QUALITY IN NURSING EDUCATION

Introduction

Education is a complex and multidimensional phenomenon. Education needs to develop

associative skills capable of interacting in a global world, which more and more values critical
reflexive capacity and the innovative and transforming character of social problems. Understood
as a complex phenomenon, quality education involves the relationship between material and
human resources, as well as teaching-learning processes, the curriculum, the experiences,
teachers’ commitment and their attitudes, and the learning expectations, in addition to the unique
performance of each student.

National discussions in Brazil focus on the desirable attributes of the educational process
with a view to the production, organization, management and dissemination of knowledge and
practices that are fundamental to the exercise of citizenship and of the profession. In order to do
so, investments have been made in new teaching-learning methodologies, in practices based on
scientific evidence, in innovative technologies and in references that support the systemic
conception and social protagonism, regarding both academic training and the professional’s
continuing and permanent education.

The construction of knowledge, especially that of Nursing, generally takes place in

evolutionary phases which do not succeed in a linear and specific way, but instead procedurally
and complementarily. In the first phase, the Florence Nightingale period, the focus of Nursing
knowledge focused on answering the question “what to do?”. In the second phase, in trying to
conquer the technical domain, Nursing sought to define “how to do it?”. The third phase focused
on investigating “why do it?”. In the fourth phase, we sought to discuss “what is proper nursing
knowledge?”9 and, in adding a fifth phase, we ask: how to promote quality education in Nursing
as a complex and multidimensional phenomenon, in view of the need to understand complex
relationships that were not taught to us in the mechanistic educational model?

QUALITY ASSURANCE IN NURSING

Introduction

Quality assurance( QA ) is a way of preventing mistakes or defects in manufactured products and

avoiding problem when delivering solution or services to customers. Quality assurance refers to
administrative and procedural activities implemented in a quality system so that requirements
and goals of a product, service or activity will be fullfilled. It is the systematic measurement,
comparison with a standard, monitoring of processes and an associated feedback loop that
confers error prevention. His can be constructed with quality control, which is focused on
process output.

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History of quality assurance

The process of systematic evaluation of health care is not new; QA activities date back to
Florence Nightingale. She urged that all nursing care being rendered be evaluated. She
communicated her findings and received public support. The government interest in health care
accountability resulted in the regular evaluation of hospital care

In 1940s and 1950s, the genaral public become more aware of organizing, planning and
evaluating methods of health care services.

In 1952, the Joint Commision on Accreditation of Hospitals was founded . it provides standardas
for accreditation.

In 1955 American Nurses Association (ANA) published its functions. Standards and
qualification for practice, and the national league for nursing published what peiple can expect of
a modern nursing service.

Definitions

Quality assurance is a programme adopted by an institution that is designed to promote the best
possible care. - Deloughery

QA is a judgement concerning the process of care based on the extent to which that care
contributes to valued outcomes. – Donabedian, 1982

QA is a management system designed to give maximum guarantee and ensure confidence that
the service provided is up to the given accepted level of quality, the standards prescribed for that
service which is being achieved with a minimum of total expenditure

- British Standards Institute

Concepts of QA

QA is a process centered approach to ensure that a company or organization is providing the best
possible product or services. It is related to quality control, which focuses on the end result.
Although these terms are sometimes used interchangeably, quality assurance focuses on
enhancing and improving the process that is used to create the end result, rather than focusing on
the result itselt.

QA is a wide - ranging concept covering all matters that individually or collectively influence the
quality of a product.

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Need of quality assurance in nursing education

In the era of quality orientation, human rights and a consumer driven society, the quest is for the
best quality of education. The nursing and midwifery education institutions (NMEI) are expected
to provide quality instructions, and perform their roles effectively in producing qualified
graduates who will satisfy the demand and expectations of the society.the following factors will
assist us to realize the need for quality assurance in nursing education.

 Competition : there is a drastic increase in the number of nursing schools and colleges in
India. This mushrooming has led to deteriorating quality of education provided to student
nurses and competition among educational institutions for students and funds. In order to
survive in such a situation, educational institutions need to improve their quality.
 Client satisfaction : Students, parents or sponsoring agencies are the customers of the
educational establishment are nowadays highly conscious of their rights and finding
value for teir money and time expended. They are now demanding good quality teaching
and receiving employable skill sets.
 Maintaining standards : standards are formally documented requirements and
specification against which performance can be measured.
 Accountability : every institution is accountable to its stakeholders in terms of the funds
used to it. Care for quality will guarantee accountability of the funds utilized and inform
the stakeholders about taking appropriate decisions.
 Improve employee morale and motivation
 Credibility, prestige and status :
 Image and visibility : quality institutions have the capacity to attract better stakeholder
support.

Development of quality assurance models

Quality assurance program is a carefully planned, phased process or it may be implemented in

one step as part of a fundamental organization.

i. Foster commitment of Quality : this process must continue throughout the life a project
and at all levels of organization. Commitment can done through awareness – raising
seminars, special planning meetings or one to one discussion with an organization’s
leader.
ii. Conduct a preliminary review of Quality related activities : it is important to conduct an
initial review of the organization and to develop a general description of the eisting
system.
iii. Develop the purpose and vision for the Quality assurance effort : purpose is to build
consensus between manager and to set boundaries for the quality assurance effort. The
vision will help staff to understand how their day to day work related to quality
improvement.

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 iv. Determine level and scope of initial Quality assurance activities : scope of initial quality
assurance activities depend on the resources available, the implementation time frame
and the receptivity of management and programme staff to the idea of quality assurance.
v. Assign responsibility for Quality assurance: an existing committee or management body
will take on responsibility for quality assurance, integrating it into the general
management structure.
vi. Develop written Quality assurance plan: written quality assurance plan is a written
document that describes the program objectives and scope, define lines of responsibility
and authority to put forth implementation strategies. The plan helps the staffs to relate
quality, goals and objectives to their routine activities.
vii. Critical management system : QA efforts will focus on three critical management system;
supervision, training and management information system.
viii. Disseminate quality assurance experience : dissemination strategy should be devised to
share experience inside and outside the organization. Conferences that are conducted at
local, regional, national and international level will reinforce success encourage dialogue
and creativity,
ix. Manage change : a careful phased approach to change is required and an open and
trusting environment must be cultivated.

FACTORS AFFECTING QA IN NURSING CARE

 Lack of resources : insufficient resources, infrastructure, equipment, money for recurring

expenses and staff make it impossible for output of a certain quality.
 Personnel problems : lack of trained, skilled and motivated employees, staff in discipline
etc. affect the quality of care.
 Unreasonable patients and attendants: illness, anxiety, absence of immediate response to
treatment, unreasonable and uncooperative attitude which in turn affect the quality of
care.
 Improper maintenance : building equipment requires proper maintenance for efficient use
 Absence of well informed population: to improve quality of nursing care it is necessary
that the people become knowledgeable and asserts their rights to quality care.
 Absence of accreditation law: there is no organization strictly empowered legislation to
lay down standards for nursing and medical care so as to regulate the nursing care.
 Inspect hospitals and ensure that basic requirements are met
 Lack of incident review procedures :
 Delayed attendance by physician/ nurse
 Lack of good hospital information system
 Absence of conducting patient satisfaction survey.
 Lack of nusing care records.
 Miscellaneous : lack of good supervision, absence of knowledge about the phylosophy of
nursing care.
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Areas of QA

Out patient department

o Courteous behavior must be extended by all, trained or untrained personnel.

o Reduction of waiting in OPD and laboratories by creating more service outlet.
o Provide basic amenities ( toilets, drinking water etc:- )
o Provision of polyclinic concept
o Providing ambulatory services or running day care centers.
o Emergency medical services.

Inpatient services: Provide a pleasant hospital stay to the patient through provision of a safe,
homely atmosphere, a listening ear, humane approach and well behaved staffs.

Specialty services: A sophisticated hospital with all high technologies types of specialty or
super specialty service will increase the image of the hospital.

Training: A continuous training program should be present consisting of on the job training,
skill training workshops, seminars and case presentations

Quality assurance models

1. Donabedian Model ( 1985 ) : model proposed for the structure, process and outcome of
quality. This model has been widely accepted as the fundamental structure to develop
many other models in QA.

Structural evaluation : this method evaluates the setting and instruments used to provide
care such as facilities, equipment, chaecteristic of the administrative organisation and
qualification of the health care providers. The data for structural evaluation can be obtained
from the existing documents of an agency from an inspector of facilities.

Process evaluation: this method evaluates activities as they relate to standards and
expectations of health providers in the management of client care. Data for this can be
collected through direct observation of providers, encounters and review of records, audit,
checklist approach and the criteria mapping approach are used to establish the client
encounter protocol.

Outcome evaluation: outcome evaluation includes the net changes that occur as a result of
health care or the net result of healthcare. The data of this method can be collected from vital
statistical records such as death certificates, in person or telephone client interviews, mailed
questionnaire and client records.

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2. ANA model: 1st proposed and accepted model of quality assurance given by Long and
Black in 1975. This helps in the self-determination of patient and family, nursing health
orientation, patient right to quality care and nursing contributions. The basic components
of the ANA model can be summarized as follows.
 Identify value
 Identify structure, process and outcome standard and criteria.
 Select measurement needed to determine degree of attainment of criteria and
standards.
 Make interpretation.
 Identify course of action.
 Choose action
 Take action
 revaluation

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3. Quality health outcome model: the uniqueness of quality health outcome model
proposed by Mitchell & Co is the point that there are dynamic relationships with
indicators that not only act upon, but also reciprocally affect the various components
4. Plan – Do – Study – Act cycle: it is an improvement model advocated by Deming. Use
of PDSA model assumes that a problem has been identified and analyzed for its most
likely causes and that changes have been recommended for eliminating the likely causes.

5. Six – Sigma: six standard deviations are the mean and generally used in quality
improvement to define the number of acceptable defect or errors produced by a process.
It consist of five components

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Define : questions are asked about key customer requirements and key process to support those
requirements.

Measures: key process are identified and data are collected.

Analyze: data are converted into information’s, causes of process variation are identified

Improve : this stage generate solutions and make and measure process changes.

Control: process that are performed in a predictable way at a desirable level are in control.

PRINCIPLES OF QUALITY ASSURANCE

Set of 9 principles, which are necessary to ensure accountability and the improvement of higher
education and vocational education and training in the QA polices and procedures should
underpin.

1. QA should include regular evaluation of institutions, their programmes or their QA

system by external monitoring bodies or agencies.
2. External monitoring bodies or agencies carrying out QA should be object to regular
review.
3. QA should include context, input, process and out dimensions, while giving emphasis to
outputs and learning outcomes.
4. QA system should include the elements such as clear and measurable objectives and
standards, guidelines for implementation including stakeholder improvement, appropriate
resources etc.
5. Consistent evaluation methods, associating self assessment and external review.
6. Feedback mechanisms and procedures for improvement, widely accessible evaluation
result.
7. QA initiatives at international, national and regional level should be coordinated in order
to ensure over view, coherence, synergy and system wide analysis.
8. QA should be a cooperative process across education and training levels and systems,
involving all relevant stakeholders, with member of states and across the community.
9. QA orientations at community level may provide reference points for evaluations and
peer learning.

Approaches to Quality Assurance

Two major categories of approaches exist in quality assurance; they are general approach and
specific approach.

General approach: it involves large governing of official bodies’ evaluation of a person’s or

agency’s ability to meet established criteria or standards at a given time.

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  Credentialing – it is generally define as the formal recognition of professional or
technical competence and attainment of minimum standards by a person or agency.
According to Hinsvack (1981) credentialing process has four functional components
I. To produce a quality product
II. To confer a unique identity
III. To protect provider and public
IV. To control the profession
 Licensure: individual licensure is a contact between the profession and the state, in which
the profession is granted control over entry into and exit from the profession and other
quality of professional practice. The licensing process requires that regulation be written
to define the scope and limits of the professional practice. the licensure of nurses has
been mandated by the law since 1903.
 Accreditation: National League for Nursing, a voluntary organization, has established for
inspecting nursing education programmes.
 Certification: it is usually a voluntary process within the profession. A person’s
educational achievement, experience and performance on examination are used to
determine a person’s qualification for functioning in an identified specialty area.

Specific approach: quality assurance are methods used to evaluate identified instance of provider
and client interaction.

o Peer review committee: these are designed to monitor client specific aspects of care
appropriate for certain levels of care
o Utilization review: activities are directed towards assuring that care is actually needed
and that the cost appropriate for the level of care provide. Three types of UR are;
 Prospective
 Concurrent
 Retrospective
o Evaluation studies: three major models have been used to evaluate quality care. They are;
 Donabedian’s structure – process – outcome model
 The tracer model
 The sentinel model

Tracer method: it is a measure of both process and outcome of care. In tracer method;
one must identify the value of a client with a particular characteristic resuming specific
health care management.

Sentinel method: it is an outcome measure for examining specific instances of client

care.

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Steps of Quality Assurance

QA is a systematic process of evaluating the quality of care given in a

particular unit or institution.

 Setting standards
 Assign responsibility
 Delineate scope of care
 Identify important aspects of care
 Determining criteria
 Evaluating performance
 Problem identification
 Problem solution monitoring and feedback

Methods of quality assurance

The purpose of QA program is to measure and improve the quality of nursing care delivered in
the institution. There for variety of QA methods have been used.

Nursing audit: nursing audit is a method for evaluating quality of nursing care through the
appraisal of the nursing process. There are two types of audits

1. Concurrent
2. Retrospective

Peer review: process by which nurses evaluate one another’s job performance against accepted
standards

Patient care profile analysis : the analysis of longitudinal or cross sectional complication of
data about patient with a particular diagnosis or problem.

Quality cycle: A quality cycle is a small group of 5- 15 employees who performs the similar
work and meet for one hour each week to solve problems related to work.

Patient satisfaction: patient satisfaction is used as one of several indicators of quality.

ROLE OF NURSE IN QA

Nurses are responsible for managing the caseload of client with needs of varying degree of
urgency. Using resources available, they must provide priority services that will promote the
highest possible level of person and group functioning and health.

QA is the role of nursing administrator to develop a formalizing tractor to develop a formalized

quality program that include a three pronged focus based on a classic approach to quality
management

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 Review organizational, Personal and environment

Focuses on standards of care and methods of delivering nursing care

Focus on the outcome of care.

NURSING STANDARDS

Definition

“A standard is a model of established practice which has general recognition and acceptance
among registered professional nurses and is commonly accepted as correct standards of practice
are agreed on levels of competence as determined by the ANA and specially nursing
organizations” ( ANA – 1996 ).

“Standards are defined as authoritative statements that describe a common level of care and
performance by which the quality of practice can be determined or measured. Standard helps
define professional practice” (Huber, 1996).

Meaning of standards

Standard is an established rule as a basis of comparison in measuring or finding capacity,

quality context and value of object in same category. Standard as a broad statement of quality.

A standard is a means of determining what something should be. In

nursing education standard refers to the established criteria for the provision of nursing
education. In case nursing practice, standards are the established criteria for the practice of
nursing. Standard is a predetermined baseline condition as level of excellence that comprises a
model to be followed and practice.

Importance of standards

In order to provide high quality of nursing education, it is necessary that nurse educator develop
standard of education and appropriate evaluation tool.

 Give direction and provide guidelines.

 Provide a baseline for evaluating quality nursing education and thereby quality care.
 Helps to plan for the faculty recruitment, development of infrastructure and others.
 Aids in curriculum planning, implementation and evaluation.
 Assist in planning for student and staff welfare activities.
 Help to improve quality of nursing care.
 A standard may helps to improve documentation of nursing care.
 May help to determine the degree to which standards of nursing care maintained.

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  Help supervisors to guide nursing staffs to improve performance.
 Standards may help to improve basis for decision making.
 Justify demands
 It may help clarify nurses area of accountability

Purposes of standards

The purpose of publishing, circulating and enforcing nursing care standards are to:

a. Improve the quality of nursing

b. Decrease the cast of nursing
c. Determine negligence

Characteristics of standards

1. The statement must be broad enough to apply a wide variety of setting.

2. Must be realistic, acceptable, and attainable.
3. Nursing care must be developed by members of the nursing profession.
4. Standards must be understandable and stated in unambiguous terms.
5. Must be based on current knowledge and scientific practice.
6. It must be reviewed and revised periodically.
7. Standards must be directed towards an optimal standard.

Sources of nursing standards

The standards can be established, developed and reviewed as enforced by variety of sources as
follows

 Professional organization like TNAI.

 Licensing bodies INC, IMC and DCI etc
 Departments of the institution, university, hospital, department of nursing.
 Patient care unit
 Government units at national, state and local government level.
 Individual, eg: personal standards

Classification of standards

Based on orientation

a. End standard: the end standards are patient oriented. They describe the changes as desired
in a patients physical status or behavior. It requires information about the patient.
b. Mean standards: the mean standards are nursing oriented, they describe the activities and
behavior designed to achieve end standards. Mean standards call for information about
nurse’s performance.

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Based on frame of reference

a. Structure standard: a structure standard involves the set up of the institution. The
philosophy, goal and objective, structure of the organization, facilities and equipment and
qualification of employee are some of the components of the structure of the
organization. The use of standards based on structure implies that if the structure is
adequate, reliable and desirable standards will be met as quality care will be given.
b. Process standard: it describe the behavior of the nurse at the desired department of
performance. A process standard involves the activities concerned with delivering patient
care. The standards are stated in action verbs that are observable and measurable terms.
c. Outcome standards: descriptive statement of desired patient care results are outcome
standard, because patients results are outcome of nursing intervention. It measure
changes in patients health care status. Outcome standards reflect the effectiveness and
result rather than process of giving care.

The nursing organization or structure is usually evaluated according to structure standards, the
activities or delivery of care are evaluated by process standards, and the patient status is
evaluated by outcome standards.

The quality of the educational process is evaluated through indicators. An indicator is a

characteristic or variable that can be measured. The indicators are classified into structure,
process and outcome. These indicators will a) measure how well executed b) develop evaluation
criteria c) design a program of continuous improvement.

The objectives for using standards and indicators for the management of the nursing school/
colleges are:

1. Identify problem situations that are likely to be improved,

2. Incorporate improvement cycles to solve the identified problem,
3. Internal comparison over time,
4. Comparisons with other institutions.

Good indicators in education

1. Be useful: give answers and is designed eor a specific purpose.

2. Validity: measur what is intends to measure
3. Reliability: the same results are reproduced if the measurement is repeated under similar
conditions.
4. Specificity: measure only the phenomenon being measured.
5. Sensitivity: measure the phenomenon being measured.
6. Measurability: based on data available or easy to obtain and easy to use
7. Relevance: able to give clear answers to relavent issues embaded in health policies.
8. Costeffectiveness

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 9. Integrity
10. Internal consistency
11. Transparency
12. Dissemination
13. Dynamism: to update and correct as far as the environment change.

DEVELOPMENT OF NURSING STANDARDS

STANDARDS FOR NURSING EDUCATION PROGRAMS

Section 1. Statement of Purpose.

(a) Board Rules are adopted to implement the Board’s authority to:

Section 2. Approval of Nursing Education Programs.

(a) Provisional Approval

(i) Before a nursing education program is permitted to admit students, the program shall submit
evidence of the ability to meet the standards for nursing education.

(A) Prior to applying for provisional approval, the parent institution desiring to initiate a nursing
education program shall, at least one year in advance of the expected opening date, submit to the
Board:

(I) A statement of intent to establish a nursing education program; and (II) A proposal which
includes at least the following information:

(B) Application for provisional approval shall be made once the proposal has been approved by
the Board and the following conditions have been met:

(C) Following Board review of the proposed nursing education program, the Board may grant or
deny provisional approval.

(D) The parent institution and director of the proposed nursing education program may be
present at the meeting to clarify information contained in any of the reports.

(E) If provisional approval is denied, the institution may request a hearing before the Board. The
provisions of the WAPA and/or Board Rules shall apply to all hearings.

(F) Following Board provisional approval, progress reports shall be made to the Board as
requested.

(G) Following graduation of the first class, a self-evaluation report of compliance with the
standards for nursing education shall be submitted by the nursing education program. A site visit
by the Board shall occur for consideration of full approval of the nursing 6-3 education program.

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 (b) Full Approval/Conditional Approval The Board may grant varying levels of approval after
provisional approval:

Section 3. Board Review of Nursing Education Programs.

(a) Annual Review. All nursing education program(s) excluding those with provisional
approval shall submit an annual report with one electronic and one hard copy providing
documentation of continued compliance with the standards for nursing education, projected
program changes, faculty data forms, and current college catalog within sixty days after the end
of each program year.

(b) Site Visits (i) Site visits of individual nursing education programs may be conducted at the
Board’s discretion; (ii) Site visits may be conducted when the Board receives evidence which
would indicate that the nursing education program is not in compliance with the standards for
nursing education

(c) Noncompliance

Section 4. Denial or Withdrawal of Approval For Nursing Education Programs.

Section 5. Appeal and Reinstatement. A parent institution may appeal the Board’s decision to
withdraw approval of a nursing education program and may request a hearing to review the
Board’s decision. The hearing and all actions related to the appeal shall be affected in accordance
with due process rights, the WAPA and/or Board Rules.

Section 6. Closure of Nursing Education Program and Storage of Records.

(a) Voluntary Closing

(b) Closing as a result of withdrawal of approval

(c) Storage of Records. The Board shall be advised of the arrangements for storage of
permanent records.

Section 7. Standards of Nursing Education. (a) The organization and administration of the
nursing education program shall be consistent with the law(s) governing the practice of nursing.

(b) Administrator Qualifications

(c) Faculty

 There shall be sufficient faculty with graduate preparation and nursing expertise to meet
the objectives and purposes of the nursing education program.
 Factors that shall be considered in determining the faculty/student ratio in clinical settings
are clinical site, level of student, number of beds, type of clinical experience, contractual

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 agreement with the agency, program and curricular objectives and the faculty’s teaching
experience.

(A) Faculty/student ratio shall be a maximum of 1:8 for clinical experiences.

(B) When clinical preceptors (partners in education) are used in a clinical setting the ratio
shall be 1:1 for the clinical preceptor/student ratio and no more than 1:15 for 6-10
faculty/student ratios.

 RN faculty shall be responsible for: Developing, implementing, evaluating, and updating

the purpose, philosophy, objectives, and organizational framework of the nursing
education program;
 Faculty policies and procedures shall be available in writing and shall include
qualifications, rights and responsibilities of faculty members, the criteria for evaluation
of performance, and promotion and tenure policies.
 Faculty teaching non-clinical nursing courses, e.g., issues and trends, pharmacology,
nutrition, research, management, and statistics, shall have preparation appropriate to
these areas of content.

(d) Students

(i) The nursing education program shall admit students to the program based upon the number of
faculty, available educational facilities and resources, and the availability of clinical learning
experiences for the student

ii) Students shall be admitted without discrimination as to age, race, religion, sex, national origin,
or marital status, using an objective process applied uniformly.

(iii) The nursing education program shall establish written policies for admission, readmission,
transfer, advanced placement, promotion, graduation, withdrawal, or dismissal.

(e) Curriculum The curriculum of the nursing education program shall enable the student to
develop the nursing knowledge, skills and competencies necessary for the level of nursing
practice.

(f) Resources.

The parent institution shall provide financial and administrative support and resources to the
nursing education program, including but not limited to:

 Physical facilities for the nursing education program;

 Access to library and instructional materials; and
 Secretarial, clerical and other support personnel services.

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(g) Clinical Facilities.

A written contract or agreement shall be executed by the parent institution conducting the
nursing education program and the cooperating clinical facility or agency; the contract shall be
signed by the responsible individual(s) of each party, and shall set forth the responsibilities of
each party.

(h) Program Evaluation The nursing education program shall have a written plan for the
systematic evaluation of the total nursing education program and its outcomes. The plan shall
include the methodology, frequency of evaluation, assignment of responsibility, and evaluative
criteria. The following areas shall be evaluated: (A) Organization and administration of the
nursing education program;

(B) Philosophy and objectives; (C) Curriculum;

(D) Educational facilities, resources, and services;

(E) Clinical resources; (F) Students’ achievement;

(G) Graduates’ performance on the licensing examination;

(H) Graduates’ nursing competence; (I) Performance of the faculty;

(J) Protection of patient safety; (K) The methods and instruments used for
evaluation purposes.

(ii) There shall be evidence that the evaluation plan is being implemented and that faculty review
evaluative data and take corrective action as needed.

P R O F E S SI O N A L S T A N D A R D S

Standard 1: Professional Responsibility and Accountability Maintains standards of nursing

practice and professional conduct

Standard 2: Knowledge-Based Practice.

Standard 3: Client-Focused Provision of Service.

Standard 4: Ethical Practice

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 ACCREDITATION

All professionals have one thing in common, that is concern for the quality of their service,
which is ensured by devoloping and enforcing the standards. Two important ways of setting
standards are accreditation of the education programme and the professional licensure.

Definition

Accredition is the process whereby an organization or agency recognizes all colleges or

university or programme of study as having met certain predetermined qualifications and
standards - Selden (1962)

Accreditation is a process by which a (non) governmental or private body evaluates the quality
of higher education institution as a whole or of a specific educational programme in order to
formally recognize it as having met certain predetermined minimal criteria or standards. The
result of this process is usually the awarding of a status, of recognition and sometimes of a
license to operate within a time limited validity. The process can imply initial and periodic self
study and evaluation by external peers.

- UNESCO

Purposes

The goal of accreditation is to ensure that education provided by institutions of higher education
meet the acceptable level of quality. The major purposes include,

 To certified the public that an institution has met established standards.

 To encourage peer review by the faculty and staff of the institution.
 To facilitate the transfer of students from one institution to another.
 To assist prospective students in deciding which institution to attend and join.
 To foster continuing improvement in nursing programs and thereby in professional
practice.
 Maintain a uniform standard for nursing education and nursing service.
 Stimulation of institutional self improvement by evaluation and inspection.
 It helps in the registration of nurses.
 It prescribes the syllabus.
 It grants recognition to school and colleges.
 To ensure safe practice of nursing by setting standards for schools and colleges preparing
the professionals.

Types

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Institutional accreditation: it is the accreditation of the institution as a whole, without
differentiation among the various curriculums. It looks at the institution as a total operating unit.
It focus attention on the general characteristic of an institution, its objectives, infrastructure,
faculty and resources.

Specialized accreditation: it is otherwise known as the program accreditation, where the

program run by the institution is accreditated with almost importance. The accreditation bodies
are often associations or councils of professions like medicine, nursing etc. the principal
objectives to ensure that the quality of education and training meets the minimum requirements
of the profession.

Types of Accreditation Agencies

Accreditation type

Regional professional

State national

Regional accreditation agencies: they are concerned with as institution as a whole. They are
general in nature. They are concerned with appraising the total of the institution of higher
learning and with safeguarding the quality of education and foundation of professional
programmes in colleges and universities. Each agency establishes criteria for the evaluation of
institution in its region. It receives those institutions periodically and publishes from time to time
a list of those institution which it has accreditated.

Professional accrediting agency: these agencies are specialized and each is concerned with
particular profession.

state accrediting agencies: accreditation in certain stages may be the function of state
agencies. It assumes the responsibility mainly for teacher education.

National accrediting agencies: in 1904 started with the accreditation of medical school
membership in some agencies composed number of some combination of nurses and doctors.

Beneficiaries of accreditation

The common beneficiaries are;

 Students
 Faculty
 Graduates
 Practicing nurses
 Consumers of nursing services
 Administrators.
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Aspects reviewed under Accreditation process

 Administration and governance

 Finance and budget
 Faculty, student and resources
 Program outcomes.

Problems

 As the number of accrediting agencies mushroomed, charges increased, decreased

standardization and duplication began.
 Has never defined quality of education.
 No relationship between accreditation standards and subsequent success of the graduates.
 Discourage innovation and experimentation.
 Evaluating an institution in terms of its own objectives and does not permit meaningful
comparisons.
 It is used by special interest groups as a means of achieving or protecting private
purposes.

Scope of accreditation

 Accreditation provides a base for both quality and quantity of higher education.
 Help the institution to know is strengths, weakness and opportunities through an
informed review process.
 Helps the institution to identify internal areas of planning and resource allocation
 Outcome provides objective data to funding agencies for performance funding.
 Initiate institutions into innovative and modern methods of pedagogy.
 Give institution a new sense of direction an identity.
 Provides society with reliable information of the quality of education offered to potential
recruiters.
 Promote intra and inter institutional interactions

Stages of accrediting programs

The accreditation process generally involves three specific steps,

o Initiation of the process and conduction of a self evaluation study.

It is conducted by the faculty, the administrators, and the staffs of the institution or
academic programme, resulting in a report that takes as its reference the set of standards and
criteria of the accrediting boy.
o Accreditation visit

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 Conducted by a team of peers, selected by the accrediting organization, which reviews
the evidence, visit the premises, and interview the academic and administrative staff,
resulting in an assessment report, including a recommendation to the commission of the
accrediting body.

o Evaluation by the board of review or peer group

An examination by the commission of the evidence and recommendation on the basis of

the given set of criteria concerning the quality and resulting in a judgement and the
communication of the formal decision to the institution and other constituencies.

Criteria for accreditation:

 Type of the training given

 Philosophy and purpose of the programme
 Date of previous inspection
 Recognition of the college by the government order no:, date and no: of seats sanctioned
for the year
 Number of the students admitted for the year after the last date of inspection and
regarding the detail of staff qualification.
 Registration no:, registration validity
 Non nursing teachers and other staff members
 Physical facilities available in the school, no: of class rooms, library, office of principal,
tutors, and laboratory.
 Hostel facilities
 Material and financial management as per norms

ACCREDITATION PROCESS
In general there are five steps for accreditation of programme
 Application for registration
 Self assessment
 the first step of the self-assessment is to select an accreditation manager. The
accreditation manager is the individual within the program responsible for coordinating
the administrative aspects of performing the self-assessment.  This includes obtaining and
documenting evidence of compliance with the standards and other scheduling and
oversight activities.
 On the site survey
The assessment team travels to the program's site as scheduled and conducts the on-site
assessment during the work week, reviewing and verifying information provided in the
program's application and documentation materials.  The assessment team conducts an
exit briefing and prepares findings on the assessment in an assessment report,
 Report preparation

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  Award of accreditation
 The recommendation will be either accreditation; conditional accreditation; or
accreditation denied. For full accreditation, compliance with standards is required. If the
report includes areas of non-compliance, the programme should be prepared to
demonstrate to the Program Review Committee how it will address all areas of non-
compliance within nine months. If the applicant program is successful in showing this,
the Program Review Committee will recommend "conditional accreditation". The
applicant program may attend the Program Review Committee meeting at which its
accreditation application will be considered. The committee's deliberation is conducted
during an executive session.
 Maintaining accredited status
After accreditation is achieved, accredited programs are expected to maintain compliance
with the standards and keep proof of compliance up to date. Each accredited program will
complete and file with the commission an annual report via the Program Assessment
Tool. Accreditation is valid for five years, after which the entity will be encouraged to
apply for reaccreditation. The reaccreditation process involves essentially the same steps
as the original application process. Reaccreditation will call for documentation and
compliance information of the program performance during the maintenance period. 

ACCREDITING AGENCIES

1. International Council of Nurses ( ICN )

The international council of Nurses was founded in 1899 by Mrs. Bedford Fenwick. It is a
federation of non political and self governing national nurses association. ICN is non partisan
body. The headquarters in Geneva. The council of National Nursing Association Representatives
( CNR ) is the governing body of ICN.

Purposes of ICN

 To represent nurses worldwide and to be the voice of nursing internationally.

 To provide means through which the national associations can share their interests in the
promotion of health and care of the sick.
 Great emphasis has been placed upon non discrimination.

Objectives of ICN

 To influence nursing, health and social policy, professional and socio-economic standards
worldwide.
 To promote the development of the strong National Nurses Association.
 To assist the national nurses associations to improve the standards of nursing and the
competence of nurses.
 To assist the national association to improve the state nurses with in their countries.
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  To serve as authoritative voice for nurses
 To establish, receive and manage funds
2. National assessment and accreditation council

National accreditation and accreditation council ( NACC ) was established by the University
Grants Commission (UGC ) on 16 th September, 1994 for ensuring quality in higher education, in
pursuance of the national policy on education and the program of action (POA ), in 1986. It is
located at Bangalore.

Vision

To make quality the defining element of higher education in India through a combination of self
and external quality evaluation and sustenance initiatives.

Mission

 To arrange for periodic assessment and accreditation of institutions of higher education or

units
 To stimulate the academic environment for promotion of quality of teaching learning and
research in higher education institutions.
 To encourage self evaluation, accountability, autonomy and innovations in higher
education.
 To undertake quality related research studies.
 To collaborate with other stakeholders of higher education for quality evaluation,
promotion and sustenance.

Accreditation refers to the certification given by NAAC which is valid for a period 5 years.

3. Indian nursing council

The Indian nursing council is an autonomous body under the Government of India, Ministry of
health and Family Welfare was constituted by the central government under section3(1) of the
Indian Nursing Council Act, 1947. The nursing council act came into existence in 1948 to
constitute a council who would safeguard the quality of nursing education in the country

Composition and constitution

INC has one president, vice president, secretary, one assistant secretary and 15 other staffs.

Committee

INC has constituted following committees;

 Executive committee: executive committee of te council to deliberate on the issues

related to maintenance of standards of nursing programmes

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  The nursing education committee: the committee is constituted to deliberate on the issues
concerning the nursing education.
 Equivalence committee: it is to deliberate on the issues of recognition of foreign
qualifications which is essential for the purpose of registration under sections 11(2)(a) or
(b) of the Indian Nursing Council Act, 1947, as amended.
 Finance committee: it is another important committee of the council, which decides upon
the matters pertaining to finance of the council in terms of budget, expenditure,
implementation of central Govt. order with respect to service conditions etc.

Philosophy of INC

INC, states that, nursing is the unique function of the nurse, that is, to assist the individual sick or
well, in the performance of those activities contributing to health or recovery, that he would
perform unaided if he had the necessary strength, will or knowledge. Keeping in this mind, the
nursing is a formal educational preparation, which should be based on sound educational
principles. It recognizes the programmes as the foundation on which the practice of nursing is
built an on which depends further professional education. It recognizes its responsibility to
society for the continued development of students as individuals, nurses, and citizens.

Aims and objectives of INC are as follow,

 To regulate the training policies and programmes in the field of nursing.

 To bring about standardization of training country.
 To regulate these standards in all training institutions uniformly throughout the country.
 To recognize institutions imparting nursing education at various diplomas, graduate and
post graduation levels.
 To promote research in nursing education
 To maintain Indian nurses register for registration of nursing personals
 To establish uniform nursing standard of training throughout the state.
 Prohibit training center, which are inadequate.
 Prohibit the practice of nursing by non qualified nurses.

Main purposes of INC

 To set standards and regulate all types of nursing educations

 To prescribe and specify minimum requirement for qualifying for a particular course in
nursing.
 Advisory role in the state nursing council.
 To collaborate with state nursing councils, schools and colleges of nursing and
examination board.

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Functions of INC

1. Prescribing of syllabi: prescribing syllabi and curriculum for various courses in nursing
and conducting the qualifing examination based on the development in science and
technology.
2. Inspection : inspections are done and granting of recognition based as the requirements,
their set up and the strength of the institutions. There are three types of inspections by
INC since 1996. They also have full freedom to withdraw recognitions. A right of appeal
against any disciplinary action is taken by the council.

Nature of inspection by INC

There are three types of inspections by INC since 1996

1 first inspection :- institutions are inspected by the INC when they apply to start a course in
nursing. This is the first step towards INC recognition. The school that seek recognition are
required to submit

 Permission letter from government

 Permission letter from state nursing council
 A copy of the inspection report of the SNA
 A bank draft for Rs. 50,000/- towards first inspection fee for School of Nursing in favour
of Secretary, Indian Nursing Council, New Delhi (ANM, GNM, Post Basic Diploma
Course).
 A bank draft for Rs. 1,00,000/- towards first inspection fee for College of Nursing in
favor of Secretary, Indian Nursing Council, New Delhi {P.B.B.Sc.(N), B.Sc.(N), M.Sc.
(N), M. Phil(N), Ph. D(N)}

2 Re inspection :- these are done for those institutions which are found unsuitable on first or
subsequent inspection by INC. once the institution takes necessary steps to remove the
deficiencies and informs the INC’s re-inspection is done within one year or earlier.

3 Periodic inspections :- once an institution is give recognition by INC the institute is required to
send an annual inspection fee regularly. The INC inspect the institute generally after 3 years.

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Process of INC inspection

School/ college after it has been INC ask for the requiste documents
inspected by SNC write to INC for and 1st inspections fee
recognition

INC sends a reminder for the Has the college/ school sent all the
NO
missing documents to school or requisite document
college
Yes
The 1st inspection is conducted by INC
The general body meeting of INC and original report submitted for
review the case and forwards it evaluation
with decision

Are the school/ college suitable or Recognition granted by INC

unsuitable/ suitable with condition suitable

Unsuitable/suitable with conditions School/ college applies for

Reinspection within one year

State nursing council

It is an autonomous statutory registration body for registering qualified nurses, midwives,
ANMs, MPHWs and health visitors. They do not have power to prescribe the syllabi for courses.

Size

There are 29 state nursing councils /examination boards or bodies in India.

Salient features

 Has provision for autonomus body, comprising the majority of nurses, and endowed with
decision making power.
 Carries out compulsory registration for all nurses and midwives practising within the
state.
 Has provision for nurses, midwives and public health nurses to elect their own
representatives to the respective state.

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  Has a power to regulate nursing education through prescribed curriculum and t ennciate
examination policies.
 Has provision for recognition of educational institution of nursing and withdrawal of such
recognition, if necessary.
 Different types of basic an post basic nursing training programmes are conducted by
some of the SNCs.

Fuctions of council

 Registration of qualified nursing professionals,

 Regulation of nursing programs by conducting inspection
 Checking malpractice and maintaining professional ethics.
 The council ensures that all facilities are available for conducting any of the nursing
programs before granting permission.
 It also conducts the surprise and periodical inspection to identify the deficiencies in that
institution. Also conduct reinspection to ensure that the deficiencies are rectified.
 Issue duplicate certificate for loss of orginal certificate
 Renewal of registration
 Abroad verification
 Publications
 Inservice education programme
 research

Coordination with INC

 INC is composed of representation of many sections including State Nursing Registration

Council (SNRC)
 If INC is to recognize any school or college of nursing, first recognition sought from the
local registration council
 To be affiliated to INC. SNRC must register person
 SNRC implement the syllabus prescribed by INC
 Time to time INC meeting of State Registrars to discuss various problems
 SNRC along with the help of INC check the unethical practices that include dishonest use
of certificates, getting registration by false or unrecognized person, representation of
registration as a medical practitioner, defect in character, bad conduct. If the rules of
conduct are not followed the disciplinary action is taken.

Board – CMAI

CMAI is a registered, nonprofit, charitable organization.

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Objectives of CMAI

 Promotion and relief of human suffering irrespective of cast, community, religion and
economic status.
 Promotion of knowledge of the factors governing health
 Coordination of activities for training doctors, nurses. Allied health professionals
 Implementation of care for comprehensive care
 Rendering health in calamities and disaster of all kind.

Functions of the nursing examination board

 To coordinate and bring a uniform standard of nursing education, in accordance with the
requirement of INC & SNC.
 To verify the eligibility requirements of the students before each examination
 To arrange to conduct examination and issue diploma certificates successful students.
 To maintain and enhance the educational standards.
 To decide the disciplinary actions against students/ staffs in case of malpractice in
examination.
 To appoint the examiners before annual and supplementary examination
 To appoint an auditor to audit the board account.

University

Types

 Central university
 State universities
 Deemed university

Functions

 Regulation of its own colleges and affiliated istitutions.

 Conducting inspection and granting permission for admission.
 Conducting examination and announcing result.
 Ensure faculty welfare and development
 Ensure stuent welfare and development
 Organizing various programs such as book exhibition, job fair, seminars, inter college
competitions, spors meet etc:

Quality improvement in Nursing Educational Institutions

The quality of nursing education could be evaluated by many indicators such as standard
curriculum, number of qualified teachers, number of students passing national examination,
number of students receiving a nursing license upon graduation, number of students getting jobs

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upon graduation. A number of research grants and number of publications in peer review
journals.

According to the WHO workshop on Report of Regional Workshop Male, Maldives, 9-11
July 2007 participants presented strategies or methods used for quality improvement in their
educational institutions. These were,

 Standards for curriculum and educational institution

 Upgrading of student admission criteria, i. e from grade 10 to grade 12
 Recruitment of students by central examination
 Curriculum revision
 Upgrading of level of nursing education, i.e from diploma to a degree programme.
 External committee to review the test or sit in one the final examination
 Formal study for higher degree of teachers
 Refresher courses for teachers
 Nursing council offering comprehensive examination to all school.

INC play very important role in providing and maintenance of quality education in India. The
INC prescribes the syllabus, scheme of examination and admission criteria. This ensures that the
education offered in all nursing institution is uniform. Minimum standards are also set for the
physical facility, teaching facility and clinical facility to start a nursing programme. The INC
conducts yearly or periodic inspections of the institutions.

Related research study

Dirce stein backer’s et al conducted a study on quality nursing education: a complex and

multidimensional phenomenon, with an objective to reflect on quality nursing education as a
complex and multidimensional phenomenon. This is a theoretical-reflexive study developed and
systematized into five units of reflection: significant learning environments; active
methodologies; interactions in different realities; collaborative networks; and complex
intervention approaches. Based on complex thinking, an analysis of the units of reflection has
shown that learning in the contemporaneity can no longer be conceived as a specific and linear
process. Quality education is related to expanding systemic interactions and associations, and to
the ability to strengthen its relation with a constantly changing complex reality.

Conclusion

Quality assurance program is an ongoing, systematic process designed to evaluate and promote
excellence in the health care provided to client. In health care system defining and maintaining
standards of nursing education and accreditation of nursing educational institutions play an
important role, as provision of quality service through well defined curriculum.

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3. Sudha R(2013),” Nursing education principles and concepts”, 1st edition, Jaypee
publications, page no: 327 – 348.
4. Northrop and Kelly(1987),” Legal issues in nursing”, Mosby publications, page no: 484 –
485.
5. Clement I (2017),” Management of nursing services and education”, 2 nd edition, Elsevier
publications, page no: 436 – 438.
6. https://emap.org/index.php/program-resources/steps-to-accreditation
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