Introduction

Dr. Barnum raises several compelling issues in her piece on Licensure, Certification, and Accreditation while positing questions as to their future relevance to the profession as they stand today. Licensure, she asserts, is a state regulatory function to guarantee the "MINIMUM" safety of the entering professional. I always thought rather simplistically about these events as:

• licensure tests minimum safety for the entering professional;
• credentialing measures advanced knowledge and skills;
• accreditation verifies the program's quality and integrity to prepare the student appropriately and according to national standards.

Questions for Tomorrow

Two interesting sets of questions for future relevance include:

1. Will we continue to require measures for quality to produce minimum or advanced competency? Are there other measures we should be considering?

   The answer to this set of questions of course will be "absolutely." Fifty years ago, outcome measures were not understood. Quality improvement has brought them to the fore. Nursing and other disciplines will need to successfully complete competency examinations in one's practice discipline (beyond the counting of curriculum inputs or process).

2. Who will be the regulatory agent of accountability? the state? the federal government? the professions? the public stakeholders? And should the processes of licensure, accreditation and credentialing be linked in order to improve accountability?

   Actually, Barnum makes a case that states really are serving in this capacity nominally. The licensure exam is already national; the passing score is national; and states recognize reciprocity with each other across state boundaries now. States serve primarily as a register of record. As competency outcome measures for individuals become the norm, states may actually have a role to play in sanctioning schools within their state boundaries who do not meet or "produce" these competencies. They could impose additional requirements or practice restrictions as well for the graduate who cannot demonstrate minimum competency in all other desired areas.

Barnum describes the "hot issue" around licensure as the proposed variety of new licensures suggested, but never approved, especially around entry to practice. This difference has been hampered, she says, by the rigidity associated with waivering or grandfathering of present RNs. I'm convinced, as Barnum, that this change will not be reached by consensus without grandfathering as long as associate degree and diploma nurses outnumber the baccalaureates for entry positions, as they will surely continue to do through several decades.

With the massive reforms in health care delivery and market forces in search of efficient and productive quality outcomes, employers care more for needed competencies than the breed, hybrid, degree or credential. Lindeman recently asserted the entry to practice as the single most divisive "wedge" issue for the profession.

The professional entry has changed over time, with added complexity and knowledge, and will likely continue to do so.

My sense is that the "entry" issue will soon be replaced with the next "hot issue": models of workforce patterns and differential practice abilities across and within disciplines. The professional entry has changed over time, with added complexity and knowledge, and will likely continue to do so. More importantly will be the issue of how each discipline's preparation, including differential levels within the nursing profession, contribute uniquely and efficiently to the productive workforce team. What do you think?

Changes in health reform, driven by financial pressures for efficient practice with respectable outcomes, will drive the profession to new levels of differential practice, preparation and competence. Licensure, accreditation and credentialing processes should be collaboratively transformed and linked to accommodate this differentiation.

Most agree that the marketplace is forcing us to think differently about tomorrow's practice and to re-engineer how we prepare nurses for these new and emerging ways of practice Along with these changes will come the cessation of our stale obsession with counting content and process based on disease models of caretaking for institutionalized sick individuals. Outcome measures of competency for different levels of practice with different populations will be the new day... for licensure, accreditation and credentialing.

New Dimensions for Tomorrow's Care Systems

I attend many interdisciplinary meetings where nursing is considered essential for these new practice futures, albeit needing new knowledge in new dimensions of tomorrow's care systems. Such areas for role expansion include genetics counseling, grade school health curriculum modules, more ethics in response to more technology, financial outcome analysis and information management, just to name a few. However, these changes are slow in coming as faculties are not engaged in these practice demands nor are they "prepared" in these areas. The resulting burden is a faculty being pushed to add yet more to the curriculum in areas their own practice does not use or understand. Accreditation, consequently, becomes the peer review gatekeeper or scapegoat against such pressure.

How can we mobilize healthy change among our faculties and use the licensure, accreditation and credentialing processes to help in these expanding knowledge areas and new roles for the profession? Must faculty have formal expertise before offering expert content? Are there other ways of making these areas available to students? With Internet potential, for example, do all schools need localized expertise? What does the OJIN readership think?

Important Questions

Accreditation is a process very much in challenge today over several issues. Recently, the Association for Academic Health Centers held a seminar to review such issues across disciplines and outlined the following concerns for all accreditation processes:

• Should the nature and control of the accreditation processes be voluntary and peer-reviewed as currently offered, or be managed by governmental regulatory controls?
• Should the responsibilities for the accreditation process be regional for institutions or specialized by discipline? federal or state in purview? institutional or program specific?
• Should accreditation site visitors be objective and representative of the discipline, including each specialized program being reviewed, or are they more representative of trade associations and membership agencies just trying to secure more resources for their own interests?
• What are the assurances that accreditation works? What quality measures should be evaluated?
• How are the public stakeholders and policy makers involved in and educated about accreditation?
• Should accreditation be the linkage to certification, licensure and students' financial aid and financial loan default?

Each question could and should engage some healthy discussion; OJIN provides an excellent forum for such interchange. Let me start the process illustrating how one of the above questions could be addressed. One could ask, "Should accreditors and site visitors be from the specialized programs being reviewed?" This would imply that programs with baccalaureate, masters, primary care practitioners, nurse midwifery and nurse anesthesia would be peer-reviewed with faculty site visitors from each program type. Responses might include noting that in principle, such a strategy is reasoned. However, in practice, it is far too costly and risks the appearance of being too self-serving. What are the alternatives? Are on-site visits the only way to provide peer review?

Accreditation site visitors' quality and representativeness is one of many issue that needs dialogue and discussion. Assurances for measuring the quality productivity of accreditation is another. What measures do you believe should be evaluated and documented as outcomes and accountability of the process? What stakeholder inputs would be necessary to ensure effective quality accreditation? What sanctions should be imposed for those that don't meet these quality measures?

Most educators are confident that accreditation is still the primary measure of academic quality. It is further true that the proliferation of accrediting bodies add to institutional costs, and university presidents are questioning the cost/benefit ratio.

Although most agree that institutional accreditation alone will not suffice to ensure quality, accreditation processes often are used as an excuse to limit innovation and experimentation, to protect discipline turf and to avoid interdisciplinary approaches to learning or to collaborative accreditation processes. How can these phenomena be avoided?

Although most agree that institutional accreditation alone will not suffice to ensure quality, accreditation processes often are used as an excuse to limit innovation and experimentation, to protect discipline turf and to avoid interdisciplinary approaches to learning or to collaborative accreditation processes. How can these phenomena be avoided?

Many agree that higher standards and better progress in American higher education over time has been the result of accreditation's peer review process. Others argue that with the reauthorization of the higher education act in 1992 and again in 1997, it may well be time for total system review and some re-engineering of this frustrating, complex, confusing and labor intensive higher education "quality" process.

Suggestions for Change

In a recent Chronicle of Higher Education article, Shattuck (1997) challenged today's higher education "quality" by suggesting colleges and universities have continually admitted ill-prepared high school graduates into gradually more diluted undergraduate programs (except science, math and engineering). As long as such "bloated systems of higher education" are dependent upon the tuition of increasing class sizes, colleges indirectly promote or at best maintain these soft standards of high school performance. He holds high schools responsible to conduct standardized tests for graduation requirements, and asks colleges and universities to raise their entrance requirements, proposing that "open admissions should become a thing of the past." Shattuck also suggests "accrediting agencies accommodate to present lax standards," adding they continue to perpetuate lax standards when they are "responsible to no one outside their profession they are charged to regulate" (p. B7).

The Task Force on Accreditation of Health Professions Education of the Pew Charitable Trust was charged with the goal to improve the health professions' accreditation processes so that they better meet evolving societal needs. Specifically noted was the idea that accreditation should have a role in improving education for the health professions.

My "desired future" accreditation process would have faculty, student and program data and information electronically submitted annually, trended for improvements over time and benchmarked with similar regional, public, private institutions that a school wishes to identify as its cohort schools.

Further, they support accreditation as a model for assessment and improvement and one that promotes interdisciplinary health professions' education, while minimizing duplication and waste, and enhancing flexibility and adaptability.

Other suggestions for future improvement include moving from evaluation of standards (the inspection function) to assessing improvements and serving as a catalyst for the improvement process. This will require benchmarking with other performance outcomes from other schools. They also suggest public participation involving multiple stakeholders and evaluating the effectiveness of the accreditation value.

My "desired future" accreditation process would have faculty, student and program data and information electronically submitted annually, trended for improvements over time and benchmarked with similar regional, public, private institutions that a school wishes to identify as its cohort schools. Then, teams of trained, paid faculty that could include someone from each program type would review the annual data and self-study for quality and improvement. No actual site visits need to occur unless suspicious information or other criteria as determined would suggest the need for random or scheduled visits. What advantages or disadvantages to this scenario does the audience envision? Imagine what we could learn from such national repositories of nursing data and information.

Summary

In summary, accreditation is a means to recognize an educational institution for standards that qualify the graduate for higher or more specialized education or for professional practice through a process of periodic self-examination and peer review that focuses on quality improvement. There is a renewed call for a balance of the interests of the institutions, the professions and the public. Reducing the proliferation, duplication and cost of accreditation will require new structures that can also increase effectiveness and quality outcomes. Reducing barriers to innovation among health professions education must be a priority.

These issues are not unique to the nursing profession nor will they be resolved with a simplistic competition from a new agency (AACN). While competition may ultimately serve as a catalyst to stimulate transformation in the accreditation industry, collaboration of limited resources in an already too costly process would provide ample opportunities for emerging partnership models. Even collaboration would not in itself offer assurances for the quality improvement and accountability being called for from employers and the public. This issue demands a response bigger than current practices.

The NLN continues to have public and employer membership representation; a commitment to improvement, and plans for improvement are underway to implement an integrated, automated, electronic information system. NLN delivers specialized nursing accreditation more effectively than state, institutional, or regional bodies or administrators can deliver, but must continue to do so with a more efficient, quality improvement approach.

Barnum asks "What is gained (with accreditation) versus what is lost (without accreditation)?" With the massive health reform underway and the need for major transformation in the education of all health providers, health care employers, professionals and the public will need better measures of quality improvement in the preparation of the nation's practitioners for tomorrow... through improved and responsive accreditation, licensure and credentialing. We can't afford to go without, especially now, nor should we transfer the process to other self-serving regulators. There are several improvements needed, and we should be about providing them.

Author

Sheila A. Ryan, PhD, RN, FAAN

Dr. Ryan served as Executive President of the National League for Nursing for a one year term ending June 1997, and is currently serving as its Chief Executive Officer on an interim basis. Since 1986, she has served as Program Director of the Commonwealth Fund Executive Nurse Fellowship Program and managed the dispersement of over six million dollars in awards. She also served on the Health Professionals Education commission for the 21st Century for the Pew Charitable Trust. As a member of the Institute of Medicine, she has served on various committees including the Primary Care Workforce Committee. In addition, Dr. Ryan presently chairs the Robert Wood Johnson Health Policy Fellowship Selection Committee. She is currently serving on the National Security Council's Committee "Maintaining Privacy and Security in Health Care Applications of the National Information Infrastructure." A member of the American Academy of Nursing, Dr. Ryan is currently Dean and Professor at the School of Nursing and Director of Medical Center Nursing at the University of Rochester in Rochester, New York.

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