Programmatic Accreditation or Institutional Accreditation? - The Development of Accreditation in Nursing Schools
2 Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Citation: Dashti-Kalantar R, et al. Programmatic Accreditation or Institutional Accreditation? The Development of Accreditation in Nursing Schools. Ann Med Health Sci Res. 2019;9:664-671
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Background: One of the important criteria in nursing education is to present education based on educational standards. In this regard, using a model of quality assurance such as accreditation as one of the well-known models is of great importance. However, in many countries, the accreditation of nursing schools has not been operational.
Objectives: The present study was conducted with the aim of developing and implementing accreditation in nursing schools, in accordance with the 2030 agenda of World Health Organization.
Method: This research was conducted in two stages. The first stage was carried out in using a purposeful approach. The articles in Persian and in English that have been published during the last 15 years (2005-2019) were analyzed through relevant databases using proper keywords. Of the 32 relevant sources, 24 articles were excluded due to not meeting the inclusion criteria, and finally, 8 articles were included. In the second stage of this directed qualitative study, directed semi-structured interviews were conducted with 13 experts in the field of nursing/ accreditation. The reliability and validity of the data was measured using Guba and Lincoln criteria. For data analysis, MAXQDA-10 software was used.
Results: The results of the study highlight the necessity of implementing the accreditation model in order to improve the quality of education for nursing students. Meanwhile, by approving both types of institutional and programmatic accreditation models, it also confirms the impact of many factors such as educational policies of societies, the role of government in the quality management, college conditions (being single-specialty or multi-specialty), and the history of accreditation. The participants were more inclined towards the institutional accreditation model in Iranian nursing schools, due to its better matching with the educational structure of the country.
Conclusion: In regard with the existence and importance of the standards associated with the basic structures and general processes of institutional accreditation model, it is recommended to apply an institutional model with the active participation of experts and executive managers, in order to commence the implementation of accreditation in developing and less-developed countries. Given the differences in the levels of education and executive capabilities, policymakers need to support the establishment and localization of the accreditation of nursing schools in accordance with WHO policies, in order to facilitate the training of competent nursing students in line with the community needs.
The accreditation of nursing schools; Nursing education; Institutional accreditation; Programmatic accreditation; Developing and undeveloped countries
Historically, focusing on the quality of nursing care and education has been effective not only in nursing care, but also in the qualitative development of health services in other health-related professions.  Therefore, the education of nurses has been increasingly noted in recent decades, training nurses in nursing schools has been the subject of many studies and discussions. One of the important criteria to guarantee the training of the empowerment and the responsiveness of nurses is providing education based on educational standards. Utilizing models for education quality assurance will be very helpful in this regard. Previous researches regard the systematic and regular assessment of nursing programs as a basis for strengthening the program by focusing on the advantages and improving the weaknesses. [2,3] The World Health Organization has also focused on accreditation through a global strategy, and considers the Workforce 2030 plan an opportunity to strengthen accreditation, and training competent and eligible nursing workforce. 
Accordingly, the WHO recommends that educational institutions establish accreditation mechanisms by 2020 as an appropriate criterion for the implementation and assessment of nursing programs, public responsiveness towards the community, the development of programs based on missions and objectives, and their compliance with national standards.  Due to its dynamism, quality assurance models seriously focus on accreditation, because a fundamental aspect of accreditation is its continuous improvement and upgrading to a higher level. [6,7] In addition, accreditation can also play an important role in the stabilization of performance, the enhancement of quality and the motivation to change. 
Now, after decades of implementing accreditation in nursing schools, nursing-specific accreditation has not yet been operational in many developing and less-developed countries, though its importance has been widely recognized in nursing education. This issue can lead to challenges in the development of accreditation, and as a result, quality assurance in nursing schools. For nursing education institutions, various types of accreditation are defined under titles like programmatic accreditation and institutional accreditation. Institutional accreditation assesses the educational capabilities of universities and colleges or schools. In this type of accreditation, regional or national monitoring is usually done. The allocation of state funding to institutions and students generally depends on their institutional accreditation status.  In programmatic accreditation, the curricula of universities are assessed, especially those related to specific professions  such as laws, nursing and engineering. Programmatic accreditation indicates that the standards established for a particular discipline are specifically approved. 
The nature of quality improvement programs, including accreditation, shows that discussing the current issues and challenges is one of the most important factors in developing them. What is obtained from the previous studies is that there are a limited number of analyses done on various types of accreditation of educational institutions in the field of nursing, and different countries have implemented either programmatic or institutional accreditation, based on specific circumstances.  In this regard, many developing and less-developed countries are also attempting to adopt the accreditation standards of developed countries in order to implement accreditation. But due to the differences in structures, available resources, and also social and cultural conditions in different countries, this issue poses a major challenge and problem in terms of how to purposefully develop the accreditation model and the achieve its goals. Despite the fact that the WHO emphasizes the development of accreditation as a model approved by governments in order to formalize it and to finance quality improvement programs,  achieving accreditation goals requires its localization and compliance with political, social and educational structures.
Given the differences in accreditation models in nursing and the differences between various communities, a question arises: “Which type of accreditation has priority in the initial stages of the implementation of accreditation in nursing schools, institutional accreditation or programmatic accreditation?” Thus in the first step, the need for a guideline to choose between institutional accreditation and programmatic accreditation in nursing schools is totally serious, especially in the developing and the less-developed countries. To this end, the present study was conducted with the aim of explaining the features of institutional accreditation and programmatic accreditation in nursing schools. The results of the study, as a guide to decision-making, can be used and referred to by nursing policy-makers at the macro level, by planners and experts in the field of accreditation and quality improvement at the moderate level, and by the managers of nursing schools at the executive level.
Materials and Methods
This study was conducted in two stages. In the first stage, institutional accreditation and programmatic accreditation were reviewed and compared through literature review. To this end, available sources were investigated using eligible databases and library sources. Both Persian and English papers in the field of nursing school’s accreditation published during the last 15 years (2005-2019) in the databases SID, Iran-Medex, Magiran, as well as PubMed, Ovid, Science Direct, CINAHL, and Google Scholar were reviewed by using the keywords accreditation, nursing school accreditation, nursing college accreditation, programmatic accreditation, and institutional accreditation. The exclusion criteria included the letters to the editors, books, book reviews and articles presented at conferences. The articles were reviewed based on the research objectives using (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) PRISMA approach.  In the initial review, 32 papers were extracted. Then, after reviewing the abstracts, 24 articles were excluded; 17 of them were not nursing-specific, 5 were book reviews or letters to the editors, and 2 had inaccessible full text. Finally, the full texts of 8 articles related to the research were examined [Figure 1].
In the second stage, a content analysis qualitative study was carried out using directed approach. In this study, the factors extracted from the first stage formed the initial structure of the second stage, as a guide. The research population consisted of nursing experts and accreditation specialists and experts from nursing schools, universities or the Ministry of Health and Medical Education. The participants were selected through purposeful sampling. Data collection was continued until data saturation. 
Data collection methods and tools
In this part of the study, data was collected through semi-structured interviews. The interviews began with open-ended questions like “How do you assess nursing education in Iran?” or “What can be done to improve the quality of nursing education?” Then, according to the responses and to give them a deeper perspective, follow-up and exploratory questions were asked, such as “Could you give more explanations in this regard?” or “What are the features of your desirable criteria?” After obtaining the participants’ consent, each interview was tape-recorded and then written down on paper for analysis.  While conducting interviews, methods such as making field notes were also used. In order to increase the accuracy of the gathered data, the researcher repeatedly listened to the interviews. In addition, the conversations were compared to the written data in order to avoid contradictions.
In order to analyze the data, directed content analysis method provided by Elo & Kyngäs, has been used. Directed content analysis consists of the three phases of preparation, organizing and reporting.  In the preparation phase, measures were aimed at selecting the participants as well as preparing the interview conditions and the questions. The organizing phase consisted of the interviews and their precise but flexible codification. In this phase, it was attempted to extract all the concepts by reviewing and re-codifying the study. In the reporting phase, the results of the previous phases were summarized and prepared for publication after editing. Guba and Lincoln criteria were also used in order to assess and ensure the accuracy and the validity of the findings: dependability, confirmability, transferability, and credibility.  The researcher made efforts to meet the above criteria through carefully choosing the participants, having long-term contacts with participants and gaining their trust, integrating data collection methods (interviews, field notes, memoing), allocating sufficient time for conducting the interviews, concurrent data collection and analysis in order to record the findings, continuous review and comparison of data and classes in terms of similarities and differences, re-checking the findings with the participants, and providing conditional and extensive data analysis, along with deep and rich descriptions of research for readers. Data analysis was done using MAXQDA-10 software.
In order to observe the ethical principles in the research, an informed consent was obtained from the participants for its inclusion in the study prior to each interview. Data confidentiality was ensured in terms of protecting privacy, and accurate data maintenance and presentation.
The first stage
In the literature review, 32 articles on the accreditation of nursing and midwifery schools were reviewed and finally, 8 articles were included. Seven articles were in English published in foreign journals, and one in Farsi. Two studies were conducted in the United States and one study in each of the countries Australia, Iran, China, the Philippines, Afghanistan, and Lesotho [Table 1]. [18-25]
|Authors/ Title and Year||Question/ Research Objectives||Country||Tool||Framework/ Research Type||Results|
|Cross-sectional description of nursing and midwifery pre-service education accreditation in east, central, and southern Africa in 2013
McCarthy CF (2017) 
|Helping the nursing education train quality nurses||The African Continent||Standard researcher-made questionnaire||Descriptive||Recommending programmatic accreditation and implementing periodic revision of accreditation standards
Institutions affiliated to the Accreditation Commission for Education in Nursing (ACEN) participate in the improvement of educational programs’ quality.
|Accreditation and its Relationship to the Performance in the Nurse Licensure Examination of Higher Education Institutions in the Philippines
Dator W 2016 
|Investigating the relationship between the accreditation and performance in nursing licensure exams||The Philippines||Investigating the school documents and students’ results||Correlational descriptive||The programmatic accreditation of nursing programs is implemented in most regions of the country.
Students' performance in the nursing licensure exam is significantly correlated with accreditation.
To improve the quality of nursing education in The Philippines, accreditation needs to be developed.
|The accreditation of nursing education in Australia. Ralph N (2015) ||Investigating the role of nursing and midwifery board of Australia and accreditation standards in the development of nursing education at the national level||Australia||Text-review checklist||Descriptive, exploratory||The limited number of studies done on the accreditation of nursing education programs along with the relevant processes in Australia and other countries
Emphasis on the improvement of nursing education through the accreditation standards
The development of national accreditation standards by the Australian Nursing and Midwifery Board is considered an achievement.
Emphasis on the ongoing development and enhancement of standards
Emphasis on the development, implementation, and the monitoring of the implementation of accreditation standards by well-known experts in accordance with research-based evidences
|Practical strategies for nursing education program evaluation Lewallen L.P (2015) ||How are teachers and administrators of nursing programs motivated for beginning and implementing the assessment of programs?||The USA||Accreditation-standards checklist, accreditation documents||descriptive, exploratory||The assessment should be a part of everyday activities, because the quality is not something that can be easily achieved.
Nursing programs should demonstrate their commitment to data collection and actions based on the findings of the assessment.
Results should be shared with stakeholders.
Performing regular assessments to strengthen the nursing program
The assessment should focus on the advantages, and improving the weaknesses.
|The implications of accreditation criteria when transforming a traditional nursing curriculum to a competency-based curriculum Botma Y (2014) ||Determining the status of nursing education assessment in the country||Lesotho||Content analysis interview||Descriptive, exploratory||Local, national and international cooperation should be established between the educational institutions in order to promote nursing education.
rofessional monitoring agencies should develop regulations, laws, and the minimum standards for the accreditation of nursing schools and health care services.
Nursing instructors in Lesotho are committed to improving the situation through better nursing education in the form of competency-based nursing programs.
Changing and supporting a competency-based curriculum requires an extensive empowerment of nursing instructors.
|Developing Clinical Nursing Education Standards in Iran Based on International Standards Naseri N (2010) ||The formulation of accreditation standards of clinical nursing education||Iran||questionnaire, Delphi technique, literature review||Descriptive, exploratory||Confirming the possibility of using international models for the initial formulation of standards.
Emphasis on the need for the compliance of the international standards with the educational structures of the country
Proposing 55 localized standards for the accreditation of clinical nursing education
|Accreditation standards for academic quality of baccalaureate degree nursing programs in China Meng M (2010) ||The development of accreditation standards for the promotion of nursing education programs||China||Interview||Mixed: content analysis||Providing accreditation standards for undergraduate nursing programs and accreditation tools in China
Emphasis on the educational objectives in compliance with the international competence, the ability to perform interdisciplinary clinical practices, the ability to use The Traditional Chinese Medicine, and creativity.
Confirming the necessity of the accreditation of nursing programs in China, and the improvement of the quality of undergraduate nursing programs
|The establishment of an accreditation system for midwifery education in Afghanistan: Maintaining
quality during national expansion Jeffrey M et al. (2008) 
|The implementation of an accreditation model for the development and promotion of midwifery in Afghanistan||Afghanistan||Checklist, the accreditation documents of schools||Case study (exploratory, descriptive)||Quality should be considered a goal, not a task.
The development of midwifery education standards in Afghanistan
The need for the formulation of new standards defining higher levels of quality or a different understanding of quality
Table 1: The characteristics of studies conducted on the accreditation of medical schools.
Accreditation provides major benefits to nursing schools, nursing programs, and nursing graduates. It indicates that the nursing school or the program being implemented there is assessed. In addition, it paves the way for the verification of academic certificates and leads to the development of professional and educational skills for graduates.
Accreditation is a professional and specialty program that assesses and verifies curriculums. Programmatic accreditation illustrates the overall picture of the quality of the nursing program and its development, and is more affected by the standards approved by the accreditation agency. In order to receive certifications for programmatic accreditation, the school must include the highest set of approved professional and educational standards in its curriculum. Educational standards are developed by institutions and accreditation centers, and ensure that students completing the program meet the essential requirements for becoming capable nurses. Programmatic accreditation is a reliable tool for demonstrating the quality of nursing education programs which requires the development and adaptation of nursing education standards with significant and up-to-date scientific sources. However, various types of program accreditation implemented by different organizations may have differences at the first glance. Therefore, the development and implementation of accreditation standards should be monitored by skilled experts and professionals in the relevant field.
In the past decades, organizational theories have affected qualitative studies in organizations. Accordingly, studies on education and curriculums in the organizations offering educational services have also been considered from an organizational point of view. In this regard, along with the expansion of educational institutions, a major part of institutional functions have focused on the quality of educational services and their improvement. Institutional accreditation is one of the criteria for the quality of higher education in each institution. It is a process in which the organization is assessed by the external third parties known as accreditation institutions. The institutional accreditation’s being mandatory or voluntary varies from country to country or even from state to state in the same country depending on the educational rules and the political structure. It can also be done either regionally or nationally. Providing an educational certificate to colleges, after obtaining an initial authorization, may be done under the supervision of the Nursing Board, the Ministry of Education, or both.
The second stage
The participants in the second part of the study were 13 nursing experts and accreditation specialists affiliated to Iranian universities of medical sciences. The age range was from 38 to 61. Two of them held Masters, 10 had PhDs and one was a general practitioner. The shortest job experience was 8 years, and the longest was 33 years. Four of them were males and nine were females. The Professional opinions of nursing experts indicate the importance of accreditation and the positive outcome of both institutional accreditation and program accreditation models in the quality of nursing education. The themes related to the executive characteristics of accreditation in nursing schools (institutional and programmatic accreditation) are presented as examples in Table 2.
|The Main Theme||Themes/ Categories||Sub-Categories||Some of the Relevant Codes|
|The Accreditation of nursing schools||Institutional accreditation||Influenced by national/regional educational policies at the macro level||Standards are imposed by The Ministry.
…We may give our opinions, but our duty is to implement the common model in the country.
|The provision of certificates, directly or indirectly by the government||…Anyway, quality management is governmental in our country.
Assessments are done by the university’s experts.
|More appropriate outcome and impact in multidisciplinary schools||…Our universities are multidisciplinary; Programmatic accreditation involves us in several programs.|
|Suitable for the development of structures and curriculums||Our colleges have many problems.
…In fact all the college’s units should be assessed.
The quality of education is not only influenced by curriculums.
|Programmatic accreditation||Influenced by the educational policies of the institution/ school/ university||Accreditation should be consistent with the educational needs of the community
Each university should have its own duties.
|The provision of certificate by professional accreditation institutions||…It is necessary that the experts in each field monitor accreditation.|
|Suitable for the development of specialized nursing curriculums||Through programmatic accreditation… we can find our educational problems.
Programmatic accreditation is more practical for the development of the discipline.
Table 2: The themes related to the executive characteristics of nursing school’s accreditation.
A participant who has experienced the implementation of both accreditation models as an internal evaluator at his/her college believes, “Accreditation in our nursing school... has had impact on the quality of education; in other words, changes have happened. We have implemented both models of accreditation... accreditation in this case is much more coherent, more complete, and fully compatible with nursing and midwifery schools.” In line with this opinion, another expert says, “The fact is both models are useful, because accreditation is a way of measuring the quality and helps us develop our quality on the right path.” From another perspective, some participants consider the implementation of accreditation or any quality improvement program as something related to the educational macro-policies of each country. For example, one of the participants, regardless of the method and the models under discussion, believes, “Any type of monitoring or accreditation can have positive consequences” and has no special idea about prioritizing any specific model at the executive level.
One of the participants with experiences in executive management in the field of accreditation says, “Expert comments on this matter should be made by teachers and experts in the field of nursing”; however, as an expert in the implementation of accreditation in nursing schools believes, “In comparison, I think that programmatic accreditation is much more practical. This is my personal opinion since I’ve experienced both types of standards. As for B.Sc. in nursing (…) naturally, I believe that programmatic accreditation will be a priority.” Programmatic accreditation is also noteworthy for nursing professionals. Without ignoring the benefits of institutional accreditation model, one of the nursing professors finds the programmatic model more appropriate, “The programmatic model can help us more. We can discover our weaknesses and find out the problems with education (…) We are trying, but we do not train good graduates.”
Nursing and accreditation experts participating in the study acknowledged the differences between the practice of programmatic and institutional accreditation, “It can be said that institutional accreditation is the assessment of an institution at the macro level. In fact, all the units of the institution should be assessed. But a specific or programmatic accreditation puts more emphasis on the quality assessment in an educational course or curriculum.” Accordingly, the experts with a general and comprehensive view of the quality improvement have supported institutional accreditation. “In my opinion, assessments in nursing schools should be done at an institutional level. Because we cannot just say that the quality of education in nursing students only depends on educational matters. Obviously, all the units have to cooperate in order to pave the way for the practice of education”, said a nurse administrator.
Considering the current status of nursing schools in Iran and the governmental structure of higher education centers, another participant believes that the only effective way in the current situation is to perform institutional accreditation. He says, “In my opinion, the assessment should necessarily be done in the as an institutional one.” But other participants, despite the lack of explicit emphasis on the priority of the implementation of institutional accreditation model, suggested it as a basis for the implementation of accreditation in nursing schools. One mentions, “I suggest that both models should be considered: the institutional accreditation as a basis for work along with which the programmatic accreditation.” Another participant regards the prioritization of one model over the other as impossible saying, “It is not proper to say which should be implemented at first, because they are both complementary to one another.” However, later, by acknowledging that in the institutional accreditation, the structures and processes are more discussed, he says, “Since processes and structures are discussed in the institutional accreditation, I think it’s a good idea to begin the nursing accreditation with this model.”
Therefore, according to the viewpoints of most participants, it was evident that the use of a variety of standard assessment methods was approved in order to prevent mere documentation. Regardless of various types of accreditation models, participants emphasized that the priority should be given to making an objective and realistic assessment, as one mentions, “Anyway, assessments should be evidence-based and not mere documentation.”
The reviewed sources repeatedly note that accreditation is a major principle for ensuring education and achieving organizational goals. [26,27] However, the present study was carried out in two stages due to the limited resources for providing an effective strategy for choosing the type and the method of implementing accreditation in nursing schools. Investigating the findings from both stages shows that accreditation is regarded and approved as a practical model in terms of quality improvement. In addition, the participants and reviewed sources approved the implementation of accreditation system as an effective, necessary and continuous model for quality improvement in nursing. Despite the consistency of results in favor of accreditation, the variety of accreditation types remains a major challenge in debates regarding the quality assurance and responsiveness in nursing schools. It should be acknowledged that the definition of standards cannot be a goal. Standards should be used in an accreditation model through which institutions will be able to observe continuous improvement in the quality of education. 
The review of sources confirmed the impact of the implementation of both types of programmatic and institutional accreditation models in the process of the accreditation of nursing schools. [27,29] However, the analysis of research results somewhat prioritizes the implementation of institutional accreditation in nursing schools. This prioritization is more explicit for communities where there is governmental monitoring on nursing schools. Even in developed countries such as the United States, where programmatic accreditation comes first, most professional accreditation agencies appraise those educational institutions that have already been approved by one of the regional accreditation agencies. 
Most experts participating in the study also referred to various points in regard with the advantages of institutional accreditation in nursing schools. But none of them denied the advantages of programmatic accreditation. Perhaps the step-by-step and multi-stage development of accreditation is an effective strategy to benefit from the advantages of both institutional and programmatic accreditations. The previous studies also put emphasis on the continuous development of accreditation. The developing process of accreditation should not stop after its first achievement. 
As the process continues, new standards are defined that introduce and create a higher level of quality or a different understanding of quality. It makes sense that each educational system continuously moves towards quality improvement. But it is only desirable and achievable if there is a public acceptance and consensus upon it.  Accordingly, based on the review of national procedures and accreditation standards of each country, efforts should be made to establish and empower the accreditation of nursing and midwifery schools.  Therefore, a comprehensive initial assessment of the status of nursing schools as well as the expert opinions concerning an appropriate model and basic standards is necessary for the implementation of accreditation prior to any decision-making. Accreditation standards need to be developed by experts in the field of nursing and nursing education. Similarly, accreditation criteria and standards are formulated by professional groups and nursing experts, and it is necessary to review at least every 5 years in order to ensure that the standards are up-to-date and in line with daily needs.  In addition, studies regard short-term and long-term planning essential for success in the accreditation process. 
According to the results of the study, the current approach to accreditation standards is one of the important factors in the establishment and implementation of accreditation in nursing schools. The principles of a standard model should be based on the data indicating that adhering to standards and their implementation will ultimately enhance the outcome.  This concept in nursing schools means training nurses who have the capability to provide adequate and proper care for care seekers. In addition, as medical science education moves to competency-based education,  it is necessary to consider these principles in selecting the accreditation model and formulating its standards. In the Promoting Excellence in Nursing Education (PENE) model. Pross introduces the three main components of visionary caring leadership, expert faculty and dynamic curriculum in the promotion of nursing education programs.  Responding to the above items will be more possible in the form of an institutional accreditation model. Therefore, it is necessary to consider these items while choosing an accreditation model and formulating standards.
In line with the results of the study, implementing the accreditation of nursing schools in each community should be based on the assessment of college situations, and in compliance with the executive structure and regional/national education macro-policies. Clearly, the early stages of implementing a successful accreditation model in nursing schools should not be an exception. McKimm believes that the status of current curriculums and the political and administrative structures of countries are influential even in later stages and during making decisions concerning the international or national implementation of accreditation.  Nevertheless, it should be acknowledged that none of these models alone provide a comprehensive approach to promotion, and the implementation of both accreditation models in later stages and during the completion of quality assurance model is recommended according to the opinions of the participants in the study. However, reaching assurance in this regard requires clear evidences of the impact of the implementation of accreditation on institutions, university programs and graduates.
The overall result of this study shows that the accreditation model is a point of agreement among nursing experts and sources for the promotion of nursing education. Based on this study, both institutional and programmatic accreditation models can play an important role in the improvement of education quality in nursing schools because both models dynamically and continually seek to provide and promote educational effectiveness at the national or even global level. Naturally, with the approach chosen in each country for the establishment and selection of accreditation, challenges specific to the same community are revealed. In order to minimize the challenges ahead, more considerations should be given to choosing the accreditation approach. Considering that standards related to basic structures and general processes are further highlighted in the institutional accreditation model, it is recommended to use institutional model in the developing and less-developed countries in order to implement accreditation. In addition, the current and future deficiencies of the implementation of accreditation in each community should be investigated and resolved with the active participation of nursing executive managers and experts within the structure of that community. Due to the differences in the levels of education and executive capabilities, the mere adoption of models without localization -even from the developed countries- is not recommended because it makes the achievement of goals and the nature of accreditation in a logical consistency with standards and objectives more challenging.
Given the ever-increasing development of knowledge, it is essential that governments, especially in less-developed countries, support the establishment of structures for nursing school’s accreditation, in line with the WHO policies in order to facilitate the training of graduates with the ability to provide safe care consistent with community needs. In regard with the limitations of this study in addressing the executive problems and barriers to the implementation of accreditation in different countries, it is recommended that future studies focus on these issues and challenges against the practical implementation of accreditation in less-developed countries in order to facilitate the development of accreditation, especially institutional accreditation.
The authors declare that they have no competing interests.
This article is the result of a Ph.D. dissertation in nursing conducted in the School of Nursing of Jundishapur University of Medical Sciences, Ahvaz, under the ethical code IR.AJUMS. REC.1396.839 and the design code U-96138. The authors truly appreciate the participants in the study as well as the Research Deputy of the School of Nursing, Ahvaz Jundishapur University for supporting this study.
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