Introduction

It is redundant to mention that health care, delivery of services, and the educational preparation of health care professionals is in transition. Chaos, perhaps, is a better term. Professional nursing embraced President Clinton's activities to transform the present health care system. Congress and the President could not agree on a comprehensive plan and the Health Security Act of 1993 died in Congress. What we are left with is one component of health care delivery, specifically, managed care, fueling the pervasive changes in health care. The rapidly changing nature of health care certainly affects the planning and implementation of educational programs in nursing.

Contemporary issues in nursing education include that of accreditation. Just as the practice area is changing through managed care, nursing education and its accrediting bodies are changing. Nursing education has been forced to enter discussions regarding the role of and need for accreditation and to make recommendations related to accreditation in current and future aspects of its existence.

Role

As a dean charged with the leadership of a school of nursing, I have had the opportunity to look at the real role of accreditation. One of the questions often asked is: "Do we need accreditation in the health care arena of today?" The answer is that we do. We need accreditation to promote consistently high standards in nursing education.

The ultimate goal of any nursing program, I believe, is to prepare the highest quality of graduate for practice today and tomorrow. Every activity, course, admission decision, clinical site selection, and evaluation is driven by that goal. Accreditation has to be a measure of quality. In the dynamic state of nursing education today, accreditation must act as illumination to help programs move forward in sustaining current quality programs, developing new relevant programs, and creating an environment which promotes positive trends in nursing education.

"Do we need accreditation in the health care arena of today?" The answer is that we do. We need accreditation to promote consistently high standards in nursing education.

It needs to be a measure above the regulatory requirements of minimum standards. Too often today, we are caught up in fads and fancy phrases which can get someone's attention but have little substance. We must move away from fads to focus our attention on the effective trends happening in health care and nursing education.

As a profession, nursing has the responsibility for its own definition and self-governance. Certainly, states play a role in the regulation of nursing. Because preparation of quality professionals across programs and states is essential, accreditation is also needed. Schools of nursing are aided by standards of practice of specialty groups but consistency across jurisdictions helps to develop a strong practice workforce.

I look to an accrediting agency to focus on quality, performance outcomes, and identification of practice knowledge and content which are consistent across programs. Accreditation should set forth expectations of program performance above minimums set by states.

Consistency across colleges and universities, as well as states, is a very important issue at the moment. At the same time it is worthwhile to note that consistency does not mean identical. We do not need a cookie cutter approach to program planning. Rather, we need a set of substantive guidelines which when implemented serve to produce a quality product. It is the very nature of American higher education to be different and often unique. Differing missions, philosophies, and student bodies serve to offer variety. Prospective students can chose from the broadest selection of higher education in the world. Students choosing nursing need to know that those programs accredited by a national nursing accrediting agency will offer a program which meets or exceeds standards considered appropriate by a body of nursing peers. Criteria and standards need to drive the designation of accreditation, not politics and relationships.

Because there is such a specific set of measurable outcomes, performance standards and professional behaviors, a specialty accrediting agency within nursing is needed. Although regional agencies may be used in concert with nursing accreditation agencies, it is not enough to use only regional accrediting agencies that focus on entire colleges or universities. A nursing accrediting agency is also required.

Need

Dr. Barnum has given us an excellent overview of the collective processes that control the preparation and practice of nursing in her article, Licensure, Certification, and Accreditation. Separate and distinct regulations, some mandated and others "elective," drive the parameters of nursing education. There is often an interrelationship between and among the regulatory bodies governing nursing education. State boards of nursing regulate nursing as they approve and monitor programs of nursing so that they meet minimum standards of education. Programs of nursing ultimately prepare graduates of programs to practice in state jurisdictions. Graduates obtain licensure after qualifying through NCLEX examination. Renewal/ approval of nursing programs by state boards is based on annual reports, NCLEX examination results, self study, survey visits, or other criteria established by the board. State boards give the nursing program the opportunity to open its doors, to function, and to offer a program which meets minimum requirements to prepare graduates for safe practice.

If we have state regulatory bodies that monitor nursing education programs, why is there a need for an accrediting agency? It is because regulatory bodies differ from state to state. Their focus is on meeting minimum criteria for program delivery. Minimum standards vary from state to state. Although most states use the state board to regulate and approve nursing programs (National Council of State Boards of Nursing, June 1997), there are in fact four distinct methods of approval and monitoring of programs in states and jurisdictions.

New York State is an example of a jurisdiction where a state agency other than the State Board for Nursing approves and monitors nursing programs; Mississippi and Puerto Rico do the same. This can lead to fragmentation of regulation oversight and may ultimately have an influence on the quality of nursing programs in the state. New York State has had an additional stress on the regulation and quality management of its nursing programs. Philosophical changes in the role of the government brought on by a new Republican governor, along with severe economic conditions and large decreases in the state budget, have severely impeded the ability of the state agency to regulate nursing programs. This can be seen in the mediocre performance of graduates on the NCLEX examination. Concerns about the quality of graduates extends to the quality of nursing practice and also the quality of students entering graduate programs of nursing. The consumer or student also has a right to expect a certain level of quality and preparation in nursing programs. Since there is such a variety of methods of approval by states, consistency is not assured. The standards of an accrediting agency need to be higher than minimal requirements.

Another example illustrating the need for an accreditation agency that demands more than minimal standards includes the increasing number of programs preparing graduate level nurse practitioners. The explosion in the number of these programs is directly related to managed care and the focus on primary care. Some programs have started with little or no resources, limited faculty expertise, limited experience with graduate program development, and no knowledge of graduate program evaluation.

Debate ... has focused on the need for second licensure or advanced certification instead of examining the root of the problem -- identifiable, consistent competencies validated across programs and jurisdictions.

Students flock to nurse practitioner programs as they see a future secure job situation. New York State's experience certainly mirrors this experience. In the last 5 to 10 years, the number of registered nurse practitioner programs has grown from 15 to 40. The State Education Department does not require national certification or testing of any type to receive certification to become a nurse practitioner. By virtue of completion of a state registered nurse practitioner program in New York State, a graduate becomes certified as an NP.

Nursing educators all over the country are concerned about the evaluation of quality standards for advanced practice. The recent activities of the National Council of State Boards to develop a national nurse practitioner licensing and/or certifying examination directs attention to the concern over consistent competencies across jurisdictions. Debate on this issue has focused on the need for second licensure or advanced certification instead of examining the root of the problem--identifiable, consistent competencies validated across programs and jurisdictions. Competencies must be defined and enacted by each program. Concern that programs have not included these competencies have some suggesting legislative mandate to insure a minimum standard of competency.

Although there is a need for an accrediting body, in addition to state regulating agencies, resources needed to implement accreditation activities must be considered. The human capital necessary for the preparation of documents, analysis of materials and production costs are enormous. The accreditation process must include data instruments and collection processes which are labor efficient. These instruments must be able to be used over time so that a profile of the program and/or school emerges clearly.

In the past accreditation activities were seen in a rather episodic context. One of the first questions a prospective faculty member asks when interviewing for a position is "when was the last time you had a site visit?" and "when will the next site visit be made?" Faculty often gage the type of work that will be asked of them based on the answer to those two questions. Accreditation to faculty means a set of laborious activities, including reports, meetings, review of programs, and sometimes changes in curricula. Depending on the size of the program, the faculty member may have a small or very substantive role in activities that continue for one or two years. Accreditation activities are seen as very labor intensive and the time detracts from other aspects of the faculty role including time for scholarly activity. The amount of time and commitment made to accreditation activities are often not reflected in promotion and tenure decisions at colleges and universities. As an administrator, I try to balance the need for school and university service activities and professional/faculty development activities essential to faculty retention and promotion.

Recommendations for Accrediting Schools of Nursing

The role of accreditation in the future is many fold. It defines standards of quality in nursing education programs. To refer only to clinical practice standards and then deduce what is needed for nursing education is backward. Colleagues in nursing practice must be a part of the discussions along with faculty who represent the variety of nursing programs today. Potential standards must be debated in a wide arena of nursing educators and then build to consensus. A fine example of this process is the development of two Essentials Documents, one for undergraduate education and one for graduate education which were created by task forces of American Association of Colleges of Nursing. Although not defined as standards of quality, these documents serve as guidelines for curriculum development.

There also needs to be a variety of methods to build documents, standards and/or guidelines for quality nursing programs. Criteria for evaluation would follow from these documents. Today many nursing programs focus on the criteria for evaluation and plan accreditation activities around them. That seems to me to be also backward. Ongoing communication through meetings, conferences, workshops, town meetings, and a variety of Internet communication technologies will serve to produce, by the accrediting agency, the widest understanding of a definition of program quality. Along with extensive communication with nursing educators, an infrastructure needs to be put in place that supports this type of activity. Beginning, developing, and expanding programs of nursing in this changing health care environment is a dynamic process.

Finally with the expansion in the number of graduate programs, particularly nurse practitioner programs, it is important to cooperate with specialty and role-related organizations when developing and evaluating programs. Cooperation among organizations which can build to an alliance of interest groups can help nursing programs build and develop programs without redundancy, loss of resources, or confusion of disparate standards. Indeed efficiency, efficacy, and clarity of purpose will flow from consistent quality indices.

Summary

In the past when I have thought about accreditation activities, I was reminded of the Alan Arkin film, The Russians Are Coming, The Russians Are Coming. Anxiety and concern over the production of a document called the self study only led to a visit by real people. As they approached the school, anxiety led to panic and the most unusual activities from cleaning, straightening, and power dressing to concern, self-doubt, and feelings of inadequacies emerged. It was the fear of the unknown that led to a sense of confusion and conflicting messages.

Accreditation is needed. However, accreditation must become an integral part of the daily functioning of the program or school, not an episodic event. It is justifiable use of resources when it leads to overall continuous program improvement. By incorporating quality standards of nursing education into ongoing activities, a seamless, continuous development of the program and/or school exists. I believe this is attainable and will contribute to quality nursing education. I support nursing education accreditation and applaud recent efforts to establish a relevant, contemporary and accountable organization to support college and university nursing programs.

Author

Mary S. Collins, PhD, RN

Mary S. Collins came to Binghamton University in 1976 with a variety of Public Health Nursing experiences. Her current areas of scholarship include identification of and meeting today's healthcare needs and preparing nursing students to meet these needs. Activities related to meeting current healthcare needs include the clarification of roles of Advanced Practice Nurses; offering managed care analyses; identifying criteria for a managed care program for Medicaid clients; and facilitating the implementation of a case management model. Additionally, she has been actively involved in preparing students to practice in tomorrow's healthcare environment by establishing pedagogy-curriculum to meet future teaching and learning needs and investigating the professional development of graduate students in nursing. Dr. Collins serves as a program Evaluator for National League for Nursing Accreditation. She is currently Dean and Associate Professor, Decker School of Nursing, Binghamton University, Binghamton, NY.

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