to programs1: · Currently on warning status; or · Having outstanding Follow-Up Reports requested by the Commission.2

1. 2. If the request for a delay is made after the continuing accreditation application materials have been sent out to programs, a processing fee is applicable. If a program does not submit the Follow-Up Report by the date requested, the program will be presented to the Commission at the next Commission meeting for action.

POLICY #7: WITHDRAWAL Voluntary Withdrawal From NLNAC Accreditation Accredited programs voluntarily withdrawing from NLNAC accreditation must submit written notification to the Executive Director of their decision. When a nursing program voluntarily withdraws from NLNAC, the program's accreditation will continue through the end of its accreditation cycle*. At that point, the program will be removed from NLNAC's listings of accredited nursing programs, and the files purged.

*Fall Cycle: July 1 to December 31 Spring Cycle: January 1 to June 30

NLNAC Withdrawal of Accreditation NLNAC accreditation may be withdrawn if a program refuses an Accreditation, Follow-Up Visit, or Focused Visit. Accreditation may also be withdrawn if the program fails to submit the SelfStudy or Follow-Up Report as specified by the Commission. The program will be removed from NLNAC's listings of accredited nursing programs, and the files purged. The NLNAC reserves the right to withdraw recognition of accreditation of any program that, after due notice, fails to meet its financial obligations. Such withdrawal of recognition will be recorded as expiration of accreditation in NLNAC official files. Payment of annual accreditation and service fees to NLNAC is an obligation for recognition of accreditation status.

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POLICY #8: OPPORTUNITIES FOR THIRD PARTY COMMENTS ON PROGRAMS SCHEDULED FOR EVALUATION As part of ongoing efforts to make the accreditation process responsive to a broad range of constituents, the National League for Nursing Accrediting Commission invites third party comments on programs being reviewed for initial or continuing accreditation. The NLNAC welcomes comments from interested individuals from the nursing community, students, and graduates, as well as the public-at-large. The Commission expects a sincere and thoughtful attempt by programs undergoing review to identify their public and invite comments on the program. NLNAC requires programs to publish basic information about the visit in appropriate outlets (e.g., nursing program newsletter, governing organization publications, website, local newspapers, local radio, posting at clinical agencies used by the program). Guidelines for the solicitation of third party comments will be provided to the nursing program. During the accreditation visit, a time is to be set aside for the site visit team to meet with interested members of the public. In addition, the public may submit comments in writing to NLNAC to be shared with the site visitors.

POLICY #9: PUBLIC DISCLOSURE ABOUT THE PROGRAM When a nursing education program makes a public disclosure of its accreditation status, it must accurately cite each program (i.e., master's degree, baccalaureate degree, associate degree, diploma, practical nursing). The public disclosure must include the name, address, and telephone number of the National League for Nursing Accrediting Commission. If the program publishes incorrect or misleading information about its accreditation status or any action by NLNAC relative to its accreditation status, the program must immediately provide public correction via a news release or other media. Furthermore, if a governing organization or program elects to make public the contents from either the Site Visitors' Report, Summary of Deliberations of the Evaluation Review Panel, or the Commission decision letter, it must provide full sentences and context. Should the statements be misinterpreted, the program must correct this misinterpretation through a clarifying release to the same audience that received the information. When it is determined that an institution is in violation of this policy, the NLNAC Executive Director will inform the governing organization through a formal letter. If the violation is not corrected, the Executive Director shall report the matter to the Commission for appropriate action.

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POLICY #10: APPEAL PROCESS The purpose of the appeal process is to provide the opportunity for review of the accreditation process. Decisions Eligible for Appeal · · Denial of Initial Accreditation Denial of Continuing Accreditation

Notice of Appeal A nursing program that has been denied initial or continuing accreditation status may appeal the decision within thirty (30) days of receipt of notice of such denial by filing a written notice of appeal via hand delivery or certified/registered mail. The notice of appeal shall be sent by the chief executive officer of the appellant governing organization to the NLNAC Executive Director. Upon receipt of the notice, the prior accreditation status of the nursing program shall be maintained until the disposition of the appeal. The appeal process will be completed within ninety (90) days of receipt by the NLNAC of the governing organization's notice of appeal. The Notice of Intent to Appeal Fee must accompany the written notice of the appeal. The Appeal Process Fee must be paid prior to scheduling the hearing. Appointment of an Appeal Panel Within ten (10) working days of receipt of the notice of appeal, the Executive Director shall appoint an Appeal Panel. The Panel will consist of individuals selected from a Commission approved list maintained by NLNAC of persons qualified to serve as appeal panel members. The appellant governing organization will have the opportunity to review the proposed panel members for any conflicts of interest. Such conflicts must be reported to the NLNAC Executive Director within ten (10) working days. The Appeal Panel will consist of three members: two nurse educators from the same program type and one non-nurse educator. In order to qualify for the Appeal Panel, an individual must be currently active in education with knowledge and experience of the peer review process. The nurse educator members will be selected from the list of current site visitors. Evaluation Review Panel members and Commissioners may not serve on the Appeal Panel. Procedures for Governing the Appeal Process The NLNAC Executive Director will deliver the formal charge to the Appeal Panel when it convenes after which he/she will exclude him/herself from the proceedings. The Panel will select a chairperson who will be responsible for ensuring effective implementation of the process and for filing the Panel's recommendation with the Executive Director. Two representatives of the program under review may appear before the Panel. One will be the chief executive officer or designee of the governing organization and the other, the program dean or director. Governing organization representatives as well as the NLNAC have the right to be assisted by their respective counsels. Although attorneys may be present and advise their clients, the Appeal Panel shall not be bound by the technical rules of evidence usually employed in legal proceedings.

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Documents for the Hearing The appellant program may submit for the hearing any documentation or written arguments that are temporally related and relevant to the concerns cited by the Commission. A copy of all documents submitted in evidence for the hearing shall be received by each Panel member at least three weeks prior to the scheduled hearing. Such documents will include the program file, the record of Commission action, and any written materials submitted by the appellant program. The documents comprising of the program file, the record of commission action, together with oral and written presentation to the Appeal Panel, shall be the basis for the discussion and recommendation of the Appeal Panel. The Hearing The Appeal Panel shall meet and review the written record and receive the oral presentation. Presentations are not to exceed sixty (60) minutes in length and shall be limited to: clarification of the record; arguments to address compliance by the program with the published accreditation standards and criteria; and review of the administrative procedures leading to the denial decision. While conducting their review, the Panel will consider only information in the record at the time the Commission imposed the decision for denial. Proceedings before the Appeal Panel are not of an adversarial nature as typical in a court of law, but rather, provide an administrative mechanism for peer review of a denial of an accreditation decision about a nursing program. While an attorney representing the program may participate in the proceedings, witnesses may not be crossexamined, and objections to testimony are not permitted. The Decision Based upon a review of all oral and written information presented, the Appeal Panel will determine by a majority vote whether the accreditation process has been properly implemented. The chairperson of the Appeal Panel verbally informs the school representative(s) of the recommendation to be made to the Commission and the reason for the recommendation. The recommendation to the Commission shall be one of the following: · · · Affirm the Commission decision to deny accreditation; Advise that the Commission grant continuing accreditation with a revisit in eight (8) years; or Advise that the Commission grant initial accreditation with a revisit in five (5) years.

The NLNAC staff will communicate the Commission's decision in writing and its basis to the chief executive officer of the governing organization with a copy to the dean/director of the nursing program within thirty (30) days. A copy of the decision letter will be forwarded to the appeal panel members and the U.S. Department of Education; a copy will also be maintained in the NLNAC office.

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POLICY #11: PUBLIC NOTICE OF PROPOSED POLICY CHANGES NLNAC provides notice of proposed new or revised policies. Interested parties are given an opportunity to comment prior to implementation.

POLICY #12: RECORDS ON FILE NLNAC maintains the following materials for each accredited program: · · · · · · · · Self-Study Reports (two most recent) Program Catalog (most recent) Site Visitors' Reports (two most recent) Program Response Forms (two most recent) Summaries of the Deliberations of the Evaluation Review Panel (two most recent) Commission actions on accreditation status (two accreditation cycles) Initial accreditation letter Correspondence o To/from Nursing Education Unit o State Board of Nursing o Accrediting Agency of the Governing Organization Reports (as appropriate) o Interim Report o Follow-Up Report o Follow-Up Visit Report o Substantive Changes

·

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VI.

MONITORING POLICIES AND PROCEDURES

POLICY #13: INTERIM REPORT (NOT IN EFFECT) POLICY #14: REPORTING SUBSTANTIVE CHANGES It is the responsibility of each program to notify the National League for Nursing Accrediting Commission of major changes to insure maintenance of accreditation status and protection of students. Failure to report changes places the accreditation status of the program in jeopardy. NLNAC reserves the right to reconsider the accreditation status of a nursing program at any time. Substantive Change Planned Change Any program proposing a substantive change in the ownership or form of control, mission, program offerings, curriculum, credentials conferred, length of program, or establishment of an additional location must report it to the NLNAC and obtain prior approval (see table p.59). The process must be followed immediately after the proposed change has been approved internally by the school, but no later than four months before the planned implementation date. Accompanying this notification, the program must include a detailed report for review by the NLNAC staff that speaks to what drove the change and address each one of the NLNAC Standards and Criteria that are/or could be impacted by this change. Unplanned Change Substantive changes requiring immediate notification of NLNAC include: change of State Board of Nursing approval status; change in accreditation status of the governing organization; a pattern of declining NCLEX or certification pass rates; a default rate in student loan program that exceeds the regulation; and/or identified fraud in the program or adverse federal action (see table p.59). As with planned change, a report addressing unplanned changes must also be submitted. After review, staff will notify the program as indicated above. Minor Changes If a program questions whether or not a change is substantive or minor, it should seek a ruling from an NLNAC professional staff member.

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Substantive Change ­ Notification Required within 4 Months Prior to Implementation Change in ownership, legal status or form of control Change in mission or objectives Implementation of distance education (see Policy #15) Addition of courses or programs different in context or method of delivery from what was previously offered and accepted Addition of programs with a different level of credentials Significant change in length of program and fees in relation to program and credentials Changes in method of academic measurements (clock or credit or vice-versa), or change in the number of clock or credit hours Establishment of an additional location

Usual Approval Process Focused Visit required within six months after a change of ownership takes place Staff Recommendation/Focused Visit as indicated Staff Recommendation/ Focused Visit as indicated Staff Recommendation/Focused Visit as indicated Staff Recommendation/Focused Visit as indicated Staff Recommendation/Focused Visit as indicated Staff Recommendation/Focused Visit as indicated Staff Recommendation/ Focused Visit as indicated If NLNAC is the program gatekeeper, the focused visit is mandatory Closing Report including "teach out agreement" Usual Approval Process Submission of all reports required by State Board of Nursing and copies of all correspondence from/to the State Board of Nursing regarding approval status; review of rationale for adverse action to determine need for further monitoring, possible change in accreditation status to warning. Review of rationale for adverse action to determine need for further monitoring. Submission of a Report addressing factors that resulted in the decline and strategies developed to address the problem and all reports required by State Board of Nursing. Staff Recommendation/Focused Visit as indicated If NLNAC is the program gatekeeper, the focused visit is mandatory Department of Education is notified. Usual Process Staff Acknowledgement

Program Closing Other Substantive Changes ­ Notification Required Immediately Change in State Board of Nursing approval status (see Policy # 17)

Adverse action by appropriate institutional accrediting agency (see Policy #18) Identified pattern of declining performances on NCLEX, certifying examinations, and/or employment rates Title IV Participant Compliance: · Default rate in student loan program that exceeds threshold set by legislation, regulation, and policies · Fraud and abuse · Adverse action following financial or compliance audits, program review, or other information that becomes available Other Changes - Informational Change of Nurse Administrator

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Guidelines for the Preparation and Submission of the Change Report Change in Ownership The nursing program must notify NLNAC no later than four (4) months prior to a change of ownership. NLNAC staff will make a focused visit within six (6) months after a change of ownership resulting in a change of control. The Report should include the following documents: · Legal sale agreement; · State Board of Nursing approval letter; and · Institutional Accrediting Agency approval letter. Change in Curriculum When reporting changes in curriculum, include a table correlating the current curricular plan with the proposed changes along with a two (2) page syllabus of each proposed new nursing course. After reviewing the information that the program has submitted regarding a planned substantive change, NLNAC staff will notify the program of: · the need for additional information; · the need to arrange a focused visit; · a recommendation being made to the Board of Commissioners to change the date of the next scheduled accreditation site visit and/or accreditation status; and/or · NLNAC approval Additional Location* *Additional locations as defined by the U. S. Department Regulations is any location that is geographically apart from the main campus at which the institution offers at least 50 percent of an educational program. When reporting an addition of a location the nursing program should include detailed information regarding the fiscal and administrative capacity of the nursing education unit and governing organization to operate the location including information regarding personnel, facilities and resources. Programs for which NLNAC serves as Title IV funding gatekeeper are required to have a focused visit for each additional location to verify that the additional location has the personnel, facilities, and resources to deliver the program in compliance with NLNAC standards and criteria. The program report should address the: · Curriculum · Faculty · Resources o Revenues and expenditures o Personnel o Learning/physical facilities

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Submission of the Report · One (1) copy (paper and CD/Diskette) of the Report is to be sent to NLNAC no later than four (4) months before the planned implementation date. For unplanned changes, notification is required immediately/at the time the change occurs.

Staff Review and Recommendation NLNAC professional staff will review the detailed report to assure all questions of compliance with the standards and criteria are met with the implementation of the change. Requests for additional information may be made before approval is granted. Approval of the change is granted when compliance is demonstrated. If review of written materials is not sufficient or other questions arise a Focused Visit may be deemed necessary. POLICY #15: DISTANCE EDUCATION Definition of Distance Education* The regional accrediting bodies define distance education as an educational process in which the majority of the instruction occurs when a student and instructor are not in the same place. Instruction may be synchronous or asynchronous. Distance education may employ correspondence study, audio, video, and/or computer technologies. When a program implements a distance education program, NLNAC must be notified within four (4) months prior to the planned implementation. NLNAC will review the substantive change based on standards and criteria of accreditation as well as the following principles of distance education: Considerations for Implementing Distance Education NLNAC believes the quality of distance education learning depends upon: · who designs, teaches, and evaluates curriculum; · competence of the teacher; · quality of the support services; · currency of the offerings; and · provision for faculty/student and student/student interaction. There are several standards that the NLNAC recommends that faculty consider in evaluating the usage of distance education within the nursing education unit. Standard: Students Students must have: · access to the range of student services appropriate to support the program(s) including admissions, financial aid, academic advising, delivery of course materials, placement, and counseling; · knowledge and equipment necessary to use technology employed in the program and be provided with assistance when experiencing difficulty using the required technology; · means for resolving student complaints; and

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·

information related to advertising, recruiting, and admissions that adequately and accurately represents the program(s), requirements, and services available.

Standards: Faculty and Curriculum and Instruction Curriculum and Instruction allows for: · interaction between students and faculty and among the students; · faculty responsibility for oversight of distance education ensuring both the rigor of program(s) and the quality of instruction; · technology that is appropriate to the nature and objectives of the program(s); · currency of materials, programs, and courses; · policies that are clear concerning the ownership of materials, faculty compensation, copyright issues, and the utilization of revenue derived from the creation and production of software, telecourses, or other media products; · faculty support services specifically related to distance education; and · faculty development for faculty who teach in distance education program(s). Standard: Resources Library and Learning Resources assure that students have: · access to and can effectively use appropriate library resources; · their use of learning resources monitored; and · laboratories, facilities, and equipment appropriate to the courses or program(s). Fiscal and physical provision is made for: · equipment and technical expertise required for distance education; and · long-range planning, budgeting, and policy development processes that reflect the facilities, staffing, equipment, and other resources essential to the viability and effectiveness of the distance education program. Standard: Educational Effectiveness Ongoing systematic evaluation and assessments are conducted to assure: · student capability to succeed in distance education program(s) and application of the information to admission and recruiting policies and decisions; · effectiveness of its distance education programs (including assessment of student learning outcomes, student retention, and student satisfaction) and comparison to campus-based programs; and · integrity of student work and the credibility of the degree and credits awarded.

* Regional Accrediting Commissions, "Best Practices for Electronically Offered Degree and Certificate Programs" and "Joint Statement of Commitment by the Regional Accrediting Commissions for the Evaluation of Electronically Offered Degree and Certificate Programs". Chicago: Author. Available: http://www.ncahlc.org/index.php?option=com_content&task=view&id=32&Itemid=85

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POLICY #16: PROGRAM CLOSING Closing an Accredited Program To safeguard the validity of accreditation and to assure maintenance of program quality, the following policies are applied when the NLNAC is notified that an accredited program is closing: · When the decision is made to close a program in nursing, a Closing Report that fully describes the plan for closing including a teach-out agreement to be submitted to the NLNAC. Based upon the information provided in the report, the accreditation status of the program, and the date of the next scheduled accreditation visit, the Commission will take one of the following actions: · When the program is accredited without qualifications, the Commission will: o cancel the next visit and continue accreditation until closing; or o reaffirm the originally scheduled visit. · When the program is on warning, the Commission will: o extend the warning status if the program is scheduled to close within 12 months after the scheduled visit; or o determine the date of a next visit if the program is scheduled to close beyond a year after the scheduled visit. · If a program planning to close fails to submit a Closing Report to NLNAC or comply with Commission request(s), such action will constitute a declaration of choice to have accreditation status withdrawn, and the Commission will take action accordingly. · If a program previously scheduled to close extends its operation beyond the original date, a site visit is scheduled at the earliest convenient date. The procedure to be followed will depend upon the status of the program at the time the announcements about the closing and the change of plans were made. · If a program closes in the interim between Commission meetings and without prior notice to NLNAC, the closing automatically terminates NLNAC accreditation. Preparation of the Closing Report Introduction: · Name and address of governing organization · Name, credentials, and title of the chief executive officer of governing organization · Name of institutional accrediting body (date of last review and action) · Name and address of nursing education unit · Name, credentials, title, telephone number, fax number, and email address of the administrator of the nursing education unit · Name of State Board of Nursing, (date of last review and action) · Date of most recent NLNAC accreditation visit and action taken · Year the nursing program was established · Total number of full-time and part-time faculty teaching in the specified nursing program o A completed faculty profile (see Interpretive Guidelines). · Total number of full-time and part-time students currently enrolled in the specified nursing program · Length of program in semester or quarter credits, hours, or weeks.

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Information Related to Closing: In narrative form, address the following: · The ways and means for completing the designed curriculum including timetable and assurances that there will be adequate numbers of appropriately qualified faculty. The teach-out agreement should be included. A teach-out agreement that involves another nursing program must assure all current students have the opportunity to successfully complete their nursing education. · The NLNAC approves the teach-out agreement if it: o Is consistent with program type criteria; o Provides for the equitable treatment of students by ensuring that: - Students are provided, without additional charge, all of the instruction promised by the institution prior to closure but not provided to the student because of the closure. - The teach-out institution is accredited or pre-accredited by an NLNAC recognized agency, is geographically proximate to the closed institution and can demonstrate compatibility of its program structure and scheduling to that of the closed institution. · Provisions made for retention or phasing out of each faculty position necessary to carry out instructional activities; · Arrangements for continuation of essential student services (i.e., library, counseling, financial aid, health, and housing); · Specific plans for the maintenance of the records pertinent to the school and each graduate such as student files, notification of graduates, provision for security and confidentiality, and processing of requests for information. Format: · The number of text pages should not exceed fifty (50). · The appendix has no page limit. · The report should be typed on both sides of the page using 1½ or double-spaced, 1 inch margins, and bound securely. · All pages, including the appendices, are to be numbered consecutively and ordered according to a table of contents. · Each copy of the report should have a title page. · Confidential records (e.g., faculty transcripts, student records) should not be included without written permission. Submission: · Two (2) copies (paper and CD/Diskette) of the Closing Report are to be sent to NLNAC on or before the date indicated in the NLNAC staff letter acknowledging the program notice of its closing.

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POLICY #17: STATE BOARD OF NURSING APPROVAL If the program in nursing has a change in its State Board of Nursing approval status, the administrator of the program shall immediately submit to the NLNAC a report explaining the reasons for the decision, a copy of the letter received from the Sate Board of Nursing, and a report of program plans to correct the situation. Monitoring action will be determined following review of the materials. The accreditation status of the nursing program may be changed to accreditation with conditions or warning.

POLICY #18: ACCREDITATION STATUS OF THE GOVERNING ORGANIZATION If a governing organization which offers an NLNAC accredited program loses its accreditation by an appropriate accrediting agency, the administrator of the nursing program shall immediately submit to the NLNAC a report explaining the reasons for the decision, the effect of the decision on the program in nursing, and plans made by the governing organization to become fully reinstated. Monitoring action to be taken will be determined following review of materials submitted.

POLICY #19: FOCUSED VISIT A focused visit is made by NLNAC professional staff to review a situation that needs monitoring or a substantive change. The focused visit is usually one day in length. The nursing education unit assumes all costs of the focused visit. NLNAC may also conduct a focused visit to institutions that participate in Title IV financial aid compliance programs where NLNAC is the gatekeeper. Generally, NLNAC will evaluate faculty, resources, and facilities.

POLICY #20: COMPLAINTS AGAINST AN ACCREDITED PROGRAM NLNAC reviews any complaint it receives against an accredited program or the NLNAC itself, which is related to the standards, criteria, or procedures and resolves the complaint in a timely, fair, and equitable manner using established time lines for each step of the complaint procedure. A complaint is an expression of dissatisfaction about something or someone that is the cause or subject of protest. NLNAC will only act on complaints about program quality that may, if substantiated, indicate areas of non-compliance with accreditation standards and criteria. As a formal allegation against a party, program, nursing education unit, or governing organization, it is expressed as a written, signed statement by the complainant. It may be concerned with the rights of an individual, program, nursing education unit, and/or governing organization, the interpretation or application of rules, regulations, or policies of an accredited program. In addition, it may include concerns from recognized state or federal agencies. In addressing a complaint, NLNAC does not serve as arbitrator or mediator of internal disputes within nursing programs or between nursing programs. It will not intervene on behalf of an individual complainant regarding such matters as admission, progression, grades, appointment, promotion, or dismissal of faculty members or students. NLNAC's role is to ensure that the policies and

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procedures of an institution regarding complaints are implemented fairly and as written, or if not present, to make certain that such policies and procedures of a program, nursing education unit, or governing organization are developed and implemented. A potential complainant should use all available appeal or grievance means at the program, nursing education unit, or governing organization before filing a complaint with NLNAC. A complaint may be filed by any of the following representatives of NLNAC communities of interest including: · Student(s) currently enrolled in an accredited nursing program, nursing education unit, or governing organization; · Applicant(s) to an accredited nursing program or nursing education unit; · Other interested parties. PROCEDURE 1. The complaint is presented to NLNAC as a written, signed, and dated statement with supporting evidence. 2. NLNAC responds to the complainant in writing that a copy of the complainant is being forwarded to the nurse administrator, and if appropriate, the chief executive officer of the governing organization. 3. NLNAC sends a copy of the complaint to the nurse administrator along with a request for verification that the complainant has used all available institutional avenues to address the complaint. 4. The nurse administrator's response to the complaint is submitted to NLNAC. 5. If the analysis by NLNAC finds that the policies and procedures have been implemented fairly and as written, the Executive Director will complete the file by sharing this finding in writing with the complainant and the nurse administrator. 6. If the analysis by the NLNAC finds that (a) the policies and procedures were not in place; or (b) the policies and procedures had not been implemented fairly and/or completely, the complaint will be submitted to the Commission for corrective action. 7. The Board of Commissioners can (a) accept the recommended corrective action; (b) change the accreditation status; (c) request a focused visit; and/or (d) place the program on conditional or warning status. TIME LINE

2. Within fourteen (14) days of receipt

3.

Within fourteen (14) days of receipt

4. Within thirty (30) days 5. Within fourteen (14) days

6. Within fourteen (14) days

7.

At the next scheduled meeting, complaints are to be referred to a subsequent Commission meeting if the next scheduled meeting does not allow the fourteen (14) to thirty (30) day response time by the NLNAC Executive Director and the thirty (30) day response time by the nurse administrator.

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POLICY #21: COMPLAINTS AGAINST THE NATIONAL LEAGUE FOR NURSING ACCREDITING COMMISSION The Executive Committee of the National League for Nursing Accrediting Commission receives complaints made against NLNAC staff, Commissioners, appeal panels, or program evaluators with respect to monitoring of a program's compliance with NLNAC standards and criteria or adherence to accreditation procedures. When such a complaint is received, the Executive Committee operating under the Conflict of Interest Policy appoints a special committee to investigate the complaint in a timely, fair, and equitable manner. Commissioners shall not participate in any capacity on the special committee. PROCEDURE 1. The complaint is presented to NLNAC as a written, signed, and dated statement. 2. All written complaints received regarding monitoring of a program's compliance with NLNAC standards and criteria or adherence to accreditation procedures shall be forwarded to the Chair of the Commission. 3. The Chair will review the complaint and may request, as necessary, additional information from the complainant or the Commission staff. 4. The Chair will appoint a special committee of three persons composed of: · 1 representative from nursing education; · 1 representative from nursing service; · and 1 public member. 5. The special committee presents its findings to the Commission for action. TIMELINE

2. Within ten (10) days of receipt

3. Within ten (10) days of receipt

4. Within fourteen (14) days

5. At the next scheduled meeting The special committee presentation is to be referred to a subsequent Commission meeting if the next scheduled meeting does not allow a thirty (30) day review time by the special committee.

6. The Board of Commissioners can (a) affirm that policies and procedures have been applied appropriately; and/or (b) recommend changes be made. 7. The complainant will be notified of action taken by the Commission. 7. Within thirty (30) days of the Commission meeting

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POLICY #22: PROGRAM ACCREDITATION STATUS IN RELATION TO STATE AND OTHER ACCREDITING AGENCY ACTIONS · NLNAC accredits only those programs in institutions that are legally authorized under applicable state law to provide a program of education beyond the secondary level and have institutional accreditation. NLNAC does not grant initial accreditation status to a program when the governing organization in which the program resides has: o been denied accreditation, placed on public probationary status, or had its accreditation revoked by a recognized accrediting agency. o had its legal authority to provide postsecondary education suspended, revoked, or terminated by a state agency. NLNAC does not grant continuing accreditation status to a program when the governing organization is: o subject to an adverse action by a recognized institutional accrediting agency potentially leading to the suspension, revocation, or termination of its accreditation. o subject to an adverse action by a state agency potentially leading to the suspension, revocation, or termination of the governing organization's legal authority to provide postsecondary education. o threatened by loss of accreditation, and due process procedures required by the action have not been completed. o threatened by suspension, revocation, or termination by a state agency of the governing organization's legal authority to provide postsecondary education, and due process procedures required by the action have not been completed. NLNAC does not grant initial or continuing accreditation status to a program during a period in which the nursing education unit: o is the subject of an adverse action by a state agency potentially leading to the suspension, revocation, or termination of approval. o has been notified of a threatened loss of approval, and due process procedures required by the action have not been completed. o has been denied approval, placed on public probationary status, or had its approval revoked by a state agency. o had its legal authority to provide nursing education suspended, revoked, or terminated by a state agency. If NLNAC grants initial or continuing accreditation to a program notwithstanding the actions of a recognized institutional accrediting agency or a state agency, NLNAC will provide an explanation to the Secretary, U.S. Department of Education, consistent with NLNAC accrediting standards, as to why it granted accreditation. If NLNAC is notified that the governing organization of an accredited program has received an adverse action or been placed on probationary status by a recognized institutional accrediting agency or a state agency, NLNAC will promptly review the program to determine what action should be taken. If NLNAC is notified that an accredited nursing program has received an adverse action or been placed on probationary status by a state agency, NLNAC will promptly review the program to determine what action should be taken.

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POLICY #23: PUBLIC NOTICE OF PROPOSED NEW OR REVISED STANDARDS AND CRITERIA Standards and criteria and interpretive guidelines are developed, reviewed, and revised periodically by means of procedures that involve continuous input from accredited schools (by program type) and identified communities of interest. NLNAC ensures the circulation of proposed revisions to the standards and criteria and the opportunity for comment from interested parties. POLICY #24: ASSESSMENT OF THE ADEQUACY OF STANDARDS AND CRITERIA, NLNAC PROCESS, AND PRACTICES NLNAC maintains an ongoing systematic program of review designed to ensure that: (1) the Standards and Criteria are valid and reliable indicators of the education provided by a program it accredits and are relevant to the educational needs of affected students1; (2) NLNAC processes are reliable and assess knowledge and consistency of observations, applications, decisions, and perceptions2; and (3) there are broad communications and consultations across constituencies3. The findings from the ongoing review are used for development, maintenance, and revision of the NLNAC standards and criteria, processes, and practices. Evidence to support ongoing systematic review appears in Commission minutes, annual reports, the NLNAC Newsletter, NLNAC website, and at NLNAC forums.

1. Table p.72 2. Table p.73 3. Table p.74

The Process of Review · · · · · · Is comprehensive; Occurs at regular intervals; Examines each standard and its accompanying criteria as a whole; Involves all relevant constituencies in the review; Affords relevant constituencies meaningful opportunity to provide input into the review; and Requires that needed changes be made promptly in order to improve NLNAC's effectiveness, efficiency, and consumer friendliness of NLNAC products and services.

Aspects of the Review A full review of the NLNAC standards and criteria occurs every three years with: · Review of ongoing data analysis; · Review of literature for trends in evaluation, nursing practice, and nursing education; · Review of USDOE regulations; · Distribution of draft versions to constituencies for comment; · Review of comments and revision of drafts; · Distribution of the revised drafts for comments; · Review of comments and revision of drafts as needed; and · Commission adoption of revised standards and criteria.

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Reliability of NLNAC Processes Reliability is assured by: · Analysis of internal consistency and reliability of the accreditation status recommendations/decisions across the three levels of review per program type and among all five program types per accreditation review cycle and trended over time; · Identification of strengths and areas needing development by criterion per program type across the three levels of review and among the five program types per accreditation review cycle and trended over time; and · Analysis of the perceived effectiveness of the planning and conduct of the accreditation site visit by the nursing program and the site visit teams for per program type, each accreditation review cycle, and trended over time. Communication and Broad Consultation Practices Communication is assured by: · Solicitation of comments on proposed new or revised policies from all interested parties; · Report to constituents of the Annual Report findings (Report to Constituents and website) as aggregate data trended over time; and · Broad consultation across constituencies. Planned use of Data Analysis Data analysis is used to: · Maintain validity and relevance of the NLNAC standards and criteria; · Maintain reliability of the NLNAC accreditation processes and practices; · Continue to identify and disseminate information in appropriate arenas regarding specific education needs of programs and program evaluators as groups; · Continue to identify and disseminate information in appropriate arenas regarding specific developmental needs for individual programs and program evaluators; and · Continue to identify and disseminate information in appropriate arenas regarding areas in which change needs to be facilitated. Evaluation of the Site Visit For each site visit, the nursing program, team chair, and team members are given an evaluation form to complete. The information is used to: · Improve the quality of accreditation process; · Identify potential team chairs; and · Identify site visitors that may require special consideration. The NLNAC staff analyzes the data each cycle using the information to improve the process. The data are reported in aggregate form and trended over time.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-VI: Monitoring Policies

Annual Report All accredited programs are required to submit an Annual Report. The Annual Report will request the following information (at a minimum): · Enrollment figures; · Graduation figures; · Faculty numbers and credentials; · Substantive change information; · Complaints against the program; · Job placement rates; and · NCLEX and certification examination pass rates. The NLNAC Staff will review the information to assure that programs continue to comply with policies and reporting requirements. Significant changes will be referred to the NLNAC Commissioners who may consider rescheduling or reaffirming the date for the accreditation visit or requesting a report. Data will be compiled by the individual program for monitoring purposes and reported in aggregate form, trended over time. Programs with Title IV-HEA responsibilities must also submit information regarding compliance with its Title IV responsibilities and the result of financial or compliance audits. The annual report form is distributed electronically. Programs may respond on-line or by downloading the form and submitting it by fax to NLNAC.

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NLNAC ONGOING SYSTEMATIC PROGRAM OF REVIEW

What will be evaluated: Standards and Criteria

p.72

Time/Frequency Cycle: Every three years Commission Decision Report of Findings Development Maintenance

Statement: NLNAC will in an ongoing manner assess and revise as needed the NLNAC Standards and Criteria for Accreditation of Nursing Programs to insure their adequacy to evaluate the quality of the nursing program and its relevance for student educational needs. Equal or greater than 80% of the identified constituent groups of interest rate the NLNAC Standards and Criteria for the Accreditation of Nursing Programs appropriate to evaluate quality and relevance of nursing education programs.

Expected Level of Achievement:

Evidence: Accreditation Manual with Interpretive Guidelines

Responsibility: Professional Staff Accredited Programs Evaluation Review Panel Members Commissioners

Components

Assessment Method

Revision/ Clarification

Each standard and each criterion under the standard.

Phase I Formation of a Task Force representing all program types Review of data analysis regarding reliability and validity of current Standards and Criteria Review literature for trends in evaluation, nursing practice, nursing education, and healthcare Develop Draft I ­ Standards and Criteria Distribute Draft I ­ Standards and Criteria for comment to: all NLNAC accredited nursing programs, site visitors, nurse administrators and faculty, evaluation review panel members, Commissioners, NLN Board of Governors and CEO, and other selected individuals and/or groups having an interest in nursing education and practice

Phase II Review comments from communities of interest Develop Draft II ­ Standards and Criteria Approval by Board of Commissioners

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section I-VI: Monitoring Policies

Phase III Distribute Draft II ­ Standards and Criteria to communities of interest Review of comments from communities of interest Final Draft of Standards and Criteria prepared by Task Force Adoption of Standards and Criteria by Board of Commissioners Distribution of Standards and Criteria to all accredited nursing programs and communities of interest Implementation of Standards and Criteria

NLNAC ONGOING SYSTEMATIC PROGRAM OF REVIEW

What will be Evaluated: NLNAC Processes

Statement: NLNAC will in an ongoing manner assess and revise (as needed) the processes of accreditation to insure their adequacy to consistently apply the NLNAC Standards and Criteria for Accreditation of Nursing Programs.*

Expected Level of Achievement: There will be at least 90% consistency in accreditation status recommendations/decisions across the three levels of review. Responsibility: Professional Staff Site Visitors Evaluation Review Panel Members Commissioners Time/Frequency Cycle: Every two years

Evidence: NLNAC Mission Statement Philosophy of Accreditation Annual Budget Monthly Budget Report Curriculum Vitae Policies Focused Reviews Program Evaluator Reports Assessment Method · Critique Knowledge of Accreditation · Report of Findings Development

Commission Decision Maintenance Revision/ Clarification

Components

·

Staff consultation

·

Training Principles of peer review Selection Common Practices · · · · Consistency of observations Content of Self-Studies Evaluation Consultation Consistency of decisions Consistency of decisions Records maintenance Audit Staff Review and report of relevance and applicability Commission action · · · · · ·

·

Site Visit

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Evaluation Panel Proceedings

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Commission Proceedings

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Data Bases

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Budget o Annual o Monthly

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Policies

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* This means the extent to which inferences made using data from NLNAC evaluation processes are appropriate and justified by the evidence and are indications

that the processes are measuring what they purport to measure.

NLNAC ONGOING SYSTEMATIC PROGRAM OF REVIEW

What will be Evaluated: NLNAC Communications and Broad Consultation

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Responsibility: Professional Staff Accredited Programs Site Visitors Evaluation Review Panel Members Commissioners NLN Education Advisory Council Time/Frequency Cycle: Every two years Commission Decision Development Maintenance Assessment Method · · · Number of hits Number of site visits Frequency of responses to requests for comment Analysis of question(s) Frequency Frequency and content of communications Annual Report · · · · Report of Findings · Responses NLN Nursing Education Advisory Council Reponses Annual Report Evaluation of complaints Appeal process Reversal of decisions · · · · · ·

Statement: The Commission will regularly seek data on NLNAC effectiveness from consultants, educational programs, Commissioners, evaluators, and the public.

Expected Level of Achievement: Any pattern of comments identifying lack of effectiveness of NLNAC will result in staff review of the concern.

Evidence: Accreditation Manual with Interpretive Guidelines Directory of Accredited Programs Forums Newsletters NLNAC Annual Report Program Evaluator Forum Book Report to Constituents Self-Study Forum Book Website

Components

Revision/ Clarification

·

Website

·

Questions posed regarding Standards and Criteria

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Communications with Nursing Education Units, Nurse Administrators, Major Organizations, NLN Nursing Education Advisory Councils

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Call for consultants

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Satisfaction with Standards and Criteria

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Complaints

SECTION II: INTERPRETIVE GUIDELINES BY PROGRAM TYPE GENERAL INFORMATION Introduction The purpose of the Interpretive Guidelines is to provide nursing education units with specific information to facilitate their development of a Self-Study Report that presents their uniqueness and excellence while effectively demonstrating their compliance with nationally established standards and criteria for nursing education. This guide is presented in six chapters: General Information, Master's Degree Nursing Programs, Baccalaureate Degree Nursing Programs, Associate Degree Nursing Programs, Diploma Nursing Programs, and Practical Nursing Programs. The `General Information' chapter provides information applicable to all program types while the subsequent chapters are program specific. Substantive Changes to this Edition The Commission approved changes in the faculty education requirements for Practical Nursing Programs (see Criterion 5, p.149). Directions for Use The program specific chapters in this section are to be used in the preparation of Sections Two and Three of the Self-Study Report as discussed in the `Guidelines for Writing the Self-Study' (p.22). Each program specific chapter contains the seven standards with their accompanying criteria. Each criterion is followed by a sub-section identified as `Documentation confirms'. The statements listed in this sub-section establish the level of expectation required for each criterion to be met and are program specific. When presenting each standard in the report, all the criteria within that standard must be addressed. Furthermore, to assure completeness of the presentation, all of the `Documentation confirms' subsection statements per criterion must also be addressed. The presentation should include specific examples of how each criterion has been met. The evidence may be included within the body of the report or in the appendix. Supplemental material not discussed in the report may be placed in the "display room" for review by the site visit team. This is an example of how a nursing education unit can balance the need to offer a complete presentation of the program with the page limitation requirement of the Self-Study Report. The use of tables and charts may be a very effective tool in the Self-Study Report. Each standard includes a list of suggested tables; these lists are offered strictly as suggestions. The only table required is the Faculty Profile Form (see Standard II, Faculty). A listing entitled `Suggested Indicators' is also provided for each standard. Again, these listings are offered strictly as suggestions. They are provided to stimulate thinking regarding how to effectively demonstrate that the criteria are met.

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GLOSSARY FOR INTERPRETIVE GUIDELINES Administrative Services ­ Management services that directly support the function of the nursing education unit (i.e., information technology, institutional research, finance). Advanced Practice Nurse (APN) ­ A clinical nurse specialist, nurse practitioner, certified registered nurse anesthetist, and certified nurse midwife. Benchmark ­ A statement of expected achievement, frequently aspirational in nature, posed generally by a group or organization. A means by which programs can compare themselves with a larger group. Branch Campus ­ Branch campus as defined by the U.S. Department of Education means any location of an institution of higher education other than the main campus, at which the institution offers at least 50% of an educational program. Candidate ­ A status that is granted after an NLNAC professional staff review of a nursing program's potential to achieve NLNAC accreditation. Chief Executive Officer ­ The official who has the primary responsibility of carrying out the administrative policies of the governing organization. Clerical Services ­ Office services that support the functioning of the nursing education unit (i.e., secretarial). Cognates ­ Non-nursing courses that are foundational to the nursing courses in the program(s) under review. Competencies ­ See Educational Objectives Complaint ­ An expression of dissatisfaction about something or someone that is the cause or subject of protest. A formal allegation against a party or institution usually expressed in a written, signed statement. Comprehensive Library ­ Demonstrates depth and scope of its parts as well as specialized sources of information; interlibrary, telefacsimile, and other technology for locating and storing documents; documentation of resources for access to holdings as well as ownership of holdings; analysis of aggregate print and electronically published resources; collections of reinforcing materials that are current and comprehensive enough to meet the nursing unit purposes; electronic representation of documents and online catalogs; and assistance for the use of library services, for accessing and manipulating information and electronic reference sources, and for facilitating skill development. Credentialing: Accreditation ­ A voluntary, non-governmental process that uses peer review to determine if academic programs meet public confidence. Institutional accreditation evaluates an entire institution as a whole. Specialized accreditation evaluates particular unit or schools within the institution. Approval ­ The term generally referred to by most state boards of nursing to describe authorization of nursing education programs meeting minimal standards as defined in the Nurse Practice Act or State Rules and Regulations.

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Certification ­ The process by which an organization, association, voluntary agency, or state licensing board grants recognition that an individual possesses predetermined knowledge and/or skills specified for practice in an area of specialization. Licensure ­ The process by which a governmental agency gives affirmation to the public that the individuals engaged in an occupation or profession have minimal education, qualifications, and competencies necessary to practice in a safe manner. Criteria ­ Statements which identify the variables that need to be examined in evaluation of a standard. Curriculum Integrity ­ The presentation of a program of study that flows from the governing organization's mission through the program philosophy to the student outcomes. It is demonstrated by: · A statement of philosophy that reflects the mission of the governing organization and the program, the contemporary reality of clinical practice in health care, and the program's fundamental beliefs about human beings and how they learn. · A curriculum design that reflects an organizing framework which provides the basis for the program planning, implementation, and evaluation; identifies educational objectives; and drives selection of the content, scope, and sequencing of course work. · Didactic instruction and supervised practice that follow a plan documenting the learning experiences appropriate for the development of the competencies required for graduation and that delineates the instructional content and methods used to develop and evaluate competencies. · Evaluation tools and methods consistent with the objectives and competencies of the didactic and clinical components of the program, and that provide regular feedback to students and faculty with timely indicators of student progress and academic standing. · Student access to current, up-to-date learning resources, including but not limited to: instructional aids, classrooms and laboratories; a supply of current books, journals, periodicals, computers, software, and other materials needed to meet the requirements of the curriculum (i.e., libraries, on-line services, interlibrary loan centers) in sufficient quantity to facilitate the program's educational objectives; teaching methods; number of students; safety/health standards of the institution; efficient operation of the program; and achievement of program goals. Differentiated Education ­ The articulation, by each program type, as to how graduates of the program have been educated to acquire knowledge, skill, and ethical qualities. It is the identification of skills and core competencies needed and the educational experiences that reflect those skills and core competencies. Distance Education ­ An educational process in which the majority of the instruction occurs when a student and instructor are not in the same place. Instruction may be synchronous or asynchronous. Distance education may employ correspondence study, audio, video, and/or computer technologies. Diversity ­ Variety within any specified category (e.g., cultural, racial, ethnic, gender, educational and experiential background). Document ­ see Published Document(s).

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"Documentation Confirms" ­ Statements that focus on a stated accreditation criterion in order to clarify what is required to meet the criterion. All areas under `Documentation confirms' are to be addressed in the Self-Study Report. Educational Objectives ­ Terminal objectives; competencies, behaviors, characteristics of the graduate at the completion of the program of study. Expected Level of Achievement ­ An acceptable index that reflects desired program outcome. Faculty: Adjunct ­ Person who has been contracted to teach a specific course (theory/clinical) or component of a course. Credentials ­ Nursing faculty have a minimum of a master's degree with a major in nursing from a regionally accredited institution or national accrediting body approved by the Commission. Nursing faculty that do not hold the graduate degree in nursing are expected to have a baccalaureate degree in nursing and an educational plan to obtain a master's degree within a reasonable timeframe (five years or less). Expertise ­ How a faculty member maintains currency in both educational and clinical practices (e.g., certification, continuing education, formal advanced education, clinical practice, research, and publications). Full-time ­ Person who teaches nursing and has full-time faculty employment status as defined by the governing organization and the nursing education unit. Ideally, full-time faculty have a major commitment to the governing organization and to the nursing education unit, and handle the governance activities and committee work (i.e., advisement and counseling; curriculum planning, maintenance, and revision; and program evaluation). Non-Nurse Professional ­ A person who is not a nurse and is teaching a nursing course, such as dietician, pharmacologist, or physiologist. Part-time ­ Person who teaches nursing and who has part-time faculty employment status as defined by the governing organization and the nursing education unit. Usually the individual has a narrower set of responsibilities than full-time faculty. Time Utilization ­ Percentages of time that reflect the manner in which the governing organization or nursing education unit characterizes, structures, and documents the nature of faculty workload. Categories frequently used are teaching, advisement, administration, committee activity, research and other scholarship activity, and service/practice. Focused Visit ­ A visit to a nursing education unit, typically by a member of the NLNAC professional staff to assess area(s) of identified concern. Gatekeeper ­ A person or an agency that is responsible to monitor compliance with the Higher Education Reauthorization Act Title IV.

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: General Information

Guidelines for Nursing Practice ­ A set of guidelines approved by a nationally recognized nursing organization for use in the development and evaluation of nursing curriculum, including but not limited to: American Nurses Association Practice Standards Associate Degree Competencies (NLN) Criteria for Evaluation of Nurse Practitioner Programs (National Task Force on Quality Nurse Practitioner Education) Essentials of Baccalaureate Education for Professional Nursing Practice (AACN) Essentials of Master's Education for Advanced Practice Nursing (AACN) Institute of Medicine, Health Professions Education: A Bridge to Quality PEW Health Commission Competencies Statement on Clinical Nurse Specialist Practice and Education (National Association of Clinical Nurse Specialist) Governing Organization ­ The institution with overall responsibility and authority for the nursing education unit (e.g., college, university, hospital, career center). Graduate Degree ­ An academic degree that is higher than a baccalaureate degree, either a master's degree and/or earned doctoral degree considered to be terminal in nature, one of which must be in nursing. The doctoral degree is considered to be a terminal degree. Interdisciplinary Collaboration ­ The interaction of nursing students with healthcare professionals from other allied health and health care disciplines; the interaction of nursing faculty with other disciplines in the mutual creation and delivery of a course(s); the delivery of courses open to both nursing and non-nursing majors with the specific intent to provide an understanding of the respective disciplines. Learning Activities/Experience ­ Opportunities provided that facilitate student achievement of the course/program objective. Mission/Philosophy ­ The governing organization and/or nursing education unit statement that designates fundamental beliefs and characteristics and provides guidance and direction for the program(s) and services offered. Nurse Administrator ­ The individual with responsibility and authority for the administrative and instructional activities of the nursing education unit within the governing organization (e.g., Dean, Chairperson, Director). Nursing Doctorate ­ A post baccalaureate degree that provides for entry into professional nursing practice and preparation for initial licensure and may include advanced nursing knowledge. The nursing doctorate is not considered a terminal degree. Nursing Education Unit ­ A school, division, department, or other specific unit offering a nursing program(s) within the structure of the governing organization. Organizing Framework ­ A set of concepts, derived from the program philosophy that are ordered in a logical and meaningful manner so as to direct the delivery of the curriculum. Parent Institution ­ See Governing organization.

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Post-Master's Certificate ­ A post-master's certificate program/option is eligible for NLNAC accreditation if that program/option is part of a master's degree nursing program that is currently accredited by NLNAC. Prerequisite Course ­ A course that is required prior to the taking of another course. The first course provides a foundation for the following course(s). A prerequisite course is included in the total credit count if all students take the course, and there are no alternative ways to meet the requirement. Program Outcomes ­ Performance indicators that reflect the extent to which the purposes of the nursing education unit are met and by which program effectiveness is documented. Program Type ­ A nursing education program that offers either a certificate, diploma, or recognized degree. NLNAC accredits five types of nursing education programs; master's, baccalaureate, associate degree, diploma, and practical nursing. Public--Any individual not included in a specifically defined group included on the site visit agenda who might wish to share comments regarding the nursing program, e.g., patients (individual or families), area residents, area politicians, faculty at large (non-nursing), students at large (nonnursing), and clinical agency personnel. Published Document(s) -- Refers to all forms of communication including paper and electronic sources. Scholarship ­ NLNAC endorses the Boyer's definition of scholarship. Boyer (1990) challenged all disciplines to embrace the full scope of academic work, moving beyond an exclusive focus on traditional and narrowly defined research as the only legitimate avenue to further the knowledge of the discipline and to obtain rewards for professional performance. He proposed that scholarship involves the following four areas, each which is critical to academic work: · · · · discovery, where new and unique knowledge is generated; teaching, where the teacher creatively builds bridges between his or her own understanding and the student's learning; application, where the emphasis is on use of new knowledge in solving society's problems; and integration, where new relationships among disciplines are discovered.

These four aspects of scholarship are salient to academic nursing, where each specific area supports the values of a profession committed to both social relevance and scientific advancement. Standard ­ Agreed upon rules to measure quantity, extent, value, and quality. Student Academic Achievement Graduation Rates ­ Number of students who graduate within a defined period of time. Definition used by NLNAC for the Annual Report: Graduation Rate = the number of students (individuals matriculated and on the formal class roster) who complete the program within 150% of the time of the stated program length (the length of the program adjusted to begin with the first required nursing course).

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Job Placement Rates ­ Number of graduates employed in a position for which the program prepared them six to nine months after graduation. Licensure/Certification Pass Rates ­ Performance on National Council Licensure Examination (NCLEX) or Certification Examination for first-time writers. Program Satisfaction ­ Adequacy of the program(s) as perceived by graduates and or employers. Total Credits ­ Number of credits required for graduation (includes pre and co-requisites). Systematic Program Evaluation ­ A written document that reflects the process of comprehensive, ongoing systematic evaluation of all program components based on NLNAC standards and criteria. Systematic evaluation includes two parts: the plan and its implementation. The plan contains at a minimum, components, levels of achievement, timeframes, and methods for assessment. Implementation of the plan reflects the collection, analysis, aggregation, and trending of data and the utilization of the findings in decision making for program improvement.

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DIFFERENTIATED EDUCATION: CREATING WHAT MUST BE The NLNAC accredits all types of nursing education programs ­ master's and baccalaureate degree programs, associate degree programs, diploma programs, and practical nursing programs. The purpose of the degree, certificate, or diploma is to organize educational experiences and establish academic expectations. Thus program types are vastly different. To ignore, or diminish the differences would mean that nursing education, as we know it is misleading the public, and in so doing puts the entire health care system in jeopardy. The added value of the degree, compared to other credentials, is its provision for an experience that includes general education, a major, and education for a profession. The qualities and conditions that distinguish the nursing education program types are: · · · · · · the amount and extent of general education; the scientific knowledge, characteristics of reasoning, ethical and clinical judgment and decision-making, and interpersonal and technological skills integral to nurses' clinical expertise, roles, and scopes of nursing; the complexity, intensity, and length of the program of study; the concentration on research on the practice of nursing, and the spirit of inquiry; the identification, formulation, and evaluation of possible solutions to a broad range of society's needs that are problematic, uncommon, or complex; the opportunity to practice nursing in a variety of health care structures offering a broad spectrum of help including preventive and rehabilitation services, health counseling and education, direct care and comfort, coordination of care and case management, planning and focus on integrating care across multiple settings, and implementing new models of care delivery; the legally defined scope of practice for which the program's graduates are prepared; the range of identified essential services the graduate is expected to safely provide; the organizations and regulations by societies that maintain standards of the practice of nursing by different types of clinician; community sanctions in the form of a license or permit which serves as a social contract with society (LPN, RN, Advanced Practitioner); the particular culture (commitment and investment of time; formal and informal networks; relationships, experiences, and linkages); the complexity, comprehensiveness, structure, and process of parent institution in which different program types are based, and the range of expectation and conflicting demands on dimensions of the faculty role in teaching and learning, research and scholarship, the practice of nursing care, and public and community service.

· · · · · ·

Acceptance of these different qualities and conditions is enabling. Such acceptance demands acknowledgement of the concept of differentiated nursing practice. Differentiated practice describes the system of sorting roles, functions, and work of nurses according to education, clinical experience, and defined competence and decision-making skills required by different client needs and settings in which nursing is practiced. What this means is identifying the skills and core competencies needed, the best educational experiences and care that reflect those skills and core competencies, and accreditation policies that demand active participation in developing, measuring, and promoting educational outcomes for different practice domains and core competencies for nursing practice.

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In defining the nursing identity each program type is expected to articulate how graduates have been educated to acquire wisdom, skill, and ethical qualities including: · · · · · · technical and interpersonal competencies that are important to performance after graduation and that are likely to endure; communications, computation, and technological literacy that enable the gaining and applying of new knowledge and skills as needed; ability to arrive at informed clinical judgments ­ meaning to effectively define problems, gather and evaluate information related to those problems, and develop solutions to manage multiple problems; ability to function in a diverse community, including knowledge of different cultural and economic contexts; a range of attitudes and dispositions including self awareness, empathy, flexibility, and adaptability; ability to deploy all of the above to address specific problems in complex, real-world settings and conditions in which the development of workable solutions are required.

Problems that persist in health care demand solutions. Nursing can offer coherence amid the commotion by competing interests, and expertise in managing and solving complex care problems. Nursing can provide such solutions when nursing identity is formed by a combination of knowledge, attitudes, competencies, activities, and clinical decision-making abilities. Graduates of different types of programs must know what they know; their attitudes, competencies, activities, and decision-making abilities; and the meaning of integrity and morality. The emerging health care market will value services furnished by nurses to the extent that nursing services are needed, and as nurses make a contribution to outcomes; controlling or lowering costs, enhancing consumer satisfaction, and improving the quality of life in promotion of health for all age groups as well as competency for personal care; prevention of health problems that endanger productivity, ability to cope, and life satisfaction; reduction of the impact of health problems that endanger individuals, families, groups, and communities; and assistance in the diagnosis and treatment of illness. Further, becoming and remaining marketable means that one must be constantly learning since the need to broaden knowledge and skills is never-ending. This means more than continuing education. It means perpetual education ­ an unending quest for more and better information, whether for career development, lifestyle enhancement, or simply for the sheer pleasure of expanding one's horizons. This way of thinking has a number of implications, including gaining an education and a moral skill set, and attitude toward life-long learning and collaboration, and positioning to provide a range of health related services. Nurses who do not keep upgrading their skills will be left behind by workplace changes ­ either in low-wage, dead-end positions, or underemployed or unemployed. Agencies that fail to support nurses in their quest for new skills will be outclassed by their more enlightened competitors. Lifelong learning is the only answer for a competitive future.

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CORE COMPETENCIES NLNAC supports the Pew Health Commission Competencies for 2005, the 21 Competencies for The Twenty-First Century, an adaptation of which is referred to below, as the bases for preparing the practitioner of the future to meet society's evolving health care needs. NLNAC also recognizes the Institute of Medicine's competencies for the health professions published in Health Professions Education: a Bridge to Quality (2003.) It is essential that each nursing program interpret these skills and competencies in the content, context, function, and structure of their own program. In this way an outcome based approach to nursing education can be assured while integrating patientcentered care, interdisciplinary teams, evidence-based practice and quality improvement and information technology into every nursing program. Nurses should: · Care for community's health (population-based health and the skills associated with it) o have broad understanding of determinants of health (i.e., environment, socioeconomic conditions, behavior, genetics) o be able to work with others in the community to integrate a range of services and activities that promote, protect, and improve health o take as the unit of analysis the whole population (apply the concepts and tools of epidemiology to a variety to contexts ranging from individual patient encounters to the management of complex systems) o apply knowledge of the new sciences o advocate for public policy that promotes and protects the health of the public Expand access of effective care o participate in efforts to insure access to healthcare of individuals, families, and communities, and to improve the public's health Provide evidence-based, clinically competent, contemporary care o possess up-to-date clinical skills to control costs and improve quality; and incorporate the psychosocial-behavioral perspective into a full range of clinical practice competencies. This orientation shapes how institutions think about population values within entire systems of care. o demonstrate critical thinking, reflection, and problem-solving skills Understand the role and emphasize primary care o be willing and able to function in new healthcare settings and interdisciplinary team arrangements designed to meet the health needs of the public o participate in coordinated care o work effectively as interdisciplinary team members in organized settings that emphasize high quality cost-effective, integrated services (i.e., primary care, acute care, chronic, long-term degenerative, debilitating disease management, rehabilitative care, assistive living support), and nursing case management o insure cost-effective, appropriate care and quality of care and health outcomes o incorporate and balance cost and quality in making decisions o understand the development and use of managed systems of care as the principal mechanism for making healthcare more responsive to cost, consumer satisfaction, and health outcomes

·

·

·

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Develop outcomes measurement to assure o continuity of continuum of care (across sites, levels, and episodes of care) o comprehensiveness of care o active management of clinical quality o accountability o satisfaction (patient or family wants, demands, willingness to pay) o health status (covered lives and defined populations) o costs (predictability and savings in unit costs and resources consumption) o management of interactions between and among components of the integrated network of services o efficiency (i.e., wait for service) Insure care that balances individual, professional, system, and societal needs Practice prevention and wellness care o emphasize primary and secondary preventive strategies (i.e., occupational health, wellness centers, self-care programs, and health education and health promotion programs Involve patients and families in the decision-making processes o expect patients, families, and communities to participate in decisions regarding their personal health, and in evaluating its quality and accessibility o practice relationship-centered care with individuals and families Promote healthy life-styles o help individuals, families, and communities maintain and promote healthy behavior Assess and use communications and technology effectively and appropriately o understand and apply increasingly complex, costly technology appropriately Improve the healthcare system operations and accountability o understand that determinants and operating of the health care system from a broad, political, economic, social, and legal perspective o create strategic partnerships o partner with communities in health care decisions Understand the role of the physical environment o be prepared to assess, prevent, and negate the impact of environment hazards on the health of the population Exhibit ethical behaviors in all professional activities o embrace a personal ethic of social responsibility and service o provide counseling for patients in situations where ethical issues arise o participate in discussions of ethical issues in health care as they affect communities, society, and health professions

· ·

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·

Manage information o understand that the changes that are coming about are made possible in large measure by the explosion of the information and communication technologies o advances in data collection, storage, analysis, and distribution capacities will permit population management of health care in "real" time o powerful tools for linking and quickly analyzing large data sets will facilitate more systematic and intensive management o technology will lead to better access to information by consumers, enabling them to assume increasing levels of responsibility for their own health care o enhance the leadership to make transformation successful o develop informed leadership integrated across the various functions within nursing Accommodate expanded accountability o be responsive to increasing levels of public, governmental, and third party participation in, and scrutiny of the shape and direction of the health care o refrain from resisting inevitable changes in health care o practice leadership in the transformation to provide continuous improvement of the health care system Participate in a racially and culturally diverse society o appreciate the growing diversity of population, and the need to understand health status and health care through differing cultural values o provide culturally sensitive care to a diverse society Continue to learn and to help others to learn o anticipate changes in health care, and respond by redefining, changing, and maintaining competencies throughout one's practice life

·

·

·

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: General Information

References for Core Competencies Board on Health Care Services (HCS), Division of Health Care Services (HCS), Institute of Medicine (2003), Health Professions Education: A Bridge to Quality. Washington, DC, Chapter 3, 45­73. Available: http://www.iom.edu/reports.asp Boyer, E. L. (1990). Scholarship reconsidered: Priorities for the Professoriate (Carnegie Foundation for the Advancement of Teaching). Princeton, NJ: Princeton University Press. Regional Accrediting Commissions, Best Practices for Electronically Offered Degree and Certificate Programs and Joint Statement of Commitment by the Regional Accrediting Commissions for the Evaluation of Electronically Offered Degree and Certificate Programs. Chicago: Author. Available: http://www.ncahlc.org/index.php?option=com_content&task=view&id=32&Itemid=85 O'Neil, E. H., & the Pew Health Professions Commission (1998). Recreating health professional practice for a new century. San Francisco: Pew Health Professions Commission. Pew Health Professions Commission (1995). Critical challenges: Revitalizing the health professions for the 21st century. San Francisco: UCSF Center for the Health Professions. Available: http://www.futurehealth.ucsf.edu/summaries/challenges.html References for Standards American Association of Colleges of Nursing (1998). The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, DC: Author American Association of Colleges of Nursing (1996). The Essentials of Master's Education for Advanced Practice Nursing. Washington, DC: Author. Coxwell, G. & Gillerman, H. (Eds.). (2000). Educational Competencies for Graduates of Associate Degree Nursing Programs. New York and Sudbury, MA: NLN Press and Jones and Bartlett Publishers. National Association of Clinical Nurse Specialists (2004). Statement on Clinical Nurse Specialist Practice and Education (2nd Edition). Harrisburg, PA: Author National Association for Practical Nurse Education and Service, Inc. (2003). NAPNES Standards of Practice for Licensed Practical/Vocational Nurses. Silver Spring, MD: Author. National Task Force On Quality Nurse Practitioner Education (2002). Criteria for Evaluation of Nurse Practitioner Programs. Washington, DC: Author.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II-General Information

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Guidelines For Preparing The List Of Individuals And Groups Interviewed Classes Attended Clinical Agencies And Facilities Visited Introduction · To insure the accuracy of this information, the nursing program is asked to prepare a listing of all individuals and groups interviewed, and course numbers and names of classes to be attended, and names of clinical agencies to be visited. The list should be generated on a computer system so that it can be downloaded onto a CD/diskette for the site visitors when they arrive on-site.

·

Directions

Using the following category listings, prepare a file that lists: · The name, credentials, and title for all individuals and groups of individuals interviewed. · The course name and number for classes attended. · The full name of the facilities visited for clinical agencies. Name of Individual, Credentials, Title, and Position or Area of Responsibility EXAMPLE: PERSONS INTERVIEWED John Jones, PhD, President Robert White, MS, Vice President of Finance and Administration Name of the Group, Number in Attendance, and Short Description (Do not list names of individuals representing the various groups) EXAMPLE: GROUP MEETING Nursing Faculty, n=20, Members representing all program courses Alumnae, n=10, All graduated within the last three years Nursing Students, n=6, First level students Course Number and Title EXAMPLE: CLASSES ATTENDED N250: Health Assessment Throughout the Life Span N350: Adult Health Nursing III Full Name of the Institution EXAMPLE: AGENCIES AND FACILITIES VISITED Blue Moon Hospital and Medical Center Tri-City Health Department Norwich State Psychiatric Hospital

Individual Conference:

Group Conference:

Class(es) Attended:

Clinical Agencies and Facilities:

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: General Information

Guidelines For Preparing The Categories Of Documents Reviewed Introduction · To insure the accuracy of this information, the nursing program is asked to prepare a listing of all documents available in the "document display room" · The list should be generated on a computer system so that it can be down loaded onto a CD/diskette for the site visitors when they arrive on-site. Using the following category listings, prepare a file that lists all documents available in the "document display room" for the site visit team

Directions:

Catalog/Handbook/Manuals College Catalog (most recent) Faculty Handbook Student Manual Department of Nursing Minutes Curriculum Committee Minutes (past three years) Faculty Development Committee Minutes (past three years) External Constituencies State Board of Nurse Examiners Report (most recent) Regional Accrediting Agency Report (most recent) Nursing/Institution Documents Budget Report (past three years) Agency Contracts Student Records Faculty Curriculum Vitae Course Materials Course Syllabi Clinical Evaluation Tools

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II-General Information

p.89

NLNAC STANDARDS AND CRITERIA MASTER'S DEGREE PROGRAMS (Including Post-Master's Certificate) I. Mission and Governance There are clear and publicly stated mission and/or philosophy and purposes appropriate to postsecondary or higher education in nursing. 1. Mission and/or philosophy of the nursing education unit is congruent with that of the governing organization, or differences are justified by the nursing education unit purposes. Documentation confirms: a. philosophy/mission of the program in nursing is congruent with the mission and purposes of the governing organization. b. program purposes and objectives/competencies are: · congruent with the program philosophy/mission; · clearly stated; · publicly accessible; · appropriate to legal requirements and scope of practice; and · consistent with contemporary beliefs of the profession, including graduate/advanced practice nursing. c. commitment to cultural, racial, and ethnic diversity of the community in which the institution and the nursing education unit exist. d. programming for distance education is congruent with the philosophy and purposes of the governing organization and nursing education unit. 2. Faculty, administrators, and students participate in governance as defined by the governing organization and nursing education unit. Documentation confirms: a. participation in governance of the governing organization. b. participation in governance of the nursing education unit. 3. Nursing education unit is administered by a nurse who is academically and experientially qualified, and who has authority and responsibility for development and administration of the program. Documentation confirms: a. academic credentials of the nurse administrator are a graduate degree with a major in nursing and an earned doctorate from a regionally accredited institution; explain acceptance of other graduate credentials for the nurse administrator. b. knowledge of the program type is reflected in the experience of the nurse administrator. c. authority and administrative responsibilities are documented within the position of the nurse administrator. d. nurse administrator has adequate time to fulfill the role responsibilities.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

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4.

Policies of the nursing education unit are consistent with those of the governing organization, or differences are justified by the nursing education unit purposes. Documentation confirms: a. congruency between policies affecting nursing faculty and staff and governing organization: · non-discrimination; · faculty appointment/hiring; · academic rank; · grievance procedures; · promotion; · salary and benefits; · tenure; · rights and responsibilities; · termination; and · workload. b. accessibility of faculty policies. c. rationale for policies that differ from governing organization.

Suggested Indicators: · Nursing unit and governing organization mission and/or philosophy statement · Institutional policies · Catalog · Organizational chart · Bylaws · State Board of Nursing Regulations · Curriculum vitae, transcripts, license of nurse administrator · Position description of nurse administrator · Institutional/faculty handbook/manual · Regional accrediting body approval letter and report · State Board of Nursing approval letter and report; other regulatory agency approval letter · Professional Nursing Standards

Suggested Tables: · Comparison of governing organization and nursing education unit's mission and/or philosophy and purposes · Participation on committees of the governing organization · Participation on committees of the nursing education unit · Policies which differ from the governing organization

p.92

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

II.

Faculty There are qualified and credentialed faculty, appropriate to accomplish the nursing education unit purposes and strengthen its educational effectiveness. 5. Faculty members (full-time and part-time) are academically and experientially qualified, and maintain expertise in their areas of responsibility. Documentation confirms: a. nursing faculty are credentialed with a minimum of a master's degree with a major in nursing, with the majority holding earned doctorates from regionally accredited institutions. b. rationale for acceptance of other than the minimum required graduate credential. c. faculty credentials meet the requirements of the governing organization and any state agency which has legal authority for educational programs in nursing. d. academic and experiential preparation and variety of faculty backgrounds (full-time and part-time) are appropriate for responsibilities of the nursing education unit. e. expertise of non-nurse faculty is appropriate to the area of responsibility. f. maintenance of faculty expertise in their areas of responsibility: teaching, service, clinical practice, and/or scholarship. g. direct coordination, role development, and/or clinical management of advanced practice programs options is the responsibility of faculty certified in the respective area. 6. Number and utilization of full-time and part-time faculty meet the needs of the nursing education unit to fulfill its purposes. Documentation confirms: a. faculty/student ratios in the classroom and supervised clinical practice are sufficient to insure adequate teaching, supervision, and evaluation. b. utilization of full-time and part-time faculty is consistent with the mission/philosophy of the governing institution and purposes of the nursing education unit (teaching, scholarship, service, practice, administration). c. number and type of faculty are adequate to carry out the purposes and objectives of the graduate program. 7. Faculty performance is periodically evaluated to assure ongoing development and competence. Documentation confirms: a. process for faculty performance evaluation. b. evaluation of faculty includes teaching, scholarship, service, and practice.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

p.93

8.

The collective talents of the faculty reflects scholarship through teaching, application, and the integration and discovery of knowledge as defined by the governing organization and within the nursing education unit. Documentation confirms: a. scholarship is defined by the governing organization and the nursing education unit. b. faculty record of scholarship.

Suggested Indicators: · Credentials of faculty (i.e., curriculum vitae, transcripts, license) · State Board of Nursing Rules and Regulations · Faculty requirements of governing organization · Faculty Profile form* · Faculty files/personnel records · Documentation of faculty continuing education · Documentation of selection, orientation, monitoring, and evaluation of preceptors · Institutional/faculty handbook/manual · Teaching assignments: class and clinical practice · Faculty/student ratio · Full-time/Part-time faculty ratio · Samples of performance evaluation forms (i.e., student, self, peer, administration) · Faculty and staff appointment to state, national, international panels · Collective bargaining agreement, if appropriate · Faculty participation in scholarly academies; attainment of awards; attainment of internal or external recognition for excellence in teaching, community or professional service or practice · Number of faculty and dollar amount of scholarship support Suggested Tables: · Faculty continuing education · Faculty/student ratio: classroom and clinical · Full-time/part-time faculty ratio *REQUIRED FACULTY PROFILE FORM TO BE INCLUDED IN SELF-STUDY REPORT Governing Organization: Nursing Program:

Faculty Name FT/PT Date of Initial Appointment Rank Bachelor Degree (credential) Institution Granting Degree Graduate Degrees (credential) Institution Granting Degrees Areas of Clinical Expertise Academic Teaching (T) and Other (O)Areas of Responsibility

,,,,,,,,

,,,,,,,,

,,,,,,,,,,,,,,,,

,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

T O ,,,,,,,,,, ,,,,,,,,,,

If pursuing graduate degree, list credits earned to date.

p.94

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

III.

Students The teaching and learning environment is conducive to student academic achievement. 9. Student policies of the nursing education unit are congruent with those of the governing organization, publicly accessible, non-discriminatory, and consistently applied; differences are justified by the nursing education unit purposes. Documentation confirms: a. congruency, availability, and accessibility of student policies with the governing organization and nursing education unit, including but not limited to: non-discrimination; selection and admission; academic progression; student evaluation/grading; retention; withdrawal/dismissal; graduation requirements; grievance/complaints and appeal procedures; financial aid; transfer of credit; recruitment; and health requirements. b. rationale for policies that differ from the governing organization policies. c. process by which policies are changed and communicated to students. d. admission and academic progression policies specific to graduate education and advanced practice program options are established by faculty who teach in the graduate program and are congruent with national standards, nursing education unit purposes, and governing organization. 10. Students have access to support services administered by qualified individuals that include, but are not limited to: health, counseling, academic advisement, career placement, and financial aid. Documentation confirms: a. availability of student support services. b. academic/experiential qualifications of individuals responsible for student services. c. distance education students have access to appropriate range of student services.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

p.95

11.

Policies concerned with educational and financial records are established and followed. Documentation confirms: a. procedures for maintenance of educational records. b. procedures for maintenance of financial records.

Suggested Indicators: Student handbook/manual Demographic profile of admitted students Published student academic and non-academic policies Catalog and other publications Student retention/attrition rates Satisfaction survey results of students, graduates, alumni, employer Curriculum vitae of student support personnel Performance on certification examinations by year Number/percentage of students participating in scholarship and creative and community activities Students served by special support and student disability services Family Education Rights and Privacy Act (FERPA) American with Disabilities Act (ADA) requirements

Suggested Tables: Demographic profile of student population Student policies which differ from the governing organization

p.96

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

IV.

Curriculum and Instruction The curriculum is designed to accomplish its educational and related purposes. 12. Curriculum developed by nursing faculty flows from the nursing education unit philosophy/mission through an organizing framework into a logical progression of course outcomes and learning activities to achieve desired program objectives/outcomes. Documentation confirms: a. integrity of the curriculum addressing all tracks and post-master's options specifically as evidenced by congruence among the philosophy, organizing framework, program objectives, curriculum design, course progression, and outcome measures. b. a logical, sequential curriculum plan addressing all tracks and post-master's options that builds on knowledge and competencies of baccalaureate education and reflects master's level education. c. a set of guidelines for master's and where appropriate advanced practice nursing approved by a recognized nursing organization is utilized. d. interdisciplinary collaboration is evident in the curriculum. e. didactic instruction and supervised practice follow a plan that: documents course content and learning experiences appropriate for the development of competencies required for graduation at the master's/advanced practice level; delineates instructional methods used to develop advanced practice competencies; and is adequate for advanced practice nursing students to meet accepted criteria for certification eligibility. f. evaluation tools and methods: are consistent with course objectives/outcomes and competencies of the didactic and clinical components of the graduate program; provide for regular feedback to students and faculty with timely indicators of student progress and academic standing; are consistently applied; and are written and available to students. g. technology used is appropriate to meet student learning needs, course objectives/outcomes and course requirements. h. regular review of the rigor, currency, and cohesiveness of nursing courses by faculty. 13. Program design provides opportunity for students to achieve program objectives and acquire knowledge, skills, value, and competencies necessary for nursing practice. Documentation confirms: a. curriculum provides for attainment of knowledge and skill sets in the current master's/advanced practice of nursing, nursing theory, research, community concepts, health care policy, finance, health care delivery, critical thinking, communications, professional role development, therapeutic interventions, and current trends in health care. b. program leads students to develop professional ethics, values and accountability.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

p.97

c. students are able to achieve the objectives in the established and published program length. d. Program completion results in student eligibility to sit for advanced practice certification and/or apply for advanced practice licensure where applicable. e. clock and credit hours are consistent with published guidelines for master's/advanced practice nursing curricula. 14. Practice learning environments are selected and monitored by faculty and provide opportunities for a variety of learning options appropriate for contemporary nursing. Documentations confirms: a. agreements and contracts with practice sites are current and specify expectations and responsibilities for all parties. b. adequacy of facilities used for advanced clinical practice. c. clinical resources support sufficient numbers and varieties of graduate level experiences.

Suggested Indicators: Abbreviated course syllabi Curriculum plan(s) Class/clinical evaluation tools Professional nursing standards Description of implemented interdisciplinary collaboration Description of alternative methods to deliver academic program Description of indices to enhance teaching Educational use of technology Student records Meeting minutes Survey results from selected constituencies (i.e., student, graduate, employer satisfaction) Sample of student papers and projects Class/clinical schedules Class/clinical observations Clinical agency contracts, affiliation agreements Faculty and student evaluations of clinical agencies

Suggested Tables: Curriculum plan Philosophy, organizing framework, program objectives/outcomes/competencies Clinical agencies and their approval status

p.98

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

V.

Resources Resources are sufficient to accomplish the nursing education unit purposes. 15. Fiscal resources are sufficient to support the nursing education unit purposes and commensurate with the resources of the governing organization. Documentation confirms: a. fiscal allocations from institutional funds, not including grants, gifts, and other restricted sources are: · comparable with other units in the institution; and · sufficient for the program to achieve its goals and objectives. responsibility and authority of the nurse administrator and involvement of the nursing faculty in budget preparations are evident. resources are adequate to support faculty development, research, instruction, practice activities, and community and public service.

b. c.

16.

Program support services are sufficient for the operations of the nursing education unit. Documentation confirms: a. b. administrative services are available as needed. clerical services are available as needed.

17.

Learning resources are comprehensive, current, developed with nursing faculty input, and accessible to faculty and students. Documentation confirms: a. instructional aids, technology, software and hardware, and technical support are: · available in sufficient quantity and quality to be consistent with program objectives and teaching methods; and · available to assist students and faculty experiencing difficulty using technology. learning resources (library, skills laboratory, computer laboratory, etc.) are current and comprehensive to meet nursing education unit purposes. learning resources are adequate and accessible. mechanisms by which nursing faculty have input into the development and maintenance of learning resources.

b. c. d.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

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18.

Physical facilities are appropriate to support the purposes of the nursing education unit. Documentation confirms: a. physical facilities include classrooms, laboratories, multi-media facilities, conference rooms, and office space. b. physical facilities, instructional and non-instructional, are adequate for the nursing education unit at whatever site the graduate nursing program is offered.

Suggested Indicators: · Financial statements and other documents and financial records (i.e., program budget) · Instructional and non-instructional space · Visit to library, computer center, study skills center, learning laboratories, facilities, etc. · Access to library, information system, and communication systems · Institutional partnerships/linkages

Suggested Tables: · Nursing education unit budget · Nurse administrator and faculty salaries

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

VI.

Integrity Integrity is evident in the practices and relationships of the nursing education unit. 19. Information about the program, intended to inform the general public, prospective students, current students, employers and other interested parties, is current, accurate, clear, and consistent. Documentation confirms: a. policies and procedures are published for all education activities that have implications for the health and safety of clients, students, and faculty. b. published documents about the program are current, accurate, clear, and consistent. c. accurate representation of the program to its public(s) and provision of sufficient information to insure accountability and consumer choice is stated in the catalog/published documents: · reflecting the mission and/or philosophy and purposes of the program; · providing current and accurate information about admission policies; tuition and fees; financial aid; graduation; licensing requirements; academic policies; academic calendar; student services; program length; · clearly representing the program and career opportunities through program documents and publications, advertising, website, recruitment, admission materials, and course syllabi; and · providing clear statements of institutional accreditation status; name, address, and telephone number of the National League for Nursing Accrediting Commission as the accrediting agency of the nursing program. d. communication of accurate and consistent information about: · definition of clock and credit hours for lecture, clinical experiences, independent study, and other activities; · ratio of clock hours to credit hours; and · specific credit hours required for each course. 20. Complaints about the program are addressed and records are maintained and available for review. Documentation confirms: a. complaints about the program are documented indicating number, type and resolution of complaints. b. process of complaint resolution is available for review.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

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21.

Compliance with Higher Education Reauthorization Act Title IV eligibility and certification requirements is maintained. Documentations confirms: a. a written, comprehensive student loan repayment program addresses student loan information, counseling, monitoring, and cooperation with lenders. b. students are informed of their ethical responsibilities regarding financial assistance.

Suggested Indicators: · Catalog · Recruitment materials · Student handbook/manual · Most recent accreditation/approval reports · Published tuition and fees · NLNAC Annual Report · Record of notification to NLNAC any substantive change · Record of student complaints within the nursing education unit or to NLNAC · Annual report of ombudsperson · Evidence that students are made aware of their ethical responsibilities regarding financial assistance they received from public or private sources · Comprehensive student loan repayment program

Suggested Tables: · Tuition and fees · Type, number and resolution of formal complaint(s)

p.102

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

VII.

Educational Effectiveness: There is an identified plan for systematic evaluation including assessment of student academic achievement. 22. There is a written plan for systematic program evaluation that is used for continuous program improvement. Documentation confirms: a. b. c. d. e. program evaluation of the nursing education unit, as defined by the governing organization and the unit, demonstrates how and to what extent the program is attaining all NLNAC standards and criteria. plan contains, at a minimum: expected levels of achievement, time frames, and methods for assessment. data/information are collected, analyzed, aggregated, and trended. evaluation findings are used for decision making for program improvement. strategies are taken or will be taken to address the area(s) identified as needing improvement.

23.

Student academic achievement by program type is evaluated by: graduation rates, licensure/certification pass rates, job placement rates, and program satisfaction. Documentation confirms: a. b. c. d. e. f. g. measurement by graduation rates of students who complete the program within a defined period of time. measurement by performance of licensing/certification examinations of program graduates. measurement by job placement rates of master's degree graduates within one year after graduation. measurement by program satisfaction as measured by graduates and/or employers. data are collected, analyzed, aggregated, and trended. evaluation findings are used for decision making for program improvement. strategies are taken or will be taken to address the area(s) identified as needing improvement.

Suggested Indicator: In Self-Study Report, include systematic plan for program evaluation and assessment of outcomes with documentation of use for program improvements.

Suggested Tables: Graduation rates Certification pass rates Job placement rates Program satisfaction

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Master's Degree

p.103

NLNAC STANDARDS AND CRITERIA BACCALAUREATE DEGREE PROGRAMS I. Mission and Governance There are clear and publicly stated mission and/or philosophy and purposes appropriate to postsecondary or higher education in nursing. 1. Mission and/or philosophy of the nursing education unit is congruent with that of the governing organization, or differences are justified by the nursing education unit purposes. Documentation confirms: a. philosophy/mission of the program in nursing is congruent with the mission and purposes of the governing organization. b. program purposes and objectives/competencies are: · congruent with the program philosophy/mission; · clearly stated; · publicly accessible; · appropriate to legal requirements and scope of practice; and · consistent with contemporary beliefs of the profession. c. commitment to cultural, racial, and ethnic diversity of the community in which the institution and the nursing education unit exist. d. programming for distance education is congruent with the philosophy and purposes of the governing organization and nursing education unit. 2. Faculty, administrators, and students participate in governance as defined by the governing organization and nursing education unit. Documentation confirms: a. participation in governance of the governing organization. b. participation in governance of the nursing education unit. 3. Nursing education unit is administered by a nurse who is academically and experientially qualified, and who has authority and responsibility for development and administration of the program. Documentation confirms: a. academic credentials of the nurse administrator are a graduate degree with a major in nursing and an earned doctorate from a regionally accredited institution; explain acceptance of other graduate credentials for the nurse administrator. b. knowledge of the program type is reflected in the experience of the nurse administrator. c. authority and administrative responsibilities are documented within the position of the nurse administrator. d. nurse administrator has adequate time to fulfill the role responsibilities.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

p.105

4.

Policies of the nursing education unit are consistent with those of the governing organization, or differences are justified by the nursing education unit purposes. Documentation confirms: a. congruency between policies affecting nursing faculty and staff and governing organization: · non-discrimination; · faculty appointment/hiring; · academic rank; · grievance procedures; · promotion; · salary and benefits; · tenure; · rights and responsibilities; · termination; and · workload. b. accessibility of nursing education unit policies. c. rationale for policies that differ from governing organization.

Suggested Indicators: · Nursing unit and governing organization mission and/or philosophy statement · Institutional policies · Catalog · Organizational chart · Bylaws · State Board of Nursing Regulations · Curriculum vitae, transcripts, license of nurse administrator · Position description of nurse administrator · Institutional/faculty handbook/manual · Regional accrediting body approval letter and report · State Board of Nursing approval letter and report; other regulatory agency approval letter

Suggested Tables: · Comparison of governing organization and nursing education unit's mission and/or philosophy and purposes · Participation on committees of the governing organization · Participation on committees of the nursing education unit · Policies which differ from the governing organization

p.106

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

II.

Faculty There are qualified and credentialed faculty, appropriate to accomplish the nursing education unit purposes and strengthen its educational effectiveness. 5. Faculty members (full-time and part-time) are academically and experientially qualified, and maintain expertise in their areas of responsibility. Documentation confirms: a. nursing faculty are credentialed with a minimum of a master's degree with a major in nursing. b. rationale for acceptance of other than the minimum required graduate credential. c. faculty credentials meet the requirements of the governing organization and any state agency which has legal authority for educational programs in nursing. d. academic and experiential preparation and variety of faculty backgrounds (full-time and part-time) are appropriate for responsibilities of the nursing education unit. e. expertise of non-nurse faculty is appropriate to the area of responsibility. f. maintenance of faculty expertise in their areas of responsibility: teaching, service, clinical practice, and/or scholarship. 6. Number and utilization of full-time and part-time faculty meet the needs of the nursing education unit to fulfill its purposes. Documentation confirms: a. faculty/student ratios in the classroom and supervised clinical practice are sufficient to insure adequate teaching, supervision, and evaluation. b. utilization of full-time and part-time faculty is consistent with the mission/philosophy of the governing institution and purposes of the nursing education unit (teaching, scholarship, service, practice, administration). c. number and type of faculty are adequate to carry out the purposes and objectives of the program. 7. Faculty performance is periodically evaluated to assure ongoing development and competence. Documentation confirms: a. process for faculty performance evaluation. b. evaluation of faculty includes teaching, scholarship, service, and practice.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

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8.

The collective talents of the faculty reflects scholarship through teaching, application, and the integration and discovery of knowledge as defined by the governing organization and within the nursing education unit. Documentation confirms: a. b. scholarship is defined by the governing organization and the nursing education unit. faculty record of scholarship.

Suggested Indicators: · Credentials of faculty (i.e., curriculum vitae, transcripts, license) · State Board of Nursing Rules and Regulations · Faculty requirements of governing organization · Faculty Profile form* · Faculty files/personnel records · Documentation of faculty continuing education · Documentation of selection, orientation, monitoring, and evaluation of preceptors · Institutional/faculty handbook/manual · Faculty/student ratio · Full-time/Part-time faculty ratio · Teaching assignments: class and clinical practice · Observation of classes and clinical practice areas · Samples of performance evaluation forms (i.e., student, self, peer, administration) · Faculty and staff appointment to state, national, international panels · Collective bargaining agreement, if appropriate · Faculty participation in scholarly academies; attainment of awards; attainment of internal or external recognition for excellence in teaching, community or professional service or practice · Number of faculty and dollar amount of scholarship support Suggested Tables: · Faculty continuing education · Faculty/student ratio: classroom and clinical · Full-time/part-time faculty ratio *REQUIRED FACULTY PROFILE FORM TO BE INCLUDED IN SELF-STUDY REPORT Governing Organization: Nursing Program:

Faculty Name FT/PT Date of Initial Appointment Rank Bachelor Degree (credential) Institution Granting Degree Graduate Degrees (credential) Institution Granting Degrees Areas of Clinical Expertise Academic Teaching (T) and Other (O)Areas of Responsibility

,,,,,,,,

,,,,,,,,

,,,,,,,,,,,,,,,,

,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

T O ,,,,,,,,,, ,,,,,,,,,,

If pursuing graduate degree, list credits earned to date.

p.108

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

III.

Students The teaching and learning environment is conducive to student academic achievement. 9. Student policies of the nursing education unit are congruent with those of the governing organization, publicly accessible, non-discriminatory, and consistently applied; differences are justified by the nursing education unit purposes. Documentation confirms: a. congruency, availability, and accessibility of student policies with the governing organization and nursing education unit, including but not limited to: non-discrimination; selection and admission; academic progression; student evaluation/grading; retention; withdrawal/dismissal; graduation requirements; grievance/complaints and appeal procedures; financial aid; transfer of credit; recruitment; health requirements; and validation of prior learning/articulation b. rationale for policies that differ from the governing organization policies. c. process by which policies are changed and communicated to students. d. admission and academic progression policies are established by faculty who teach in the baccalaureate program and are congruent with the nursing education unit purposes and governing organization. 10. Students have access to support services administered by qualified individuals that include, but are not limited to: health, counseling, academic advisement, career placement, and financial aid. Documentation confirms: a. availability of student support services. b. academic/experiential qualifications of individuals responsible for student services. c. distance education students have access to appropriate range of student services.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

p.109

11.

Policies concerned with educational and financial records are established and followed. Documentation confirms: a. procedures for maintenance of educational records. b. procedures for maintenance of financial records.

Suggested Indicators: Student handbook/manual Demographic profile of admitted students Published student academic and non-academic policies Catalog and other publications Satisfaction survey results of students, graduates, alumni, employer Curriculum vitae of student support personnel Students served by special support and student disability services Family Education Rights and Privacy Act (FERPA) American with Disabilities Act (ADA) requirements

Suggested Tables: Demographic profile of student population Student policies which differ from the governing organization

p.110

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

IV.

Curriculum and Instruction The curriculum is designed to accomplish its educational and related purposes. 12. Curriculum developed by nursing faculty flows from the nursing education unit philosophy/mission through an organizing framework into a logical progression of course outcomes and learning activities to achieve desired program objectives/outcomes. Documentation confirms: a. integrity of the curriculum as evidenced by congruence among the philosophy, organizing framework, program objectives, curriculum design, course progression, and outcome measures. b. a logical, sequential curriculum plan where course content increases in difficulty and complexity. c. a set of guidelines for professional nursing practices approved by a nursing organization is utilized. d. courses in the sciences and humanities provide the foundation for the nursing curriculum. e. interdisciplinary collaboration is evident in the curriculum. f. didactic instruction and supervised practice follow a plan. Course syllabi: documents course content and learning experiences appropriate for the development of competencies required for graduation; and delineates instructional methods used to develop competencies. g. evaluation tools and methods: are consistent with course objectives/outcomes and competencies of the didactic and clinical components of the baccalaureate degree program; provide for regular feedback to students and faculty with timely indicators of student progress and academic standing; are consistently applied; and are written and available to students. h. technology used is appropriate to meet student learning needs, course objectives/outcomes and course requirements. i. regular review of the rigor, currency, and cohesiveness of nursing courses by faculty. 13. Program design provides opportunity for students to achieve program objectives and acquire knowledge, skills, value, and competencies necessary for nursing practice. Documentation confirms: a. curriculum provides for attainment of knowledge and skill sets in the current practice of nursing, nursing theory, research, community concepts, health care policy, finance, health care delivery, critical thinking, communications, therapeutic interventions, and current trends in health care. b. program leads students to develop professional ethics, values and accountability. c. students can achieve the objectives in the established and published program length. d. majority of course work in nursing is at the upper division level.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

p.111

14.

Practice learning environments are selected and monitored by faculty and provide opportunities for a variety of learning options appropriate for contemporary nursing. Documentations confirms: a. agreements and contracts with practice sites are current and specify expectations and responsibilities for all parties. b. facilities used for clinical practice are adequate. c. clinical resources support sufficient numbers and varieties of baccalaureate degree level experiences.

Suggested Indicators: Abbreviated course syllabi Curriculum plan(s) Class/clinical evaluation tools Professional nursing standards Description of implemented interdisciplinary collaboration Description of alternative methods to deliver academic program Description of indices to enhance teaching Educational use of technology Student records Meeting minutes Survey results from selected constituencies (i.e., student, graduate, employer satisfaction) Sample of student papers and projects Class/clinical schedules Class/clinical observations Clinical agency contracts, affiliation agreements Faculty and student evaluations of clinical agencies

Suggested Tables: Curriculum plan Philosophy, organizing framework, program objectives/outcomes/competencies Clinical agencies and their approval status

p.112

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

V.

Resources Resources are sufficient to accomplish the nursing education unit purposes. 15. Fiscal resources are sufficient to support the nursing education unit purposes and commensurate with the resources of the governing organization. Documentation confirms: a. fiscal allocations from institutional funds, not including grants, gifts, and other restricted sources are: · comparable with other units in the institution; and · sufficient for the program to achieve its goals and objectives. b. responsibility and authority of the nurse administrator and involvement of the nursing faculty in budget preparations are evident. c. resources are adequate to support faculty development, research, instruction, practice activities, and community and public service. 16. Program support services are sufficient for the operations of the nursing education unit. Documentation confirms: a. administrative services are available as needed. b. clerical services are available as needed. 17. Learning resources are comprehensive, current, developed with nursing faculty input, and accessible to faculty and students. Documentation confirms: a. instructional aids, technology, software and hardware, and technical support are: · available in sufficient quantity and quality to be consistent with program objectives and teaching methods; and · available to assist students and faculty experiencing difficulty using technology. b. learning resources (library, skills laboratory, computer laboratory, etc.) are current and comprehensive to meet nursing education unit purposes. c. learning resources are adequate and accessible. d. mechanisms by which nursing faculty have input into the development and maintenance of learning resources.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

p.113

18.

Physical facilities are appropriate to support the purposes of the nursing education unit. Documentation confirms: a. physical facilities include classrooms, laboratories, multi-media facilities, conference rooms, and office space. b. physical facilities, instructional and non-instructional, are adequate for the nursing education unit at whatever site the undergraduate nursing program is offered.

Suggested Indicators: · Financial statements and other documents and financial records (i.e., program budget) · Instructional and non-instructional space · Visit to library, computer center, study skills center, learning laboratories, facilities, etc. · Access to library, information system, and communication systems

Suggested Tables: · Nursing education unit budget · Nurse administrator and faculty salaries

p.114

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

VI.

Integrity Integrity is evident in the practices and relationships of the nursing education unit. 19. Information about the program, intended to inform the general public, prospective students, current students, employers and other interested parties, is current, accurate, clear, and consistent. Documentation confirms: a. policies and procedures are published for all education activities that have implications for the health and safety of clients, students, and faculty. b. published documents about the program are current, accurate, clear, and consistent. c. accurate representation of the program to its public(s) and provision of sufficient information to insure accountability and consumer choice is stated in the catalog/published documents: · reflecting the mission and/or philosophy and purposes of the program; · providing current and accurate information about admission policies; tuition and fees; financial aid; graduation; licensing requirements; academic policies; academic calendar; student services; program length; · representing the program and career opportunities through program documents and publications, advertising, website, recruitment, admission materials, and course syllabi; and · providing clear statements of institutional accreditation status; name, address, and telephone number of the National League for Nursing Accrediting Commission as the accrediting agency of the nursing program. d. communication of accurate and consistent information about: · definition of clock and credit hours for lecture, clinical experiences, independent study, and other activities · ratio of clock hours to credit hours; and · specific credit hours required for each course. 20. Complaints about the program are addressed and records are maintained and available for review. Documentation confirms: a. complaints about the program are documented indicating number, type, and resolution of complaints. b. process of complaint resolution is available for review.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

p.115

21.

Compliance with Higher Education Reauthorization Act Title IV eligibility and certification requirements is maintained. Documentations confirms: a. a written, comprehensive student loan repayment program addresses student loan information, counseling, monitoring, and cooperation with lenders. b. students are informed of their ethical responsibilities regarding financial assistance.

Suggested Indicators: · Catalog · Recruitment materials · Student handbook/manual · Most recent accreditation/approval reports · Published tuition and fees · NLNAC Annual Report · Record of notification to NLNAC of any substantive change · Record of student complaints within the nursing education unit or to NLNAC · Annual report of ombudsperson · Evidence that students are made aware of their ethical responsibilities regarding financial assistance they received from public or private sources · Comprehensive student loan repayment program

Suggested Tables: · Tuition and fees · Type, number and resolution of formal complaint(s)

p.116

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

VII.

Educational Effectiveness: There is an identified plan for systematic evaluation including assessment of student academic achievement. 22. There is a written plan for systematic program evaluation that is used for continuous program improvement. Documentation confirms: a. b. c. d. e. program evaluation of the nursing education unit, as defined by the governing organization and the unit, demonstrates how and to what extent the program is attaining all NLNAC standards and criteria. plan contains, at a minimum: expected levels of achievement, time frames, and methods for assessment. data/information are collected, analyzed, aggregated, and trended. evaluation findings are used for decision making for program improvement. strategies are taken or will be taken to address the area(s) identified as needing improvement.

23.

Student academic achievement by program type is evaluated by: graduation rates, licensure/certification pass rates, job placement rates, and program satisfaction. Documentation confirms: a. b. c. d. e. f. g. measurement by graduation rates of students who complete the program within a defined period of time. measurement by performance of licensure examinations of program graduates. measurement by job placement rates of baccalaureate degree graduates within one year after graduation. measurement by program satisfaction as measured by graduates and/or employers. data are collected, analyzed, aggregated, and trended. evaluation findings are used for decision making for program improvement. strategies are taken or will be taken to address the area(s) identified as needing improvement.

Suggested Indicator: In Self-Study Report, include systematic plan for program evaluation and assessment of outcomes with documentation of use for program improvements.

Suggested Tables: Graduation rates NCLEX pass rates Job placement rates Program satisfaction

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Baccalaureate Degree

p.117

NLNAC STANDARDS AND CRITERIA ASSOCIATE DEGREE PROGRAMS I. Mission and Governance There are clear and publicly stated mission and/or philosophy and purposes appropriate to post secondary or higher education in nursing. 1. Mission and/or philosophy of the nursing education unit is congruent with that of the governing organization, or differences are justified by the nursing education unit purposes. Documentation confirms: a. philosophy/mission of the program in nursing is congruent with the mission and purposes of the governing organization. b. program purposes and objectives/competencies are: · congruent with the program philosophy/mission; · clearly stated; · publicly accessible · appropriate to legal requirements and scope of practice; and · consistent with contemporary beliefs of the profession. c. commitment to cultural, racial, and ethnic diversity of the community in which the institution and the nursing education unit exist. d. programming for distance education is congruent with the philosophy and purposes of the governing organization and nursing education unit. 2. Faculty, administrator, and students participate in governance as defined by the governing organization and nursing education unit. Documentation confirms: a. participation in governance of the governing organization. b. participation in governance of the nursing education unit. 3. Nursing education unit is administered by a nurse who is academically and experientially qualified, and who has authority and responsibility for development and administration of the program. Documentation confirms: a. academic credentials of the nurse administrator is a graduate degree with a major in nursing; explain acceptance of other graduate credentials for the nurse administrator. b. knowledge of the program type is reflected in the experience of the nurse administrator. c. authority and administrative responsibilities are documented within the position of the nurse administrator. d. nurse administrator has adequate time to fulfill the role responsibilities.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

p.119

4.

Policies of the nursing education unit are consistent with those of the governing organization, or differences are justified by the nursing education unit purposes. Documentation confirms: a. congruency between policies affecting nursing faculty and staff and governing organization: · non-discrimination; · faculty appointment/hiring; · academic rank; · grievance procedures; · promotion; · salary and benefits; · tenure; · rights and responsibilities; · termination; and · workload. b. accessibility of nursing education unit policies. c. rationale for policies that differ from governing organization.

Suggested Indicators: · Nursing unit and governing organization mission and/or philosophy statement · Institutional policies · Catalog · Organizational chart · Bylaws · State Board of Nursing Regulations · Curriculum vitae, transcripts, license of nurse administrator · Position description of nurse administrator · Institutional/faculty handbook/manual · Regional accrediting body approval letter and report · State Board of Nursing approval letter and report; other regulatory agency approval letter

Suggested Tables: · Comparison of governing organization and nursing education unit's mission and/or philosophy and purposes · Participation on committees of the governing organization · Participation on committees of the nursing education unit · Policies which differ from the governing organization

p.120

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

II.

Faculty There are qualified and credentialed faculty, appropriate to accomplish the nursing education unit purposes and strengthen its educational effectiveness. 5. Faculty members (full-time and part-time) are academically and experientially qualified, and maintain expertise in their areas of responsibility. Documentation confirms: a. nursing faculty are credentialed with a minimum with a master's degree with a major in nursing. b. rationale for acceptance of other than the minimum required graduate credential. c. faculty credentials meet the requirements of the governing organization and any state agency which has legal authority for educational programs in nursing. d. academic and experiential preparation and variety of faculty backgrounds (full-time and part-time) are appropriate for responsibilities of the nursing education unit. e. expertise of non-nurse faculty is appropriate to the area of responsibility. f. maintenance of faculty expertise in their areas of responsibility, such as: teaching, service, clinical practice, and/or scholarship. 6. Number and utilization of full-time and part-time faculty meet the needs of the nursing education unit to fulfill its purposes. Documentation confirms: a. faculty/student ratios in the classroom and supervised clinical practice are sufficient to insure adequate teaching, supervision, and evaluation. b. utilization of full-time and part-time faculty is consistent with the mission/philosophy of the governing institution and purposes of the nursing education unit (teaching, scholarship, service, practice, administration). c. number and type of faculty are adequate to carry out the purposes and objectives of the program. 7. Faculty performance is periodically evaluated to assure ongoing development and competence. Documentation confirms: a. process for faculty performance evaluation. b. evaluation of faculty is in keeping with the mission/philosophy of the nursing education unit and includes areas such as: teaching, scholarship, service, and practice.

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p.121

8.

The collective talents of the faculty reflects scholarship through teaching, application, and the integration and discovery of knowledge as defined by the governing organization and within the nursing education unit. Documentation confirms: a. b. scholarship is defined by the governing organization and the nursing education unit. faculty record of scholarship.

Suggested Indicators: · Credentials of faculty (i.e., curriculum vitae, transcripts, license) · State Board of Nursing Rules and Regulations · Faculty requirements of governing organization · Faculty Profile form* · Faculty files/personnel records · Documentation of faculty continuing education · Institutional/faculty handbook/manual · Faculty/student ratio · Full-time/Part-time faculty ratio · Samples of performance evaluation forms (i.e., student, self, peer, administration) · Faculty and staff appointment to state, national, international panels · Collective bargaining agreement, if appropriate · Faculty participation in scholarly academies; attainment of awards; attainment of internal or external recognition for excellence in teaching, community or professional service or practice · Number of faculty and dollar amount of scholarship support

Suggested Tables: · Faculty continuing education · Faculty/student ratio: classroom and clinical · Full-time/part-time faculty ratio *REQUIRED FACULTY PROFILE FORM TO BE INCLUDED IN SELF-STUDY REPORT Governing Organization: Nursing Program:

Faculty Name FT/PT Date of Initial Appointment Rank Bachelor Degree (credential) Institution Granting Degree Graduate Degrees (credential) Institution Granting Degrees Areas of Clinical Expertise Academic Teaching (T) and Other (O)Areas of Responsibility

,,,,,,,,

,,,,,,,,

,,,,,,,,,,,,,,,,

,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

T O ,,,,,,,,,, ,,,,,,,,,,

If pursuing graduate degree, list credits earned to date.

p.122

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

III.

Students The teaching and learning environment is conducive to student academic achievement. 9. Student policies of the nursing education unit are congruent with those of the governing organization, publicly accessible, non-discriminatory, and consistently applied; differences are justified by the nursing education unit purposes. Documentation confirms: a. congruency, availability, and accessibility of student policies with the governing organization and nursing education unit, including but not limited to: non-discrimination; selection and admission; academic progression; student evaluation/grading; retention; withdrawal/dismissal; graduation requirements; grievance/complaints and appeal procedures; financial aid; transfer of credit; recruitment; health requirements; and validation of prior learning/articulation b. rationale for policies that differ from the governing organization policies. c. process by which policies are changed and communicated to students. d. admission and academic progression policies are established by faculty who teach in the associate degree program and are congruent with the nursing education unit purposes, and governing organization. 10. Students have access to support services administered by qualified individuals that include, but are not limited to: health, counseling, academic advisement, career placement, and financial aid. Documentation confirms: a. availability of student support services. b. academic/experiential qualifications of individuals responsible for student services. c. distance education students have access to appropriate range of student services.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

p.123

11.

Policies concerned with educational and financial records are established and followed. Documentation confirms: a. procedures for maintenance of educational records. b. procedures for maintenance of financial records.

Suggested Indicators: Student handbook/manual Demographic profile of admitted students Published student academic and non-academic policies Catalog and other publications Satisfaction survey results of students, graduates, alumni, employer Curriculum vitae of student support personnel Annual campus safety compared to national average Student served by special support and student disability services Family Education Rights and Privacy Act (FERPA) American with Disabilities Act (ADA) requirements

Suggested Tables: Demographic profile of student population Student policies which differ from the governing organization

p.124

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

IV.

Curriculum and Instruction The curriculum is designed to accomplish its educational and related purposes. 12. Curriculum developed by nursing faculty flows from the nursing education unit philosophy/mission through an organizing framework into a logical progression of course outcomes and learning activities to achieve desired program objectives/outcomes. Documentation confirms: a. integrity of the curriculum as evidenced by congruence among the philosophy, organizing framework, program objectives, curriculum design, course progression, and outcome measures. b. a logical, sequential curriculum plan where course content increases in difficulty and complexity c. a set of guidelines for professional nursing practices approved by a nursing organization is utilized. d. courses in the sciences and humanities provide the foundation for the nursing curriculum. e. interdisciplinary collaboration is evident in the curriculum. f. didactic instruction and supervised practice follow a plan. Course syllabi: documents course content and learning experiences appropriate for the development of competencies required for graduation; and delineates instructional methods used to develop competencies; g. evaluation tools and methods: are consistent with course objectives/outcomes and competencies of the didactic and clinical components of the associate degree program; provide for regular feedback to students and faculty with timely indicators of student progress and academic standing; are consistently applied; and are written and available to students. h. technology used is appropriate to meet student learning needs, course objectives/outcomes and course requirements. i. Regular reviews of the rigor, currency, and cohesiveness of nursing courses by faculty. 13. Program design provides opportunity for students to achieve program objectives and acquire knowledge, skills, value, and competencies necessary for nursing practice. Documentation confirms: a. curriculum provides for attainment of knowledge and skill sets in the current practice of nursing, community concepts, health care delivery, critical thinking, communications, therapeutic interventions, and current trends in health care. b. program leads students to develop professional ethics, values and accountability. c. students can achieve the objectives in the established and published program length. d. total credits provide a balanced distribution of credits with no more than 60% of the total credits allocated to nursing courses e. Total credits in the curriculum are within the generally accepted limits of 60-72 semester credits or 90-108 quarter credits (this credit range was calculated using a 1:1 credit to contact hour ratio for theory, and a 1:3 credit hour ratio for clinical learning experiences).

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p.125

If credits for clinical learning experiences are allocated at a rate other than 1:3, include a table in the self -study that converts the clinical learning experience credit allocation to 1:3 to effectively demonstrate the total program credits based on the above stated assumptions

Total Program Credits Course Number Credits Theory credits Clinical credits Clinical credits Based on a 1:3 ratio

Total

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

14.

Practice learning environments are selected and monitored by faculty and provide opportunities for a variety of learning options appropriate for contemporary nursing. Documentations confirms: a. agreements and contracts with practice sites are current and specify expectations and responsibilities for all parties. b. facilities used for clinical practice are adequate. c. clinical resources support sufficient numbers and varieties of associate degree level experiences.

Suggested Indicators: Abbreviated course syllabi Curriculum plan(s) Class/clinical evaluation tools Professional nursing standards Description of implemented interdisciplinary collaboration Description of alternative methods to deliver academic program Educational use of technology Student records Meeting minutes Survey results from selected constituencies (i.e., student, graduate, employer satisfaction) Sample of student papers and projects Class/clinical schedules Class/clinical observations Clinical agency contracts, affiliation agreements Faculty and student evaluations of clinical agencies

Suggested Tables: Curriculum plan Philosophy, organizing framework, program objectives/outcomes/competencies Clinical agencies and their approval status

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

p.127

V.

Resources Resources are sufficient to accomplish the nursing education unit purposes. 15. Fiscal resources are sufficient to support the nursing education unit purposes and commensurate with the resources of the governing organization. Documentation confirms: a. fiscal allocations from institutional funds, not including grants, gifts, and other restricted sources are: · comparable with other units in the institution; and · sufficient for the program to achieve its goals and objectives. b. responsibility and authority of the nurse administrator and involvement of the nursing faculty in budget preparations are evident. c. resources are adequate to support faculty development and instruction. 16. Program support services are sufficient for the operations of the nursing education unit. Documentation confirms: a. administrative services are available as needed. b. clerical services are available as needed. 17. Learning resources are comprehensive, current, developed with nursing faculty input, and accessible to faculty and students. Documentation confirms: a. instructional aids, technology, software and hardware, and technical support are: · available in sufficient quantity and quality to be consistent with program objectives and teaching methods; and · available to assist students and faculty experiencing difficulty using technology. b. learning resources (library, skills laboratory, computer laboratory, etc.) are current and comprehensive to meet nursing education unit purposes. c. learning resources are adequate and accessible. d. mechanisms by which nursing faculty have input into the development and maintenance of learning resources.

p.128

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

18.

Physical facilities are appropriate to support the purposes of the nursing education unit. Documentation confirms: a. physical facilities include classrooms, laboratories, multi-media facilities, conference rooms, and office space. b. physical facilities, instructional and non-instructional, are adequate for the nursing education unit at whatever site the associate degree program is offered.

· · · ·

Suggested Indicators: Financial statements and other documents and financial records (i.e., program budget) Instructional and non-instructional space Visit to library, computer center, study skills center, learning laboratories, facilities, etc. Access to library, information system, and communication systems

Suggested Tables: · Nursing education unit budget · Nurse administrator and faculty salaries

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

p.129

VI.

Integrity Integrity is evident in the practices and relationships of the nursing education unit. 19. Information about the program, intended to inform the general public, prospective students, current students, employers and other interested parties, is current, accurate, clear, and consistent. Documentation confirms: a. policies and procedures are published for all education activities that have implications for the health and safety of clients, students, and faculty. b. published documents about the program are current, accurate, clear, and consistent. c. accurate representation of the program to its public(s) and provision of sufficient information to insure accountability and consumer choice is stated in the catalog/published documents: · reflecting the mission and/or philosophy and purposes of the program; · providing current and accurate information about admission policies; tuition and fees; financial aid; graduation; licensing requirements; academic policies; academic calendar; student services; program length; · clearly representing the program and career opportunities through program documents and publications, advertising, website, recruitment, admission materials, and course syllabi; and · providing clear statements of institutional accreditation status; name, address, and telephone number of the National League for Nursing Accrediting Commission as the accrediting agency of the nursing program. d. communication of accurate and consistent information about: · definition of clock and credit hours for lecture, clinical experiences, independent study, and other activities; · ratio of clock hours to credit hours; and · specific credit hours required for each course. 20. Complaints about the program are addressed and records are maintained and available for review. Documentation confirms: a. complaints about the program are documented indicating number, type, and resolution of complaints. b. process of complaint resolution is available for review.

p.130

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

21.

Compliance with Higher Education Reauthorization Act Title IV eligibility and certification requirements is maintained. Documentations confirms: a. b. a written, comprehensive student loan repayment program addresses student loan information, counseling, monitoring, and cooperation with lenders. students are informed of their ethical responsibilities regarding financial assistance.

Suggested Indicators: · Catalog · Recruitment materials · Student handbook/manual · Most recent accreditation/approval reports · Published tuition and fees · NLNAC Annual Report · Record of notification to NLNAC of any substantive change · Record of student complaints within the nursing education unit or to NLNAC · Annual report of ombudsperson · Evidence that students are made aware of their ethical responsibilities regarding financial assistance they received from public or private sources · Comprehensive student loan repayment program

Suggested Tables: · Tuition and fees · Type, number and resolution of formal complaint(s)

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

p.131

VII.

Educational Effectiveness: There is an identified plan for systematic evaluation including assessment of student academic achievement. 22. There is a written plan for systematic program evaluation that is used for continuous program improvement. Documentation confirms:

a.

program evaluation of the nursing education unit, as defined by the governing organization and the unit, demonstrates how and to what extent the program is attaining all

NLNAC standards and criteria.

b. plan contains, at a minimum: expected levels of achievement, time frames, assessment methods. c. data/information are collected, analyzed, aggregated, and trended. d. evaluation findings are used for decision making for program improvement. e. strategies are taken or will be taken to address the area(s) identified as needing improvement. 23. Student academic achievement by program type is evaluated by: graduation rates, licensure/certification pass rates, job placement rates, and program satisfaction. Documentation confirms: a. b. c. d. e. f. g. measurement by graduation rates of students who complete the program within a defined period of time. measurement by performance of licensure examinations of program graduates. measurement by job placement rates of associate degree graduates within one year after graduation. measurement by program satisfaction as measured by graduates and/or employers. data are collected, analyzed, aggregated, and trended. evaluation findings are used for decision making for program improvement. strategies are taken or will be taken to address the area(S) identified as needing improvement.

Suggested Indicator: In Self-Study Report, include systematic plan for program evaluation and assessment of outcomes with documentation of use for program improvements.

Suggested Tables: Graduation rates NCLEX pass rates Job placement rates Program satisfaction

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NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Associate Degree

NLNAC STANDARDS AND CRITERIA DIPLOMA PROGRAMS I. Mission and Governance There are clear and publicly stated mission and/or philosophy and purposes appropriate to postsecondary or higher education in nursing. 1. Mission and/or philosophy of the nursing education unit is congruent with that of the governing organization, or differences are justified by the nursing education unit purposes. Documentation confirms: a. philosophy/mission of the program in nursing is congruent with the mission and purposes of the governing organization. b. program purposes and objectives/competencies are: · congruent with the program philosophy/mission; · clearly stated; · publicly accessible; · appropriate to legal requirements and scope of practice; and · consistent with contemporary beliefs of the profession. c. commitment to cultural, racial, and ethnic diversity of the community in which the institution and the nursing education unit exist. d. programming for distance education is congruent with the philosophy and purposes of the governing organization and nursing education unit. 2. Faculty, administrator, and students participate in governance as defined by the governing organization and nursing education unit. Documentation confirms: a. participation in governance of the governing organization. b. participation in governance of the nursing education unit. 3. Nursing education unit is administered by a nurse who is academically and experientially qualified, and who has authority and responsibility for development and administration of the program. Documentation confirms: a. academic credentials of the nurse administrator is a graduate degree with a major in nursing; explain acceptance of other graduate credentials for the nurse administrator. b. knowledge of the program type is reflected in the experience of the nurse administrator. c. authority and administrative responsibilities are documented within the position of the nurse administrator. d. nurse administrator has adequate time to fulfill the role responsibilities.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

p.133

4.

Policies of the nursing education unit are consistent with those of the governing organization, or differences are justified by the nursing education unit purposes. Documentation confirms: a. congruency between policies affecting nursing faculty and staff and governing organization: · non-discrimination; · faculty appointment/hiring; · academic rank; · grievance procedures; · promotion; · salary and benefits; · tenure; · rights and responsibilities; · termination; and · workload. b. accessibility of nursing education unit policies. c. rationale for policies that differ from governing organization.

Suggested Indicators: · Nursing unit and governing organization mission and/or philosophy statement · Institutional policies · Catalog · Organizational chart · Bylaws · State Board of Nursing Regulations · Curriculum vitae, transcripts, license of nurse administrator · Position description of nurse administrator · Institutional/faculty handbook/manual · Regional accrediting body approval letter and report · State Board of Nursing approval letter and report; other regulatory agency approval letter

Suggested Tables: · Comparison of governing organization and nursing education unit's mission and/or philosophy and purposes · Participation on committees of the governing organization · Participation on committees of the nursing education unit · Policies which differ from the governing organization

p.134

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

II.

Faculty There are qualified and credentialed faculty, appropriate to accomplish the nursing education unit purposes and strengthen its educational effectiveness. 5. Faculty members (full-time and part-time) are academically and experientially qualified, and maintain expertise in their areas of responsibility. Documentation confirms: a. nursing faculty are credentialed with a minimum of a master's degree with a major in nursing. b. rationale for acceptance of other than the minimum required graduate credential. c. faculty credentials meet the requirements of the governing organization and any state agency which has legal authority for educational programs in nursing. d. academic and experiential preparation and variety of faculty backgrounds (full-time and part-time) are appropriate for responsibilities of the nursing education unit. e. expertise of non-nurse faculty is appropriate to the area of responsibility. f. maintenance of faculty expertise in their areas of responsibility, such as: teaching, service, clinical practice, and/or scholarship. 6. Number and utilization of full-time and part-time faculty meet the needs of the nursing education unit to fulfill its purposes. Documentation confirms: a. faculty/student ratios in the classroom and supervised clinical practice are sufficient to insure adequate teaching, supervision, and evaluation. b. utilization of full-time and part-time faculty is consistent with the mission/philosophy of the governing institution and purposes of the nursing education unit (teaching, scholarship, service, practice, administration). c. number and type of faculty are adequate to carry out the purposes and objectives of the program. 7. Faculty performance is periodically evaluated to assure ongoing development and competence Documentation confirms: a. process for faculty performance evaluation. b. evaluation of faculty is in keeping with the mission/philosophy of the nursing education unit and includes areas such as: teaching, practice, service, and scholarship.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

p.135

8.

The collective talents of the faculty reflect scholarship through teaching, application, and the integration and discovery of knowledge as defined by the governing organization and within the nursing education unit. Documentation confirms: a. scholarship is defined by the governing organization and the nursing education unit. b. faculty record of scholarship.

Suggested Indicators: · Credentials of faculty (i.e., curriculum vitae, transcripts, license) · State Board of Nursing Rules and Regulations · Faculty requirements of governing organization · Faculty Profile form* · Faculty files/personnel records · Documentation of faculty continuing education · Institutional/faculty handbook/manual · Faculty/student ratio · Full-time/Part-time faculty ratio · Samples of performance evaluation forms (i.e., student, self, peer, administration) · Faculty and staff appointment to state, national, international panels · Collective bargaining agreement, if appropriate · Faculty participation in scholarly academies; attainment of awards; attainment of internal or external recognition for excellence in teaching, community or professional service or practice · Number of faculty and dollar amount of scholarship support Suggested Tables: · Faculty continuing education · Faculty/student ratio: classroom and clinical · Full-time/part-time faculty ratio *REQUIRED FACULTY PROFILE FORM TO BE INCLUDED IN SELF-STUDY REPORT Governing Organization: Nursing Program:

Faculty Name FT/PT Date of Initial Appointment Rank Bachelor Degree (credential) Institution Granting Degree Graduate Degrees (credential) Institution Granting Degrees Areas of Clinical Expertise Academic Teaching (T) and Other (O)Areas of Responsibility

,,,,,,,,

,,,,,,,,

,,,,,,,,,,,,,,,,

,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

T O ,,,,,,,,,, ,,,,,,,,,,

If pursuing graduate degree, list credits earned to date.

p.136

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

III.

Students The teaching and learning environment is conducive to student academic achievement. 9. Student policies of the nursing education unit are congruent with those of the governing organization, publicly accessible, non-discriminatory, and consistently applied; differences are justified by the nursing education unit purposes. Documentation confirms: a. congruency, availability, and accessibility of student policies with the governing organization and nursing education unit, including but not limited to: non-discrimination; selection and admission; academic progression; student evaluation/grading; retention; withdrawal/dismissal; graduation requirements; grievance/complaints and appeal procedures; financial aid; transfer of credit; recruitment; health requirements; and validation of prior learning/articulation b. rationale for policies that differ from the governing organization policies. c. process by which policies are changed and communicated to students. d. admission and academic progression policies are established by faculty who teach in the diploma nursing program and are congruent with the nursing education unit purposes and governing organization. 10. Students have access to support services administered by qualified individuals that include, but are not limited to: health, counseling, academic advisement, career placement, and financial aid. Documentation confirms: a. availability of student support services. b. academic/experiential qualifications of individuals responsible for student services. c. distance education students have access to appropriate range of student services.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

p.137

11.

Policies concerned with educational and financial records are established and followed. Documentation confirms: a. procedures for maintenance of educational records. b. procedures for maintenance of financial records.

Suggested Indicators: Student handbook/manual Demographic profile of admitted students Published student academic and non-academic policies Catalog and other publications Satisfaction survey results of students, graduates, alumni, employer Curriculum vitae of student support personnel Annual campus safety compared to national average Students served by special support and student disability services Family Education Rights and Privacy Act (FERPA) American with Disabilities Act (ADA) requirements

Suggested Tables: Demographic profile of student population Student policies which differ from the governing organization

p.138

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

IV.

Curriculum and Instruction The curriculum is designed to accomplish its educational and related purposes. 12. Curriculum developed by nursing faculty flows from the nursing education unit philosophy/mission through an organizing framework into a logical progression of course outcomes and learning activities to achieve desired program objectives/outcomes. Documentation confirms: a. integrity of the curriculum as evidenced by congruence among the philosophy, organizing framework, program objectives, curriculum design, course progression, and outcome measures. b. a logical, sequential curriculum plan where course content increases in difficulty. c. a set of guidelines for professional nursing practices approved by a nursing organization is utilized. d. courses in the sciences and humanities provide the foundation for the nursing curriculum. e. interdisciplinary collaboration is evident in the curriculum. f. didactic instruction and supervised practice follow a plan. Course syllabi: documents course content and learning experiences appropriate for the development of competencies required for graduation; and delineates instructional methods used to develop competencies. g. evaluation tools and methods: are consistent with course objectives/outcomes and competencies of the didactic and clinical components of the diploma program; provide for regular feedback to students and faculty with timely indicators of student progress and academic standing; are consistently applied; and are written and available to students. h. technology used is appropriate to meet student learning needs, course objectives/outcomes and course requirements. i. regular reviews of the rigor, currency, and cohesiveness of nursing courses by faculty. 13. Program design provides opportunity for students to achieve program objectives and acquire knowledge, skills, value, and competencies necessary for nursing practice. Documentation confirms: a. curriculum provides for attainment of knowledge and skill sets in the current practice of nursing, community concepts, health care delivery, critical thinking, communications, therapeutic interventions, and current trends in health care. b. evidence that program leads students to develop professional ethics, values and accountability. c. students are able to achieve the objectives in the established and published program length. d. clock and clinical hours meet individual state board of nursing/state department of education requirements.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

p.139

14.

Practice learning environments are selected and monitored by faculty and provide opportunities for a variety of learning options appropriate for contemporary nursing. Documentations confirms: a. agreements and contracts with practice sites are current and specify expectations and responsibilities for all parties. b. facilities used for clinical practice are adequate. c. clinical resources support sufficient numbers and varieties of diploma level experiences.

Suggested Indicators: Abbreviated course syllabi Curriculum plan(s) Class/clinical evaluation tools Professional nursing standards State Board of Nursing report Description of implemented interdisciplinary collaboration Description of alternative methods to deliver academic program Educational use of technology Student records Meeting minutes Survey results from selected constituencies (i.e., student, graduate, employer satisfaction) Sample of student papers and projects Class/clinical schedules Class/clinical observations Clinical agency contracts, affiliation agreements Faculty and student evaluations of clinical agencies

Suggested Tables: Curriculum plan(s) Philosophy, organizing framework, program objectives/outcomes/competencies Clinical agencies and their approval status

p.140

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

V.

Resources Resources are sufficient to accomplish the nursing education unit purposes. 15. Fiscal resources are sufficient to support the nursing education unit purposes and commensurate with the resources of the governing organization. Documentation confirms: a. fiscal allocations from institutional funds, not including grants, gifts, and other restricted sources are: · comparable with other units in the institution; and · sufficient for the program to achieve its goals and objectives. b. responsibility and authority of the nurse administrator and involvement of the nursing faculty in budget preparations are evident. c. resources are adequate to support faculty development and instruction.

16.

Program support services are sufficient for the operations of the nursing education unit. Documentation confirms: a. administrative services are available as needed. b. clerical services are available as needed.

17.

Learning resources are comprehensive, current, developed with nursing faculty input, and accessible to faculty and students. Documentation confirms: a. instructional aids, technology, software and hardware, and technical support are: · available in sufficient quantity and quality to be consistent with program objectives and teaching methods; and · available to assist students and faculty experiencing difficulty using technology. b. learning resources (library, skills laboratory, computer laboratory, etc.) are current and comprehensive to meet nursing education unit purposes. c. learning resources are adequate and accessible. d. mechanisms by which nursing faculty have input into the development and maintenance of learning resources.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

p.141

18.

Physical facilities are appropriate to support the purposes of the nursing education unit. Documentation confirms: a. physical facilities include classrooms, laboratories, multi-media facilities, conference rooms, and office space. b. physical facilities, instructional and non-instructional, are adequate for the nursing education unit at whatever site the diploma nursing program is offered.

Suggested Indicators: · Financial statements and other documents and financial records (i.e., program budget) · Instructional and non-instructional space · Visit to library, computer center, study skills center, learning laboratories, facilities, etc. · Access to library, information system, and communication systems

Suggested Tables: · Nursing education unit budget · Nurse administrator and faculty salaries

p.142

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

VI.

Integrity Integrity is evident in the practices and relationships of the nursing education unit. 19. Information about the program, intended to inform the general public, prospective students, current students, employers and other interested parties, is current, accurate, clear, and consistent. Documentation confirms: a. policies and procedures are published for all education activities that have implications for the health and safety of clients, students, and faculty. b. published documents about the program are current, accurate, clear, and consistent. c. accurate representation of the program to its public(s) and provision of sufficient information to insure accountability and consumer choice is stated in the catalog/published documents: · reflecting the mission and/or philosophy and purposes of the program; · providing current and accurate information about admission policies; tuition and fees; financial aid; graduation; licensing requirements; academic policies; academic calendar; student services; program length; · clearly representing the program and career opportunities through program documents and publications, advertising, website, recruitment, admission materials, and course syllabi; and · providing clear statements of institutional accreditation status; name, address, and telephone number of the National League for Nursing Accrediting Commission as the accrediting agency of the nursing program. d. communication of accurate and consistent information about: · definition of clock and credit hours for lecture, clinical experiences, independent study, and other activities · ratio of clock hours to credit hours; and · specific credit hours required for each course. 20. Complaints about the program are addressed and records are maintained and available for review. Documentation confirms: a. complaints about the program are documented indicating number, type, and resolution of complaints. b. process of complaint resolution is available for review.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

p.143

21.

Compliance with Higher Education Reauthorizations Act Title IV eligibility and certification requirements is maintained. Documentations confirms: a. a written, comprehensive student loan repayment program addresses student loan information, counseling, monitoring, and cooperation with lenders. b. students are informed of their legal/ethical responsibilities regarding financial assistance. c. for schools for which NLNAC is the gatekeeper: findings of student loan default rate, financial aid audit, and program financial reviews.

Suggested Indicators: · Catalog · Recruitment materials · Student handbook/manual · Most recent accreditation/approval reports · Published tuition and fees · NLNAC Annual Report · Record of notification to NLNAC of any substantive change · Record of student complaints within the nursing education unit or to NLNAC · Evidence that students are made aware of their ethical responsibilities regarding financial assistance they received from public or private sources · Comprehensive student loan repayment program · Constitution Day Activity

Suggested Tables: · Tuition and fees · Type, number and resolution of formal complaint(s)

p.144

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

VII.

Educational Effectiveness: There is an identified plan for systematic evaluation including assessment of student academic achievement. 22. There is a written plan for systematic program evaluation that is used for continuous program improvement. Documentation confirms: a. b. c. d. e. program evaluation of the nursing education unit, as defined by the governing organization and the unit, demonstrates how and to what extent the program is attaining all NLNAC standards and criteria. plan contains, at a minimum: expected levels of achievement, time frames, and assessment methods. data/information are collected, analyzed, aggregated, and trended. evaluation findings are used for decision making for program improvement. strategies are taken or will be taken to address the area(s) identified as needing improvement.

23.

Student academic achievement by program type is evaluated by: graduation rates, licensure/certification pass rates, job placement rates, and program satisfaction. Documentation confirms: a. b. c. d. e. f. g. measurement by graduation rates of students who complete the program within a defined period of time. measurement by performance of licensure examinations of program graduates. measurement by job placement rates of diploma graduates within one year after graduation. measurement by program satisfaction as measured by graduates and/or employers. data are collected, analyzed, aggregated, and trended. evaluation findings are used for decision making for program improvement. strategies are taken or will be taken to address the area(s) identified as needing improvement.

Suggested Indicator: In Self-Study Report, include systematic plan for program evaluation and assessment of outcomes with documentation of use for program improvements.

Suggested Tables: Graduation rates NCLEX pass rates Job placement rates Program satisfaction

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Diploma

p.145

NLNAC STANDARDS AND CRITERIA PRACTICAL NURSING PROGRAMS I. Mission and Governance There are clear and publicly stated mission and/or philosophy and purposes appropriate to postsecondary or higher education in nursing. 1. Mission and/or philosophy of the nursing education unit is congruent with that of the governing organization, or differences are justified by the nursing education unit purposes. Documentation confirms: a. philosophy/mission of the program in nursing is congruent with the mission and purposes of the governing organization. b. program purposes and objectives/competencies are: · congruent with the program philosophy/mission; · clearly stated; · publicly accessible; · appropriate for scope of practice; and · consistent with contemporary beliefs of the profession. c. commitment to cultural, racial, and ethnic diversity of the community in which the institution and the nursing education unit exist. d. programming for distance education is congruent with the philosophy and purposes of the governing organization and nursing education unit. 2. Faculty, administrator, and students participate in governance as defined by the governing organization and nursing education unit. Documentation confirms: a. participation in governance of the governing organization. b. participation in governance of the nursing education unit. 3. Nursing education unit is administered by a nurse who is academically and experientially qualified, and who has authority and responsibility for development and administration of the program. Documentation confirms: a. academic credentials of the nurse administrator is a graduate degree with a major in nursing; explain acceptance of other graduate credentials for the nurse administrator. b. knowledge of the program type is reflected in the experience of the nurse administrator. c. authority and administrative responsibilities are documented within the position of the nurse administrator. d. nurse administrator has adequate time to fulfill the role responsibilities.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

p.147

4.

Policies of the nursing education unit are consistent with those of the governing organization, or differences are justified by the nursing education unit purposes. Documentation confirms: a. congruency between policies affecting nursing faculty and staff and governing organization: · non-discrimination; · faculty appointment/hiring; · academic rank, if appropriate; · grievance procedures; · promotion; · salary and benefits; · tenure, if appropriate; · rights and responsibilities; · termination; and · workload. b. accessibility of nursing education unit policies. c. rationale for policies that differ from governing organization.

Suggested Indicators: · Nursing unit and governing organization mission and/or philosophy statement · Institutional policies · Catalog · Organizational chart · Bylaws · State Board of Nursing Regulations · Curriculum vitae, transcripts, license of nurse administrator · Position description of nurse administrator · Institutional/faculty handbook/manual · Regional accrediting body approval letter and report · State Board of Nursing approval letter and report; other regulatory agency approval letter

Suggested Tables: · Comparison of governing organization and nursing education unit's mission and/or philosophy and purposes · Participation on committees of the governing organization · Participation on committees of the nursing education unit · Policies which differ from the governing organization

p.148

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

II.

Faculty There are qualified and credentialed faculty, appropriate to accomplish the nursing education unit purposes and strengthen its educational effectiveness. 5. Faculty members (full-time and part-time) are academically and experientially qualified, and maintain expertise in their areas of responsibility. Documentation confirms: a. majority (at least 50%) of full-time nursing faculty engaged in didactic teaching are credentialed with a minimum of a master's degree in nursing from a governing organization accredited by an NLNAC approved accrediting agency. b. majority of part-time nursing faculty are credentialed with a minimum of a master's degree with a major in nursing from a governing organization accredited by an NLNAC approved accrediting agency. c. remaining nursing faculty, both full-time and part-time, are credentialed with a minimum of a baccalaureate degree in nursing with current evidence of one of the following: progress towards a master's degree in nursing, evidence of course work, continuing education, or certification relevant to current teaching role. d. rationale for acceptance of other than the minimum required graduate credential. e. faculty credentials meet the requirements of the governing organization and any state agency which has legal authority for educational programs in nursing. f. academic and experiential preparation and variety of faculty backgrounds (full-time and part-time) are appropriate for responsibilities of the nursing unit. g. expertise of non-nurse faculty is appropriate to the area of responsibility. h. maintenance of faculty expertise in their areas of responsibility such as: teaching, service, clinical practice, and/or scholarship. 6. Number and utilization of full-time and part-time faculty meet the needs of the nursing education unit to fulfill its purposes. Documentation confirms: a. faculty/student ratios in classroom and supervised clinical practice are sufficient to insure adequate teaching, supervision, and evaluation. b. utilization of full-time and part-time faculty is consistent with the mission/philosophy of the governing institution and purposes of the nursing education unit (teaching, scholarship, service, practice, administration.) c. Number and type of faculty are adequate to carry out the purposes and objectives of the program. 7. Faculty performance is periodically evaluated to assure ongoing development and competence. Documentation confirms: a. process for faculty performance evaluation. b. evaluation of faculty is in keeping with the mission/philosophy of the nursing education unit and includes areas such as: teaching, scholarship, service, and practice.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

p.149

8.

The collective talents of the faculty reflects scholarship through teaching, application, and the integration and discovery of knowledge as defined by the governing organization and within the nursing education unit. Documentation confirms: a. b. scholarship is defined by the governing organization and the nursing education unit. faculty record of scholarship.

Suggested Indicators: · Credentials of faculty (i.e., curriculum vitae, transcripts, license) · Individual plans for meeting the academic credential of a master's in nursing degree · State Board of Nursing Rules and Regulations · Faculty requirements of governing organization · Faculty Profile form* · Faculty files/personnel records · Documentation of faculty continuing education · Institutional/faculty handbook/manual · Faculty/student ratio · Full-time/Part-time faculty ratio · Samples of performance evaluation forms (i.e., student, self, peer, administration) · Faculty and staff appointment to state, national, international panels · Collective bargaining agreement, if appropriate · Faculty participation in scholarly academies; attainment of awards; attainment of internal or external recognition for excellence in teaching, community or professional service or practice · Number of faculty and dollar amount of scholarship support Suggested Tables: · Faculty continuing education · Faculty/student ratio: classroom and clinical · Full-time/part-time faculty ratio *REQUIRED FACULTY PROFILE FORM TO BE INCLUDED IN SELF-STUDY REPORT Governing Organization: Nursing Program:

Faculty Name FT/PT Date of Initial Appointment Rank Bachelor Degree (credential) Institution Granting Degree Graduate Degrees (credential) Institution Granting Degrees Areas of Clinical Expertise Academic Teaching (T) and Other (O)Areas of Responsibility

,,,,,,,,

,,,,,,,,

,,,,,,,,,,,,,,,,

,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

,,,,,,,,

T O ,,,,,,,,,, ,,,,,,,,,,

If pursuing graduate degree, list credits earned to date.

p.150

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

III.

Students The teaching and learning environment is conducive to student academic achievement. 9. Student policies of the nursing education unit are congruent with those of the governing organization, publicly accessible, non-discriminatory, and consistently applied; differences are justified by the nursing education unit purposes. Documentation confirms: a. congruency, availability, and accessibility of student policies with the governing organization and nursing education unit, including but not limited to: non-discrimination; selection and admission; academic progression; student evaluation/grading; retention; withdrawal/dismissal; graduation requirements; grievance/complaints and appeal procedures; financial aid; transfer of credit; recruitment; and health requirements. b. rationale for policies that differ from the governing organization policies. c. process by which policies are changed and communicated to students. d. admission and academic progression policies are established by faculty who teach in the practical nursing program and are congruent with the nursing education unit purposes and governing organization. 10. Students have access to support services administered by qualified individuals that include, but are not limited to: health, counseling, academic advisement, career placement, and financial aid. Documentation confirms: a. availability of student support services. b. academic/experiential qualifications of individuals responsible for student services. c. distance education students have access to appropriate range of student services.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

p.151

11.

Policies concerned with educational and financial records are established and followed. (by the institution or nursing education unit.) Documentation confirms: a. procedures for maintenance of educational records. b. procedures for maintenance of financial records.

Suggested Indicators: Student handbook/manual Demographic profile of admitted students Published student academic and non-academic policies Catalog and other publications Student records Process for student health care coverage Satisfaction survey results of students, graduates, alumni, employer Curriculum vitae of student support personnel Annual campus safety compared to national average Students served by special support and student disability services Family Education Rights and Privacy Act (FERPA) American with Disabilities Act (ADA) requirements

Suggested Tables: Demographic profile of student population Student policies which differ from the governing organization

p.152

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

IV.

Curriculum and Instruction The curriculum is designed to accomplish its educational and related purposes. 12. Curriculum developed by nursing faculty flows from the nursing education unit philosophy/mission through an organizing framework into a logical progression of course outcomes and learning activities to achieve desired program objectives/outcomes. Documentation confirms: a. integrity of the curriculum as evidenced by congruence among the philosophy, organizing framework, program objectives, curriculum design, course progression, and outcome measures. b. a logical, sequential curriculum plan where course content increases in difficulty and complexity c. a set of guidelines for nursing practices approved by a nursing organization. d. content in the sciences and humanities provide the foundation for the nursing curriculum. e. interdisciplinary collaboration is evident in the curriculum. f. course syllabi delineate instruction methods and clinical experiences that describe course content and learning experiences appropriate for the attainment of expected competencies. g. didactic instruction and supervised practice follow a plan. Course syllabi: documents course content and learning experiences appropriate for the development of competencies required for graduation; and delineates instructional methods used to develop competencies. h. evaluation tools and methods: are consistent with course objectives/outcomes and competencies of the didactic and clinical components of the practical nursing program; provide for regular feedback to students and faculty with timely indicators of student progress and academic standing; are consistently applied; and are written and available to students. i. technology used is appropriate to meet student learning needs, course objectives/outcomes and course requirements. j. regular reviews of the rigor, currency, and cohesiveness of nursing courses by faculty. 13. Program design provides opportunity for students to achieve program objectives and acquire knowledge, skills, value, and competencies necessary for nursing practice. Documentation confirms: a. curriculum provides for attainment of knowledge and skill sets in the current practice of practical nursing, community concepts, health care delivery, critical thinking, communications, therapeutic interventions, and current trends in health care. b. program leads students to develop ethics, values and accountability. c. students are able to achieve the objectives in the established and published program length. d. clock and clinical hours meet individual state board of nursing/state department of education requirements.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

p.153

14.

Practice learning environments are selected and monitored by faculty and provide opportunities for a variety of learning options appropriate for contemporary nursing. Documentations confirms: a. agreements and contracts with practice sites are current and specify expectations and responsibilities for all parties. b. facilities used for clinical practice are adequate. c. clinical resources support sufficient numbers and varieties of practical nursing level experiences.

Suggested Indicators: Abbreviated course syllabi Curriculum plan(s) Class/clinical evaluation tools Professional nursing standards Evidence of collaboration with other health care disciplines Description of alternative methods to deliver academic program Educational use of technology Student records Meeting minutes Survey results from selected constituencies (i.e., student, graduate, employer satisfaction) Sample of student papers and projects Class/clinical schedules Class/clinical observations Clinical agency contracts, affiliation agreements Faculty and student evaluations of clinical agencies

Suggested Tables: Curriculum plan Philosophy, organizing framework, program objectives/outcomes/competencies Clinical agencies and their approval status

p.154

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

V.

Resources Resources are sufficient to accomplish the nursing education unit purposes. 15. Fiscal resources are sufficient to support the nursing education unit purposes and commensurate with the resources of the governing organization. Documentation confirms: a. fiscal allocations from institutional funds, not including grants, gifts, and other restricted sources are: · comparable with other units in the institution; and · sufficient for the program to achieve its goals and objectives. b. responsibility and authority of the nurse administrator and involvement of the nursing faculty in budget preparations are evident. c. Resources are adequate to support faculty development and instruction.

16.

Program support services are sufficient for the operations of the nursing education unit. Documentation confirms: a. administrative services are available as needed. b. clerical services are available as needed.

17.

Learning resources are comprehensive, current, developed with nursing faculty input, and accessible to faculty and students. Documentation confirms: a. instructional aids, technology, software and hardware, and technical support are: · available in sufficient quantity and quality to be consistent with program objectives and teaching methods; and · available to assist students and faculty experiencing difficulty using technology. b. learning resources (library, skills laboratory, computer laboratory, etc.) are current and comprehensive to meet nursing education unit purposes. c. learning resources are adequate and accessible. d. mechanisms by which nursing faculty have input into the development and maintenance of learning resources.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

p.155

18.

Physical facilities are appropriate to support the purposes of the nursing education unit. Documentation confirms: a. physical facilities include classrooms, laboratories, multi-media facilities, conference rooms, and office space. b. physical facilities, instructional and non-instructional, are adequate for the nursing education unit at whatever site the practical nursing program is offered.

Suggested Indicators: · Financial statements and other documents and financial records (i.e., program budget) · Instructional and non-instructional space · Visit to library, computer center, study skills center, learning laboratories, facilities, etc. · Access to library, information system, and communication systems

Suggested Tables: · Nursing education unit budget · Nurse administrator and faculty salaries

p.156

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

VI.

Integrity Integrity is evident in the practices and relationships of the nursing education unit. 19. Information about the program, intended to inform the general public, prospective students, current students, employers and other interested parties, is current, accurate, clear, and consistent. Documentation confirms: a. policies and procedures are published for all education activities that have implications for the health and safety of clients, students, and faculty. b. published documents about the program are current, accurate, clear, and consistent. c. accurate representation of the program to its public(s) and provision of sufficient information to insure accountability and consumer choice is stated in the catalog/published documents: · reflecting the mission and/or philosophy and purposes of the program; · providing current and accurate information about admission policies; tuition and fees; financial aid; graduation; licensing requirements; academic policies; academic calendar; student services; program length; · clearly representing the program and career opportunities through program documents and publications, advertising, website, recruitment, admission materials, and course syllabi; and · providing clear statements of institutional accreditation status; name, address, and telephone number of the National League for Nursing Accrediting Commission as the accrediting agency of the nursing program. d. communication of accurate and consistent information about: · definition of clock and credit hours for lecture, clinical experiences, independent study, and other activities · ratio of clock hours to credit hours; and · specific credit hours required for each course. 20. Complaints about the program are addressed and records are maintained and available for review. Documentation confirms: a. complaints about the program are documented indicating number, type, resolution of complaints. b. process of complaint resolution is available for review.

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

p.157

21.

Compliance with Higher Education Reauthorizations Act Title IV eligibility and certification requirements is maintained. Documentations confirms: a. a written, comprehensive student loan repayment program addresses student loan information, counseling, monitoring, and cooperation with lenders. b. students are informed of their legal/ethical responsibilities regarding finical assistance. c. for schools for which NLNAC is the gatekeeper: findings of student loan default rate, financial aid audit, and program financial reviews.

Suggested Indicators: · Catalog · Recruitment materials · Student handbook/manual · Most recent accreditation/approval reports · Published tuition and fees · NLNAC Annual Report · Record of notification to NLNAC of any substantive change · Record of student complaints within the nursing education unit or to NLNAC · Evidence that students are made aware of their ethical responsibilities regarding financial assistance they received from public or private sources · Comprehensive student loan repayment program · Constitution Day Activity

Suggested Tables: · Tuition and fees · Type, number and resolution of formal complaint(s)

p.158

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

VII.

Educational Effectiveness There is an identified plan for systematic evaluation including assessment of student academic achievement. 22. There is a written plan for systematic program evaluation that is used for continuous program improvement. Documentation confirms: a. b. c. d. e. program evaluation of the nursing education unit, as defined by the governing organization and the unit, demonstrates how and to what extent the program is attaining all NLNAC standards and criteria. plan contains, at a minimum: expected levels of achievement, time frames, assessment methods. data/information are collected, analyzed, aggregated, and trended. evaluation findings are used for decision making for program improvement. strategies are taken or will be taken to address the area(s) identified as needing improvement.

23.

Student academic achievement by program type is evaluated by: graduation rates, licensure/certification pass rates, job placement rates, and program satisfaction. Documentation confirms: a. b. c. d. e. f. g. measurement by graduation rates of students who complete the program within a defined period of time. measurement by performance of licensure examinations of program graduates. measurement by job placement rates of practical nursing graduates within one year after graduation. measurement by program satisfaction as measured by graduates and/or employers. data are collected, analyzed, aggregated, and trended. evaluation findings are used for decision making for program improvement. strategies are taken or will be taken to address the area(s) identified as needing improvement.

Suggested Indicator: In Self-Study Report, include systematic plan for program evaluation and assessment of outcomes with documentation of use for program improvements.

Suggested Tables: Graduation rates NCLEX pass rates Job placement rates Program satisfaction

NLNAC Accreditation Manual and Interpretive Guidelines 2006 Edition Section II: Practical Nursing

p.159

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