Accreditation

Accreditation process of
Nursing Program
By-Isha Thapa Magar
MN 1st
Year

Accreditation/Approval
 Is process of granting approval, providing
with credentials that standards have been
maintained or met.
 Is the certification of organizations.
 Provides documented validation of
qualifications of organizations to carry out its
stated goals & objectives.

Definition
 Accreditation is a self-regulatory process
by which governmental & nongovernmental
organizations grant formal recognition to
programs or institutions that meet stated
standards of quality by fulfilling indicators
established by each institution.

 It is a process of quality assurance that
determines whether an institution meets
established standards for function, structure,
and performance.

 Accreditation is process by which authorized
body evaluates quality of a higher education
institution (HEI) as a whole or of a specific
educational program in order to formally
recognize it as having met certain
predetermined minimal criteria or standards.

 Accreditation is both a status & a process.
 As a status,
- It provides public notification that an
institution or program meets standards of
quality set forth by an accrediting agency.

 As a process,
- It reflects fact that in achieving recognition by
accrediting agency,
- institution or program is committed to self
study & external review by one’s peers in
seeking not only to meet standards but to
continuously seek ways in which to enhance
quality of education & training provided.

International History of Accreditation
In Nursing Program
 During the late 1800s and early 1900s:
- England first struggled with nursing
regulation, debate being self-regulation
versus legal regulation.

 Canada begin to regulate nurses in early
1900s (Clarke & Wearing, 2001).
 New Zealand was the first country to enact
an independent licensing law on August 12,
1901, & Ellen Dougherty of New Zealand
was the first nurse, worldwide, to be
registered (Report, 1985;
Spector,2004;Weisenbeck &Calico, 1991).

 In 1919 England finally enacted The Nurses
Registration Act of 1919, & this provided for
a main registry for general nurses who met
certain qualifications. It further established
supplemental registries for male nurses &
specialists in mental disease, care of
children, and infectious diseases (Report,
1985).

 In the U.S, North Carolina enacted the first
registration law in 1903, followed by New
York, New Jersey, and Virginia. However, the
early registration laws did not define the
scope of practice.
 New York, in 1983, was the first state to
define a scope of practice and to adopt a
mandatory licensure law (Flanagan, 1976;
Weisenbeck, 1991).

 After the registration laws were enacted in
the U.S., state boards of nursing begin to
emerge for the purpose of regulating nurses
and protecting the public.
 The first nurse inspectors was Annie
Damer, in New York (American Nurses
Association [ANA], 2001).

 When national nursing organizations
began to accredit nursing education
programs, boards of nursing continued with
their approval processes, utilizing the
standards of education found in nursing
practice acts & rules and regulations.

 As a result, nursing's dual process for
evaluating nursing education programs
evolved in 1990s, of two national nursing
accrediting agencies in U.S. are CCNE and
NLN-AC .

Accreditation at National Level
National accreditation organizations perform
accreditation process throughout U.S & review
institutions in their entirety.

1. NLN-AC
 National League for
Nursing(NLN) is a
national organization for
faculty nurses & leaders in
nursing education which
was founded in 1893.
 The first organization for
nursing in US.

 In 1912, it was renamed the National
League for Nursing Education (NLNE).
 In 1952, the NLNE combined with
the National Organization for Public Health
Nursing and the Association for Collegiate
Schools of Nursing as the National League
for Nursing, and assume responsibility for
the accreditation of nursing schools in the
U.S.

 In 1996, the 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).
 In 2001, NLNAC was renamed to
the Accreditation Commission for
Education in Nursing (ACEN).

 In 2014, the NLN created an additional
commission for nursing education
accreditation, the Commission for Nursing
Education Accreditation (CNEA)

2. CCNE
 In 1996, American Association of Colleges of
Nursing (AACN), as the national advocacy
organization for America's baccalaureate &
higher-degree nursing education programs,
created autonomous accrediting
organization, Commission on Collegiate
Nursing Education (CCNE).

 Is an autonomous nursing
education accrediting agency that
contributes to improvement of the public's
health.
 The CCNE is recognized by the U.S.
Secretary of Education as a national
accreditation agency.

 The CCNE is the only nursing education
accrediting agency dedicated exclusively to
accreditation of bachelor's and graduate-
degree nursing education programs.

Accreditation at Regional Level
 All colleges & universities must meet
additional regulations & standards
established by regional accrediting bodies,
which function under federal authority.

 This ensures that;
o academic institutions actually offer programs &
services they proclaim
o they meet their mission & obligations to public,
what is particularly critical for publicly supported
institutions.

 Accreditation by regional bodies requires
years of planned activities & report writing,
followed by site visits by evaluators, with final
decisions ultimately made by a review
board.

 Once granted, the accreditation status may
be as 5years.
 When new programme is added then for such
new accreditation should be conducted.
 Depending on the fulfillment of standard
criteria Accreditation is done yearly also.

Accreditation of Nursing Program in
Nepal
 Need & demand for accreditation has
arisen because of rapid growth in number
& variety of HEIs and programs since
1990s in Nepal.

 Accrediting Body of Nursing Program In
Nepal
1. University Grants Commission (UGC)
2. Nepal Nursing Council (NNC)

1. University Grants Commission
(UGC)
 The University Grants Commission (UGC)
was established after the implementation of
multi-university concept in Nepal.
 The University Grants Commission (UGC) is
a statutory body established by an act of
parliament [Act No 25 (1993)].
 The Commission started functioning since
July 1994.

 UGC is responsible for ;
• allocation & disbursement of grants to
universities & their campuses,
• regulating their activities & formulating policies &
programs on establishment of new universities.

 In 2007, UGC launched Quality Assurance
and Accreditation (QAA) program as an
important aspect of reform in higher
education in Nepal.
 In order to accomplish this program, UGC
has formed a Quality Assurance and
Accreditation Committee (QAAC) for the
development & implementation of QAA
activities in higher education in Nepal.

 At present, Following are universities
providing nursing education in context of are
Nepal.
1. Tribhuvan University (TU) established in 1960;
2. Council For Technical Education and Vocational
Training (CTEVT), established in 1989
3. Kathmandu University (KU) established in 1992
(2048 B.S.);
4. Koirala Institute of Health Sciences (BPKIHS) was
established on Jan 18, 1993
5. Purbanchal University (PU) established in 1994
(2052 B.S.)
6. Pokhara University (POKU) established in 1996
(2054 B.S.)

2. Nepal Nursing Council (NNC)
 Nepal Nursing Council (NNC) is a statutory
body for establishing uniform & high
standards of Nursing education in Nepal.
 NNC was established in 1996 under Nepal
Nursing Council Act 1996.
 NNC is one of many statutory bodies related
to Healthcare in Nepal.

 NNC grants recognition of nursing
qualifications, gives accreditation to
Nursing schools, administers Nursing
Licensing Exam (NLEN) & maintains the
registration of Registered Nurses in
Nepal.

1. Institutional
accreditation
a. Regional
accreditation
b. National
accreditation
2. Specialized or
programmatic
accreditation
1. Probationary
accreditation
2. Provisional
accreditation
3. Full accreditation

1. Institutional Accreditation
 Refers to accreditation of school, college,
universities or institution as a whole.
 Institutional accreditation status is
achieved by a college or university that
meets quality standards & fulfills the
requirements designated by accreditation
organization.

 In order to meet requirements for institutional
accreditation status, all aspects of college or
university, including academic quality,
administrative effectiveness, & all other
related services of the institution, are
reviewed by accreditation organization.
 It indicates & verifies that entire institution
has met certain accreditation standards of
educational quality.

2. Specialized Accreditation
 Is a type of accreditation status that is
designated for specialized departments,
programs, schools, or colleges within a
college or university that have already been
awarded institutional accreditation.

 Refers to accreditation of academic courses
such as sciences, education, commerce,
law, engineering, nursing, etc.
 Also called programmatic & professional
accreditation

OR
1.Probationary accreditation
• Enables an nursing education institution
applying for accreditation for first time to
offer nursing education for a period not
exceeding three years whilst completing
requirements for full accreditation.

2. Provisional accreditation
 Enables a nursing education institution
which has previously been accredited but
which complies with most but not all of the
required standards to operate for a period
not exceeding one year while it addresses
the areas of concern.

3. Full accreditation
 Indicates that nursing institution complies
with all the required standards & may
operate for a period of five years before
applying for re-accreditation.

Purposes
 Assuring Quality:
 Accreditation is primary means by which
universities, colleges & programs assure
education quality to students & public.

 Source of Improvement:
 Accreditation provides a source & urge for
continuous improvement in educational
practices followed by an institute, due to
periodic evaluation by the agencies.

 Easing Transfer:
 Accreditation of institutions & programs is
important to students for smooth transfer of
programs among colleges & universities.

 Recognition:
 Accreditation of institutions & their programs
makes them recognized as a symbol of high
quality education practitioner.
 The government & local agencies also openly
refer to these institutes to students &
encourage them to consider only accredited
institutes.

 Engendering Employer’s Confidence:
 Accredited status of an institution or program
is important to employers while evaluating
credentials of job applicants & providing
financial support to current employees
seeking additional education.

 For maintenance of adequate administration
requirement.
 Maintaining a uniform standard for nursing
education & nursing service.
 Stimulation of institutional self-improvement
by evaluation & inspection.

 It safeguards institution from social education
& political pressures.
 It helps in registration of nurses.
 It prescribes the syllabus.
 It grants recognition to school & colleges.

 It guides the school/college of nursing,
according to recommendation and criteria.
 It also services to prepare the competent to
serve the public.

Principle
 Based on accepted standards
 Each organization seeking accreditation will
be surveyed and evaluated in terms of the
appropriateness and adequacy of its
philosophy and objectives and its terms of the
degree and competence and which it
achieves its goals.

 Admits periodic review, criticism and
readjustment of its criteria, policies and
procedures to changes in education
 Provide opportunities for institutional growth
through self-survey and evaluation and self-
regulation.

Accreditation Process
 Generally there are 6 steps for
accreditation of nursing programme:
1. Application of registration
2. Self assessment
3. On the site survey
4. Report preparation
5. Award of accreditation
6. Maintaining accredited status

Accreditation Process
1. A self – assessment:
 Is conducted by faculty, administrators, &
staff of institution or academic program,
resulting in a report that takes as its
reference set of standards & criteria of
accrediting body.

B. A study visit:
 Is conducted by a team of peers,
selected by accrediting organization.
 They reviews evidence, visits premises,
interviews academic & administrative
staff.
 Resulting in an assessment report,
including a recommendation to
commission of accrediting body.

C. Examination by the commission:
 Examination by commission of evidence &
recommendation on basis of given set of
criteria concerning quality.
 Resulting in a final judgment &
communication of formal decision to
institution, if appropriate.

UGC ACCREDITATION
PROCEDURES
 UGC accreditation procedure consists of a
four–stage process. They are:
1. Submission of Letter of Intent (Lol)
2. Preparation & submission of Self-Study
Report (SSR)
3. Peer review
4. Final Decision of accreditation

I. Submission of a Letter of Intent (LoI)
 The HEIs have to submit a Letter of Intent in
specified format along with information &
determine eligibility in QAA.
 QAAD will send manuals & guidelines to
eligible institutions to complete entire
process of self-assessment.

II. Preparation and Submission of Self–
Study Report (SSR)
 The eligible institution itself has to prepare
Self – Study Report (SSR).
 Preparation of SSR is an internal exercise
for participating institutions expected to be
done with honesty, self-trust & confidence.

 It aims at providing an opportunity for
institutions to measure their effectiveness,
efficiency, & to identify core strengths and
weaknesses

III. Peer Review
 After receiving formal SSR report from
participating institution,
- QAAC forms a Peer Review Team (PRT) to
evaluate QAA status based on SSR and
- visit institution and inspect patterns of
evidence to validate SSR through
observation and interaction with people
concerned in respective institution.

 The team also checks validity & reliability of
information reported in SSR.
 It also provides a confidential score to
facilitate final grading.
 The PRT report & assessment will be
discussed in Technical Committee and will be
submitted to QAAC.

IV. Final Decision for Accreditation
 QAAC reviews PRT report & recommends to
UGC for accreditation status.
 UGC gives final decision.
 In case of accreditation certification will be
valid for a period of five years.

 The institutions will have to apply for
Accreditation & undergo a fresh QAA process
after five years.
 However they may apply it even before the
maturity of this period and the process will be
started accordingly

Problems & Challenges
 Quality Consciousness at all levels will take
time
 Sustenance & consistency of efforts will be
required
 Commitment on a consistent basis
 High rates of attrition will require repeated &
continual training
 Public Sector will take a longer time to get
into the process

References
 Bhattari,S. (2010). Trends & Issues in
Nursing.Dilibazar, Kathmandu: Makalu
Publication House.
 s
 Pandey,K &Bhandari ,B. (2073). A text book
of Nursing Trends and Issues. Bagbazar,
Kathmandu: Samiksha Publication Pvt.Ltd.

 The Quality Assurance and Accreditation –
UGC Nepal.(nd). Retrieved
fromugcnepal.edu.np/oldsite/files/QAA_Brief_
Intro.doc
 Types of Accreditation.(nd).Retrieved
fromhttps://www.worldwidelearn.com/accredit
ation/types-accreditation.htm
 Quality assurance and accreditation for Higher
education in Nepal. (2013). Retrieved
fromhttp://www.ugcnepal.edu.np/ugc_header
_images/QAA_Guidelines.pdf

 QAA/Reform Unit.(nd). Retrieved
fromhttp://www.pncampus.edu.np/qaa.php
 CCNE:Who We Are – The American
Association of Colleges of Nursing.(nd).
Retrieved
fromhttps://www.aacnnursing.org/CCNE-
Accreditation/Who-We-Are
 Commission on Collegiate Nursing
Education.(nd).Retrieved
fromhttps://en.wikipedia.org/wiki/Commission
_on_Collegiate_Nursing_Education

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