Montana Nurses Association 20 Old Montana State Highway Montana City, MT Main Phone (406) WEBSITE:

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2 Continuing Nursing Education Manual Approval of Individual Education Activities Council on Continuing Education 2011 Gwyn Palchak, Representative to the Board of Directors CCE Executive Committee Member Elizabeth Kinion, Bozeman CCE Executive Committee Member Pam Windmueller, Great Falls CCE Executive Committee Member Paula Roman, Helena Susan Porrovechio, Big Fork Mary Thompson, Helena Debby Lee, Denton Anna Ammons, Columbus Susan Finn, Billings Linda Ries, Sidney Sue Noem, East Helena Sandy Sacry, Helena/Whitehall Mailing Address: Montana Nurses Association 20 Old Montana State Highway Montana City MT Offices & Education Center: 20 Old Montana State Highway Montana City, MT [Exit 187 on I-15 South] (406) Continuing Education Department Barb Swehla, MN RN CE Director (406) (direct line) Sheri Marchand Smith, MSN RN-C CE Specialist (406) (direct line) Page 2 of 33

3 TABLE OF CONTENTS Montana Nurses Association Page How to Use This Manual... 4 Approval Process and Timelines... 4 Eligibility... 4 Application Processing... 5 Documentation Organization... 5 Individual Activity Application Fees... 7 Terminology and Approval Language... 8 Applicant / Provider Information... 9 How This Activity Was Planned, Advertised & Evaluated Effective Design Principles.10 Evaluation Advertising, Commercial Support, Sponsorship, Disclosures After the Workshop Required Follow-up for Your Files and MNA Frequently Asked Questions APPENDICES A Is It Continuing Education? Guidelines for Differentiating Levels of Education B Co-Providership at a Glance C Conflict of Interest (an appendix from the 2009 ANCC Application Manual) COI Decision Tree D Commercial Support / Sponsorship Decision Tree E Required Disclosure Statements F Writing Objectives & Terms G Glossary Page 3 of 33

4 How to Use This Manual This manual was prepared in accordance with the American Nurses Credentialing Center s Commission on Accreditation (ANCC COA) criteria, frequently referred to as ANCC COA 2009 criteria. Criteria affecting individual activities that were changed or added are incorporated into the forms you will need to complete and submit to MNA for approval. With MNA approval of a complete and accurate application, the ANCC COA criteria will have been met and you will be able to award continuing nursing education (CNE) contact hours. This manual is provided as a reference. Download or print the entire manual if you wish. Several sample forms are available on the website. Please be advised that the forms may change from time to time, so always use the forms provided on the: MNA website: Approval Process and Time Lines A faculty-directed CE activity (as opposed to an independent study activity) involves learner participation. The provider who plans and schedules the activity determines the pace of the activity. Contact hours are awarded based on the time allocated for the activity, plus time for participant evaluation of the activity. Examples of faculty directed CE activities include but are not limited to conventions, courses, seminars, workshops, lecture series, and distance learning activities such as teleconferences and audio conferences. Knowledge and use of adult learning principles should be reflected in all aspects of the educational design, i.e. objectives, content, teaching methods, etc. ELIGIBILITY: MNA reviews the application following broad eligibility requirements: o The activity must relate to the nursing profession and meet the definition of continuing education. See the document, Is It Continuing Education? on the website to determine whether or not your planned activity meets these requirements. o The activity s objectives must be attainable given the scope of the subject, program design, and time frames specified. o The faculty must have credentials relevant to the topic to be presented and validated on the Biographical Data Forms. TO PROCEED: A. Complete the application in its entirety using the MNA forms provided on the MNA Website and completed electronically no handwritten documents are accepted. If a speaker, for example, submits a handwritten Biographical Data Form, the nurse planner shall put the information into the electronic format and indicate on the bottom of the form that a signature was obtained in hard copy and translated to the electronic form. Forms designed for other CE accrediting agencies are not accepted. o All required sections of the application must be submitted at the same time. If any sections are missing, the CE staff will not begin processing until the required sections are completed and all documents are completed and correct. Page 4 of 33

5 o Send application documents via to Sheri Marchand Smith at or Barb Swehla at REGULAR MAIL OR FAX: Neither hard copy nor faxed applications are accepted. submissions are required. submissions must be on current MNA forms from the MNA website and in the format described in this manual. The nonrefundable application fee should arrive at the time of the submission, with its purpose clearly stated on the check or in accompanying documentation. The documents shall be organized as follows: 1) Individual Activity Documentation Form, which includes the QI Form. 2) Agenda with time frames consistent with the Objectives/Content Outline Forms. You may refer to your program brochure/flyer if the agenda is detailed on that document. 3) Objectives/Content Outline, etc. use as many of these pages as needed however, please note that you should have only 1-2 objectives per hour of presentation and these shall be presented in the same order as the agenda and the time frames and must be consistent with the time frames on the agenda as well. The nurse planner must complete this portion of the documentation in collaboration with presenters and other planning committee members. 4) Biographical data forms for planners and presenters are provided in the order of the agenda and named accordingly. Electronic signatures are acceptable and the RN planner for the event must complete the bottom section on addressing conflict of interest, etc. (or the lack thereof) for each presenter and planner. 5) Disclosure Form disclosures cannot be provided verbally they must be written and provided to participants at the beginning of the activity/event. See example in Appendix E. Disclosure statements must be based on all bio forms received and include all required elements: Disclosures of Commercial Support/Sponsorship or the lack thereof Disclosures pertaining to Conflict of Interest, Non-Bias, and Off-Label Product Use or the lack thereof Disclosures pertaining to Requirements for Successful Completion to Earn CNE Contact Hours Disclosures pertaining to planned follow up by the provider as to changes in practice made as a result of the CNE activity - Note: while a brochure may contain general disclosures, the actual written disclosures cannot be complete until all of the planners and presenters biographical data forms have been submitted, reviewed & completed by the nurse planner. 6) Brochures, blasts, website postings, flyers, and other advertisements distributed for the event - with the correct pending-approval language (see required language on page 17 of this document). 7) Evaluation Form to be used (Example provided on the MNA website) 8) Examination if used 9) Co-Provider Agreement, if applicable (See example in Appendix B) Page 5 of 33

6 B. After the application and nonrefundable review fee have been received by the MNA office, the review process begins. MNA may return applications that have not been submitted in the proper format prior to review. No application will be approved until the nonrefundable review fee has been received by MNA. o MNA CE staff will send an notification to the applicant indicating: That the application has been received; The MNA tracking number to be used on the certificates and all MNA/Applicant communications; and The review process and timing. o MNA CE staff performs a preliminary quantitative review to ensure that all documents have been included in the application. If documents are missing, an will be sent to the applicant indicating missing documents and time frame for submission of those documents; The applicant is notified that the application is incomplete until those complete and accurate documents are received by . The timing of the application begins when the application is both complete and accurate. o MNA CE staff performs an in-depth review to ensure that all documents have been completed accurately and completely. The application is considered incomplete until all documents are present and completed accurately. The applicant is notified that late fees or rush fees may apply, based on the time that the application was deemed complete and the first date of the activity. See fee structure form on the website and in this document. Most applicants can expect approval within 3 business days of the application being deemed complete (meaning all required information has been submitted and is correct according the ANCC COA requirements). When ing additional information, ALWAYS include the MNA number assigned to the application. The MNA number is VERY important to efficient tracking and follow up. If the additional information is satisfactory and arrives at MNA before the presentation date, the approval deferred or pending status will be changed to "approved". APPLICATION DECISIONS INCLUDE: Approved for a two-year period. A approved application allows the provider to repeat the CNE activity as often as desired during the two-year period of approval unless substantial changes are made. Please see the Not approved -- If the final decision is to not approve the application, rationale and future options will be provided. This rarely occurs, due to the fact that the applicant and MNA CE staff work diligently to complete the process successfully. If the applicant is unable or unwilling to reach that goal, the application process is typically abandoned. C. An letter is sent to the applicant indicating the final action on the application. The MNA application number must always be used in any correspondence or phone calls concerning the activity and MUST be on the certificates given to participants. D. If an application is not approved, the applicant may revise the application and re-submit it for approval prior to the event. E. An appeal process is available to any applicant who does not agree with the decision of the CE staff. Contact the CE Department for a copy of the appeal policy. Satisfactory appeal must be completed prior to the event or presentation of the activity. Page 6 of 33

7 F. One copy of the entire application, the review forms and all correspondence to or from the applicant will be maintained at the MNA offices for six years. Only authorized personnel have access to the files. G. As applicants proceed through the application process, they are encouraged to ask questions and seek help as needed. MNA staff can provide phone assistance or more extensive consultation can be arranged. Individual Activity Application Fees This fee schedule became effective May 2011, and is subject to change. Fees are to be submitted with the application and are not refundable once the review process has begun. MNA reserves the right to change fees at any time without notice, so always check the fee schedule provided on the MNA Website where the most current fees are posted. If requested, MNA will invoice you for the amount due. MNA approval of individual activities is granted for a period of two years. The approved activity may be repeated AS APPROVED any number of times during that two-year approval period. If objectives, faculty, content, or program design are changed, MNA must receive updated biographical data forms and/or activity documentation changes at least 30 working days prior to the start of the revised activity. There is no fee for review of program updates during the 2-year approval period as long as the updates are provided at least 30 working days prior to the start of the event. Late/rush fees apply if the updates are submitted less than 30 working days from the start of an event. All applications must be submitted electronically at least 30 working days prior to the start of the event. The date of the application begins when the application is complete (all required documents have been submitted and are filled out correctly). Number of Speakers and Planners Review Fee for 2-year Approval Applications with MNA members verified as actively serving as Lead Nurse Planner may receive a 30% discount on the regular review fee Late Fee (in addition to the regular review fee) Less than 30 working days prior to the start date of the activity Rush Fee (in addition to the late fee) Less than 10 working days prior to the start date of the activity 1 4 $100 Add $50 Add $ $200 Add $50 Add $ $250 Add $100 Add $ or more $300 Add $100 Add $150 Applications submitted under a late/rush fee will be processed at the discretion of the MNA CE staff. Page 7 of 33

8 Terminology & Approval Language CNE Contact Hours The appropriate measure of continuing nursing education is the 60-minute contact hour. A contact hour is 60 minutes of an organized learning activity that is either a didactic (educational) or independent study. Evaluation is considered part of the learning activity, for which contact hours can be awarded for a reasonable time period. The minimum number of contact hours that can be awarded is 0.5 (30 minutes). Contact hours may be calculated to the hundredths (i.e. 0.71, 1.56, etc.), however they may not be rounded up. Contact hours must be determined in a logical, defensible manner, consistent with the objectives, content, teaching/learning strategies and target audience. Welcome, introductions, breaks and viewing of exhibits are not included in the calculation of contact hours. No CEUs! Neither the ANCC Commission on Accreditation or the Montana Nurses Association has authorized use of the Continuing Education Unit (CEU) system. This means approved contact hours, NOT CEUs, will be applied for and awarded. At no time is it permissible to use the term CEU or to use any other discipline s credit within the same sentence as the nursing credit. Approval Language Applicants of Faculty Directed and Independent Study activities must use the appropriate ANCC Commission on Accreditation and MNA terminology related to approval status in all communications and on all written materials related to the educational activities. The approval statement stands alone. That is, it must begin and end on a line separate from other text. Prior to approval: This activity has been (or will be) submitted for approval by the Montana Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Once approved: This continuing nursing education activity (MNA ) was approved by the Montana Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Handouts/Teaching Materials Please do not submit handouts or teaching materials that will be given to participants with the applications sent to MNA. If handouts are to be used, they should be listed under teaching methods. Presentation tools, such as PowerPoint Presentations, and all related documentation for the activity must be kept with your original application documents for a period of six years. Awarding Contact Hours to Faculty In activities with multiple topics and presenters, faculty may be awarded contact hours for the parts of the program presented by others and in which they participate as learners. Montana does allow a presenter who has developed and presented an activity for the first time to receive contact hours for the presentation time. No contact hours may be awarded for preparation time. Page 8 of 33

9 COMPLETING THE INDIVIDUAL ACTIVITY / FACULTY-DIRECTED APPLICATION Use the form labeled Individual Activity Documentation Form. Be sure to provide all information requested. If you plan to design an independent study activity, please contact the MNA office for direction and forms. Applicant / Provider Information o Name of Applying Organization, Group, Person, etc o Contact Person For This Application -- A person (not required to be a nurse) must be identified as the contact person for the activity. If the contact person is also part of the planning committee, his/her name should be included on the planning committee list. Throughout the approval process, MNA will correspond with the person identified in this space, but may require a conversation with the nurse planner for certain aspects of the application. How This Activity Was Planned, Advertised & Evaluated 1. Assessment o Needs assessment -- The type of needs assessment used to determine the learners needs is identified. o Is this continuing education? -- The objectives and content must reflect continuing education. Basic nursing education, in-service, orientation, and personal development are not applicable for contact hours. See Is It Continuing Education? on the website and in this document. o Target audience identifying the target audience helps define who should be added to the planning committee. Specific members may be helpful, such as a LPN if content is designed for LPNs or an APRN if content is designed for APRNs. If content is expected to meet the continuing education requirements of APRNs with prescriptive authority, then an APRN with prescriptive authority might be included in the planning committee. 2. Qualified Planners and Faculty a. Planning Committee -- The planning committee must include people with certain types of expertise. These individuals must have relevant content expertise, represent the target audience and be actively involved in the planning process. At the minimum, the planning committee must consist of two people: A registered nurse who has at least a baccalaureate or higher degree in nursing. One other person. The nurse planner MUST have been a part of activity planning from beginning to end. Planning may occur in face-to-face meetings, by , conference call, fax or correspondence. Multidisciplinary activities may have planning committees with representatives of each discipline considered important to the planning. b. Faculty -- Faculty/presenters are selected to present content in an area in which they have knowledge and expertise and must document this topic-specific expertise on the Biographical Data form. DO NOT SUBMIT CURRICULUM VITAES OR ANY OTHER FACULTY INFORMATION. ONLY THE BIOGRAPHICAL DATA FORM MUST BE SUBMITTED FOR EACH PLANNER AND EACH PRESENTER. NOTE: Presenters qualifications stated on the biographical data form must articulate education and/or experience in the specific area of content being presented. Expertise in subject matter can be documented based on education, professional achievements and credentials, work experience, honors, awards, Page 9 of 33

10 professional publications, etc. The qualifications should address How does this person know about this topic, how has expertise been gained in this area of practice? Conflict of Interest/conflict resolution disclosure statements must be completed by all presenters to identify and resolve any potentially biasing relationships on the part of those who have an impact on the content of an educational activity. In addition, the faculty must declare if they will be discussing any offlabel use of products during their presentation. c. Co-Providership agreements must clearly spell out the roles of each co-provider as the activity is planned, developed, implemented, and evaluated. An example of such an agreement is provided on the: MNA Website: 3. Effective Design Principles a. Purpose/goal statement for this activity -- is a broad statement about the activity. It is not the objectives. Typically, it will include a description of how this activity will enrich the registered nurse's practice. It should be concise, clearly stated and supported by the needs assessment, objectives and content. An example might be To increase understanding about end-of-life care. The statement to help nurses get their contact hours is not acceptable. b. Successful completion of this activity -- may be achieved by a variety of methods, i.e., submission of a written post-test, self-reported level of achievement of objectives, return demonstration, evaluation, discussion with presenters, attendance at the entire activity, etc. You decide what requirements you wish to use based on your program design and target audience. c. Verification of participation -- may be achieved by roll call, sign in sheets, self-reported attendance, or return of evaluation tools. Whatever method you choose must record the learner s name, address, phone number, and a unique identifier, such as the last four digits of the Social Security number or an employee s badge number. (Sample attendance form included in the FORMS section.) d. Activity documentation -- Use the 6-column form to document how the activity will be presented. 4. Awarding Contact Hours -- Specify the maximum number of contact hours being requested and identify if, in the program design, you would offer partial contact hours for participants who do not complete the entire activity. Check further discussion about contact hours under CNE Credit in the Adhering to Criteria section. 5. Evaluation -- The primary focus of this section is the learner: Did the learner achieve the stated purpose and objectives? The evaluation component of continuing nursing education should reflect the circular nature of the educational design process. Planning begins with determining measurable outcome objectives for the learner and is complete when the learner evaluates the activity and states whether the objectives were met. Evaluation is not a subjective feeling that the learner has about enjoying the event. An effective evaluation determines if the participant gained the knowledge, skill or ability that was identified during the planning process. You will need to indicate which evaluation category is most appropriate for this activity, and what method(s) you will use in evaluating the activity. Page 10 of 33

11 a. Categories of evaluation include such topics as learner satisfaction, knowledge enhancement, skill and attitude change, change in practice/performance, and relationship of the practice change to quality of service. The planning committee needs to determine how each category could be assessed. EXAMPLE: If Skill and attitude change is checked, what skill and/or attitude should change and how would the change be assessed or monitored long-term? Does your program design support this level of evaluation? b. Methods of evaluation -- should be determined by the course objectives, time frame, and teaching methods. Various tools may be used, such as checklists, rating scales, questionnaires, and tests. The evaluation tool for presenter-directed activities must address the following six items: 1. Learner s achievement of EACH educational objective. 2. Expertise of EACH individual presenter. 3. Relationship of objectives to overall purpose of activity. 4. Effectiveness of teaching strategies by EACH individual presenter. 5. Perceived bias during an individual presentation. 6. Confirmation of disclosure. NOTE: The participant must evaluate individually EACH objective and EACH presenter for the presenterdirected activity. Include a copy of the evaluation tool. A sample tool is in the FORMS section. Following the activity, the results of evaluation help to determine the success of the activity or identify problem areas, determine whether it should be offered again or needs to be revised to achieve the objectives within the designated time. Evaluations must be summarized into a single document and retained as part of the activity file. A copy of the summative evaluation is sent to MNA as part of the required follow-up. 6. Approval Statement and Documentation of Completion (Certificate) -- Participants receive written verification of successful completion through a document that reflects the information below. A sample certificate is in the FORMS section. o Provider (applicant) name and address, including street, city, state, and zip code. o MNA CNE tracking Number. o A place for the name of participant. o Title of the activity. o Number of contact hours awarded (this may be blank if partial contact hours may be Awarded and completed at the time of distribution by the provider.) o Day, month and year of the activity/event. o City and state in which the activity was presented, (if faculty-directed activity versus an independent study format). o Correct, stand-alone MNA approval statement. 7. Advertising Marketing or promotional materials includes any method of announcing an educational activity, and may include a brochure, flyer, bulletin board announcement, newsletter, memo, or web site. This material must be provided with the application. If advertising is provided on a web site, include information on where and how to find it, and include a hard copy of the or web site advertising. Page 11 of 33

12 Advertising material may be the completed copy of a mock-up or the final material. If a mock-up of the advertising material was used, the final copy of the advertising material must be submitted to MNA as soon as it is printed. The following statement only must be included on this activity s promotional materials prior to approval: This activity has been submitted for approval by the Montana Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. After the activity is approved, promotional materials may say contact hours have been awarded by using the following statement (which must stand alone): This continuing nursing education activity was approved by the Montana Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. You are invited to advertise your educational activity in the MNA quarterly newsletter, The PULSE, and on the MNA website at no cost. Contact the CE staff regarding deadlines for publication in the MNA PULSE. Note: The date in the statement Approval valid through (insert expiration date) is included once the applicant has received approval for this activity. The date will be two years from the date of approval. If the provider must release the advertising material prior to receiving approval and has submitted an application to MNA, the provider may state the following: An application has been submitted to the Montana Nurses Association. Please call (name of person) at (the providing organization/applicant) for more information about contact hours. 8. Commercial Support and Sponsorship o Commercial interest is defined by ANCC as an entity either producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients or an entity that is owned or controlled by an entity that produces, markets, re-sells or distributes health care goods or services consumed by, or used on, patients. Exceptions are made for nonprofit or government organizations and non-health care related companies. Commercial support is not permitted to affect the design and scientific objectivity of any educational activity. Commercially supplied funds for an educational activity must be given in the form of an educational grant or in-kind assistance and are acknowledged in the brochures and/or printed material for the activity. A written agreement is required. o Sponsorship -- ANCC defines a sponsor as one who is not a commercial entity but does provide support (monetary or in-kind ) to the provider of the activity. Sponsorship must be acknowledged to learners. A written agreement is completed. Sponsors are not involved in planning, developing and implementing the educational activity. 9. Conflict Of Interest -- Conflict of Interest/conflict resolution disclosure statements must be completed by all faculty and all planners for each activity they help plan to identify and resolve any potentially biasing relationships on the part of those who have an impact on the content of an educational activity. 10. Disclosures Provided To Activity Participants Disclosures must be conveyed to learners prior to the beginning of the activity. They include: Page 12 of 33

13 1. Notice of requirements for successful completion Learners are informed in advance of the criteria to be used to determine successful completion of an educational activity. 2. Conflicts of Interest Learners are informed of any influencing financial relationships or lack thereof disclosed by planning committee members and presenters. 3. Commercial support Learners are made fully aware of the nature of any commercial support related to an educational activity. 4. Non-endorsement of products Learners are advised that the ability to provide CNE for this activity does not imply endorsement by the CNE provider, MNA or ANCC COA of any commercial products displayed in conjunction with an activity. A statement to this effect should appear so the learner is informed. 5. Off-label use Learners are notified when an educational activity relates to any product use for a purpose other than that for which it was approved by the Food and Drug Administration. Disclosures must be done in writing and accompany the electronic application. After the Workshop Required Follow-up for Your Files and With MNA Activity Repeats A provider of an approved activity may offer that exact activity as many times as desired during the 2-year approval period. If speakers change, objectives/content change, or if time frames are substantially changed, the course revision and, if applicable, new Biographical Data Forms, must be submitted (at no charge) to the MNA CE staff by no less than 30 working days prior to implementation of the changed activity. Quality Improvement A quality improvement form should be completed for each educational activity and it is the last page of the individual activity documentation form. The top of the form must be completed with the application and a completed form must be submitted within 30 days following the activity. Event Roster and Summative Evaluation are due to MNA within 30 days of completion of the workshop and ed to the MNA office. A summative evaluation is NOT the tabulation of evaluation results it must be a summary of evaluation results and includes written comments. Failure to send the completed QI form, summative evaluation and the list of attendees may jeopardize future reviews of CNE activities. Be sure to include the MNA tracking number on these materials! Record Keeping -- Materials and documents related to the educational activity must be retained securely by the organization in an easily accessible, confidential manner for a minimum of six (6) years; longer if your agency s policy requires. If you do not have an internal policy, now is a good time to create one. Include at minimum HOW the records are filed (chronological, alphabetical, etc.), WHO, by job title, can retrieve records, and WHERE are the records kept. FREQUENTLY ASKED QUESTIONS Can an activity be approved retroactively? Retroactive approval, approval for contact hours for an educational activity AFTER the activity has been presented, is not authorized by ANCC Commission on Accreditation or MNA. Approval MUST be granted PRIOR to the presentation of an educational activity. Can I withdraw my application? Will this affect further reviews? A provider has the right to withdraw an application at any time prior to completion of the approval process without prejudice to any future applications. Fees will not be refunded if the review process has begun. The provider must notify the MNA Continuing Education Department in writing of the decision to withdraw Page 13 of 33

14 the application. One complete application and a copy of all correspondence will be kept on file in the MNA office for six years if the review process has been started. How long is approval effective? The approval period for Faculty Directed and Independent Study applications is two years from the date MNA issues the approval notice. The activity may be repeated as often as wished during this two-year period as long as QI forms, summative evaluations and rosters are submitted within 30 days of each offering. If the presentation is repeated exactly as before, the provider only needs to notify MNA of the additional dates prior to the event. If minor changes are to be made, the provider must outline the changes, state the rationale for the changes (i.e., recommendations on evaluations, comments from the review process, etc.), and give any additional information needed because of the changes (i.e., new faculty qualifications, new facility description, different evaluation tool, etc.). If an application has been approved and there is a significant change in the content prior to a second or subsequent presentation, then another application must be submitted for approval. For example, significant change could be substituting a new one-hour segment for one that previously met criteria, changing objectives and content, etc. If the speaker changes, but the new speaker will continue to present the same content, and use the same objectives and time frames, just submit a memo regarding this change and the biographical data form for the new speaker. If you have any questions about whether you should write another application or just send a memo, please contact MNA CE staff. What should happen if, during the planning process, it becomes apparent that certain session(s) out of a larger presentation may potentially be repeated on their own? The provider should: 1. Identify each section of the larger presentation as a potential, separate session (e.g. Session 1: Acute Respiratory Distress; Session 2: Chronic Respiratory Distress, etc.) 2. State in the application form that learners may attend one or more sessions. (You might also wish to include the information on the advertising material.) 3. On the certificate, identify the sessions the learner attended, the date(s) and the contact hours awarded for those sessions [e.g., Learner name successfully completed Critical Care Course Sessions 1 Acute Respiratory Disease, 5 Congestive Heart Failure, & 7 MI on date(s). ] Some providers include a table on the Certificate of Attendance that lists the available sessions; learners check or initial those sessions they attend. Can an activity be re-approved after the two-year approval period expires? When the original approval period expires, any approved activity may be submitted for approval again. The cover letter must note that it is an application for approval again and indicate the previously assigned MNA number. Submit the new application electronically on the most current application forms. What if I don t agree with the review outcome? A provider who does not accept the results of the review process may request in writing that the Council reconsider the application. Contact the Continuing Education Director for the appeal procedure. Why would my approval be revoked? Approval may be revoked as a result of ANY one of the following: o Failure to remain in adherence with relevant criteria, rules and requirements defined in this manual; o Investigation and verification by the MNA CCE Approver Unit of written complaints or charges by consumers or others; Page 14 of 33

15 o o Refusal to comply with an investigation by MNA; Misrepresentation. Montana Nurses Association Revocation is effective on the date the certified letter of notification is received by the organization. All statements regarding approval status must be removed from publicity material and certificates of attendance printed or distributed after that date. Do these requirements apply to MNA districts and local units? MNA districts and local unites are not required to pay any fee for CNE that they provide. Districts and local units, as well as structural units of MNA (councils, commissions, etc.) adhere to the requirements of the MNA Provider Unit and must meet criteria of MNA s status as a Provider of continuing nursing education in order to award continuing nursing education contact hours. Other Questions or Concerns? If other issues arise that generate questions, please contact MNA at 406/ or barb@mtnurses.org. Sources Manual for Accreditation as an Approver and Provider of Continuing Nursing Education, ANCC 2009 Scope and Standards of Practice for Nursing Professional Development, American Nurses Association, #NPD-20, Washington, DC, Sample forms are available on the MNA website: Page 15 of 33

16 APPENDICES ` Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Appendix G Is It Continuing Education? Guidelines for Differentiating Levels of Education Co-Providership At A Glance Conflict of Interest (an appendix from the 2009 ANCC Application Manual) COI Decision Tree Commercial Support / Sponsorship Decision Tree Required Disclosure Statements Behavioral Objectives Bloom s Taxonomy Verbs to Use Verbs to Avoid Glossary of Continuing Education Terms Page 16 of 33

17 APPENDIX A Is It Continuing Education? Guidelines for Differentiating Levels of Education BASIC EDUCATION -- Target audience: students preparing for entry into the nursing profession and baccalaureate completion programs Basic educational information Prepares for entry into nursing practice Addresses basic standards of nursing practice ORIENTATION -- Target audience: nurses preparing for a new position or career role Educates for work at a specific institution/employer Teaches and tests for skill competency Addresses institution/employer-based standards of nursing practice IN-SERVICE -- Target audience: nurses preparing to utilize new tools/information specific to work setting/nursing role Educates to new procedures, roles, medications, or equipment Enables or increases skill competence Practice previously learned skills/knowledge Addresses institution/employer-based standards of nursing practice Promotes compliance with facility policy and procedures, Demonstrates use of facility-specific equipment, or Basic CPR, first aid, and orientation to work settings are considered in-service. PERSONAL DEVELOPMENT -- Target audience: general population Educates individuals in topics pertaining to financial management, personal hygiene/beautification, personal conduct, and other topics that do not pertain to the practice of nursing or to healthcare in general. CONTINUING EDUCATION -- Target audience: nurses seeking enhanced professional-ism and utilization of advanced nursing decisions and practice. Acquires new knowledge and skills to assist with advanced decision making Acquires greater depth of knowledge and skills in a particular area of nursing Enhances professional attitudes and behaviors Advances career goals and promotes professional development Supports innovation and creativity in practice Implements change within the individual s practice and within healthcare in general Addresses new standards of practice, laws and rules. Page 17 of 33

18 APPENDIX B CO-PROVIDERSHIP AT A GLANCE ANCC criteria state that the CE provider must maintain responsibility for the following when/if activities are coprovided: o Determination of educational objectives and content o Selection of content specialist planners and activity presenters o Awarding of contact hours, as appropriate, for the individual educational activity o Record keeping procedures o Evaluation methods and categories, and o Management of any commercial support or sponsorship. Co-provide is the process for planning, developing and implementing an educational activity by two or more organizations or agencies. (ANCC Commission on Accreditation, 2001) Nurse Planner: The collaborating organizations or individuals must determine which organization will be the primary provider and which organization(s) will be the co-provider(s) for the event. The primary provider will be responsible for submitting the application to MNA for review and approval of contact hours. This Nurse Planner is the person responsible for assuring that ANCC COA educational design criteria/rules are used to plan and implement the activity. When co-providing an educational activity, tasks involved in planning, implementing, and evaluating the activity may be shared; however, the final responsibility and accountability to insure that the criteria are met remain with the lead provider. For example, the organizations could jointly discuss desired objectives, but the final decision about which objectives to include and how they are written rests with the nurse planner. A written co-provider agreement confirms these arrangements. See sample in the FORMS section. Approval vs. Co-providing: Co-providing continuing education is not to be confused with approval of continuing education. If your Nurse Planner was not actively involved in the planning of the event, you may not provide or co-provide it. Co-provider vs. Co-sponsor: ANCC COA criteria do not use the terms sponsor or cosponsor interchangeably with co-provider. Co-providing is the term used when two or more groups work together to assess, plan, implement and evaluate continuing education activities. Advertising: Any advertising should include all names of the provider and co-provider(s). Your provider unit must be prominently mentioned in the advertising. For example, ABC Hospital and Chapter x of the Medical / Surgical Nurses Association Fees for Co-providing: There are no ANCC COA criteria or MNA policies that prevent you from charging a fee for your time, expertise and resources to participate in planning an event, issuing certificates, keeping records, etc. However, be very careful that it is clear to all parties that the fee covers your involvement, not your approval of someone else s activity. When is it NOT Co-Providership? There are instances when you may be asked to co-provide an activity and it is not appropriate to do so. As an example, an outside organization asks you to submit the paperwork for contact hours for an event they planned. In this instance, the Nurse Planner has not been involved in the planning process and, therefore, cannot co-provide. Ask the following questions to determine if what is being asked is truly co-providership. 1. Who is the other group? Are they asking you to do work they would normally need to do to have an individual activity approved? 2. Has one of your Nurse Planners been actively involved in planning since the beginning? 3. Who is putting on the event your organization or another organization? If your answer is NO to one or more of the above questions, this is not coprovidership. Page 18 of 33

19 APPENDIX C CONFLICT OF INTEREST This appendix includes additional information regarding conflict of interest from the Application Manual Accreditation Program (ANCC 2009), and includes a conflict of interest decision tree. RESOLUTION OF CONFLICT OF INTEREST A conflict of interest exists if an entity that is in a position to benefit financially from the success of a CE activity is ALSO in a position to influence the content, design, or implementation of the CE activity. 1.1 An individual or organization must disclose to the CE activity provider his/her/its relationship to the product or service developer, manufacturer, distributor or seller, IF the organization or an individual within the organization is in a position which affords him/her the opportunity to affect CE content with products or services from which, if purchased, the individual or organization might receive personal financial benefit, 1.2 The provider must be able to show that each individual who is in a position to control the content of an education activity has disclosed all relevant relationships with any entity in a position to benefit financially from the success of the CE activity. Examples of relevant relationships include (but are not limited to) those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g. stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Relevant relationships can also include contracted research sheer the institution receives a grant and manages the grant funds and the individual is the principal or a named investigator on the grant. Financial benefits are usually associated with roles such as employment, management position, independent contractor, consulting, speaking, teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received or expected. ANCC considers relationships of the individual involved in the continuing nursing education activity to include financial relationships of the individual s spouse/partner. Relevant relationships must be disclosed to the learners during the time when the relationship is in effect and for 12 months afterward. ANCC considers relationships occurring within the 12 months prior to the implementation date of the activity as relevant to conflict of interest. When a person divests himself/herself of a relationship, it ceases to be a conflict of interest but it must be disclosed to the learners for 12 months after the termination of the relationship. 1.3 An individual who refuses to disclose relevant relationships will be disqualified from being a planning committee member, a teacher, or an author of continuing nursing education and cannot have control of, or responsibility for, the development, management, presentation or evaluation of the CE activity. 1.4 The provider must have implemented a mechanism to identify and resolve all conflicts of interest prior to the education activity being delivered. Page 19 of 33

20 Conflict of Interest (COI) Decision Tree 1 1 Ohio Nurses Association 2009 Provider Manual, page 63 Page 20 of 33

21 APPENDIX D Commercial Support / Sponsorship Commercial support and/or sponsorship may be obtained for an event. This might include financial or in-kind contributions. Commercial support / sponsors are not part of the assessment, planning, implementation, and evaluation process for the activity, so they are not co-providers. Be sure to adhere to the requirements regarding use of commercial support / sponsorship and inform learners. Please see STANDARDS FOR DISCLOSURE AND COMMERCIAL SUPPORT on the MNA website for further discussion of this topic. Page 21 of 33

22 APPENDIX E Sample Required Disclosure Statements Disclosures pertaining to Commercial Support/Sponsorship: When no support or sponsorship received: This continuing nursing education is being offered without the influence of bias. No commercial support was received, the event was not sponsored. Presentations by (provider your company - name) do not imply endorsement of any product, individual, or therapeutic practice. When support or sponsorship is received: This continuing nursing education is being offered without the influence of bias. No conflicts of interest have been identified and all commercial support and/or sponsorship have been properly disclosed and documented. Presentations by (provider your company - name) do not imply endorsement of any product, individual, or therapeutic practice. Disclosures pertaining to Conflict of Interest, Non-Bias and Off-Label Product Use: When no potential or actual conflict of interest, bias, or off-label product use have been identified: This continuing nursing education is being offered without the influence of bias. No conflicts of interest have been identified and no off-label products will be discussed. Presentations by (provider your company - name) do not imply endorsement of any product, individual, or therapeutic practice. When potential or actual conflict of interest or bias have been identified: This continuing nursing education is being offered without the influence of bias. Conflicts of interest have been identified and resolved; no off-label products will be discussed. Presentations by (provider name) do not imply endorsement of any product, individual, or therapeutic practice. When discussion of off-label use will occur and has been addressed: This continuing nursing education is being offered without the influence of bias. No conflicts of interest have been identified and any discussion related to off-label use has been addressed and acknowledged. Presentations by (provider your company - name) do not imply endorsement of any product, individual, or therapeutic practice. Disclosures pertaining to requirements for successful completion of a CNE activity: In order to receive full contact-hour credit for this CNE activity, you must: Sign the Verification of Attendance form Remain until the scheduled end time; and Complete the Evaluation Form following the activity Verbally confirm participation on the Call (for conference call formats) Disclosure pertaining to follow up on the effectiveness of the CNE activity: Please be advised that a provider of continuing nursing education may request feedback from participants at some point following an activity regarding the effectiveness of the education on nursing practice improvement. Page 22 of 33

23 Bloom s traditional taxonomy appears in the triangle. The phases or levels have been updated to Creating, Evaluating, Analyzing, Applying, Understanding, and Remembering as shown in the Revised Taxonomy below. Creating Generating new ideas, products, or ways of viewing things Designing, constructing, planning, producing, inventing. Evaluating Justifying a decision or course of action Checking, hypothesizing, critiquing, experimenting, judging Analyzing Breaking information into parts to explore understandings and relationships Comparing, organizing, deconstructing, interrogating, finding Applying Using information in another familiar situation Implementing, carrying out, using, executing Understanding Explaining ideas or concepts Interpreting, summarizing, paraphrasing, classifying, explaining Remembering Recalling information Recognizing, listing, describing, retrieving, naming, finding Montana Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This document adheres to the 2009 ANCC Accreditation Criteria. (Revised 7/2011) Page 23 of 33

24 SUGGESTED VERBS IN THE COGNITIVE DOMAIN Knowledge Comprehension Application Analysis Synthesis Evaluation Define Identify List Name Recall Recognize Record Repeat Underline Cite examples of Conclude Demonstrate use of Describe Detect Differentiate Discuss Estimate Explain Express Identify Interpret Locate Predict Report Restate Review Select Tell Translate Apply Demonstrate Develop Dramatize Employ Generalize Illustrate Interpret Operate Practice Relate Schedule Shop Sketch Use Analyze Calculate Categorize Compare Contrast Criticize Debate Diagram Differentiate Distinguish Examine Experiment Inspect Inventory Question Solve Test Arrange Assemble Classify Collect Compose Construct Create Design Formulate Organize Organize Plan Prepare Propose Set up Appraise Assess Choose Compare Critique Estimate Evaluate Judge Measure Rate Revise Score Select Validate Value SUGGESTED VERBS IN THE AFFECTIVE DOMAIN Receiving Acknowledge Shares Shows awareness of Responding Valuing Organization Characterization Of Values By Value Acts willingly Listens to Practices Accepts Acclaims Agrees Cooperates Argues Debates Declares Defend Responds Selects Shows interest Acts consistently Helps Is accountable Respects Stands for Supports Takes a stand SUGGESTED VERBS IN THE PSYCHOMOTOR DOMAIN Imitation Manipulation Precision Articulation Naturalization Follows example of Carries out according to Carries out Follows lead of procedure Is skillful in using Demonstrates skill in using Follows procedure Practices Carries out Is competent Is skilled Uses VERBS TO AVOID!! Appreciate Be aware of Believe Be able to know Communicate Enjoy Grasp the significance of Have an understanding of Implement Increase Know how to Learn how to Motivate Understand Page 24 of 33

25 Refresher Courses According to the ANCC Commission on Accreditation, refresher courses may focus on functioning in a particular facility or on reinforcing basic knowledge. In those situations, the content areas would not be eligible for contact hours. However, in some cases, refresher courses provide nurses re-entering the employment field following an absence of several years with new information or a new skill set that has developed in the previous few years. In the second description of a refresher course one providing new information or a new skill set that has been developed in the few years prior to the nurse re-entering employment, the content area would be eligible for contact hours. ANCC accreditation criteria specify that contact hours be calculated only for that portion of the learning activity that is devoted to transmitting new or transferable knowledge. This includes the time spent completing the evaluation of the educational activity. Adult Education Principles There is no best method of teaching. Adults bring a rich variety of experiences to the learning situation. These experiences must be taken into consideration when planning an activity and deciding on the teaching strategy(ies)/method(s) needed to support the objectives of the activity, the content, the target audience, and the skill of the presenter. Evidence of each strategy selected in this section must be supported in the teaching methods column of the activity documentation form. See Adult Learning in the CE references. Courses Addressing Complementary or Alternative (Therapeutic) Modalities The American Holistic Nurses Association developed the following requirements regarding therapeutic modalities (complementary or alternative modalities) (2005). The MNA CE Approver unit (CCE) recommends that CNE providers follow these guidelines. 1. Therapeutic modality is clearly supported by theory or research published in professional literature in the last five years if there is research available. The research must be made available to the nurse planner / planning committee upon request. This would be required if the modality is in question by staff, nurse planners, reviewers or CCE members. 2. The learning activity clearly discriminates between use of the modality for self-care or personal development as opposed to appropriate use of the modality with a client population. 3. The learning activity defines and assures a recognized minimum of training when modalities taught are intended for professional use with a client population. 4. The learning activity is consistent with the standards of the appropriate professional association related to the topic. For example, the AHNA has the Holistic Nurses Association Standards of Holistic Nursing Practice that address holistic nursing. (Please check their website 5. Presenter has the appropriate credentials and experience to deliver the learning activity. 6. Note: The approval of contact hours by MNA is based on an assessment of the educational design criteria for the learning activity and does not constitute endorsement of the use of a specific modality in the care of clients. (Some organizations choose to include this statement on advertising or the handouts.) Page 25 of 33

26 GLOSSARY This glossary is drawn from the glossary in the American Nurses Association Scope and Standards of Practice for Nursing Professional Development (2000), the ANCC Commission on Accreditation s Application Manual (2009), and MNA policies and procedures. Accreditation: A voluntary process in which an institution, organization, or agency submits to an in-depth analysis to determine its capacity to provide or approve quality continuing education over an extended period. Administrator: The person designated to have administrative responsibility for the approver and/or provider unit. Adult Learning Principles: The basis for, or the beliefs underlying, the teaching and learning approaches to adults as learners based on recognition of the adult individual s autonomy and self direction, life experiences, readiness to learn, and problem orientation to learning. Approaches include mutual, respectful collaboration of educators and learners in the assessment, planning, implementation, and evaluation of education activities. Appeal: A process that allows the applicant to obtain a redetermination by an appellate body with regard to an adverse decision made by an original decisionmaking body. Approval: A decision made by MNA s CCE that the criteria and rules for approval of a continuing education activity or application for Approved Provider status have been met. Approval Period: All educational activities are approved for a period of two years; educational activities may be repeated as often as desired during the approval period. The Continuing Education Approver Unit does not require notification unless there are substantial changes made (i.e., content, agenda, etc). Substantial Montana Nurses Association APPENDIX H changes require that applications be resubmitted using current guidelines / submission policies available from MNA. Approved Provider: Recognition by (MNA) of a provider's capacity to award contact hours for continuing education activities, planned, implemented, and evaluated by the provider. Autonomy of the Provider Unit: The provider unit (not the larger organization) must be solely administratively and operationally responsible for coordinating all aspects of the continuing nursing education activities. Beliefs: Opinions, doctrines or principles held to be true; may be stated as a philosophy, mission, vision, or within a strategic plan. Biographical Data: Information required of persons involved in the peer review process or planning and delivery of continuing education activities. The data provided should document their qualifications relevant to the continuing education process or a specific activity with respect to their education, professional achievements and credentials, work experience, honors, awards, and/or professional publications. Commercial Interest: Any entity either producing, marketing, re-selling or distributing healthcare goods or services consumed by, or used on, patients or an entity that is owned or controlled by an entity that produces, markets, re-sells or distributes healthcare goods or services consumed by, or used on, patients. Exceptions are non-profit or government organizations and non-healthcare related companies. The definition allows an accredited [approved] provider to be owned by a firm that is not a commercial Montana Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This document adheres to the 2009 ANCC Accreditation Criteria. (Revised 7/2011) Page 26 of 33

27 interest. It also allows a provider to have a sister company that is a commercial interest, as long as the accredited [approved] provider has and maintains adequate corporate firewalls to prohibit any influence or control by the sister company over the continuing education program of the accredited [approved] provider. In this case, ANCC would expect that the accredited [approved] provider would have an adequate corporate firewall in place to prohibit any influence or control by the sister company over the continuing education program. Commercial Support: Financial, or inkind, contributions given by a commercial interest, which is used to pay all or part of the costs of a CNE activity. Commercial Supporter: An entity providing commercial support. Commission on Accreditation (COA): Appointed by and accountable to the ANCC Board of Directors, this body is responsible for development and implementation of the ANCC program for accreditation and approval of continuing nursing education. The Commission is composed of 9 members representing accredited organizations, consumers, the ANA Congress on Nursing Practice and Economics, nursing evaluation, and adult education / society. Conflict of Interest: ANCC defines a conflict of interest as when an individual has an opportunity to affect CNE content with products or services from a commercial interest with which he/she has a financial relationship. Consistency: Holding to the same or comparable principle or practice. Contact Hour: A unit of measurement that describes 60 minutes of an organized learning experience that is either didactic or clinical experience. Content: Subject matter of an educational activity that relates to the educational objectives. Content Specialist: An individual with documented qualifications that Montana Nurses Association demonstrate education, knowledge and experience in a particular subject matter. Continuing Competence: Demonstration of knowledge and skills in meeting professional role expectations. Also: Ongoing professional nursing competence according to level of expertise, responsibility, and domains of practice as evidenced by behavior based on beliefs, attitudes, and knowledge matched to and in the context of a set of expected outcomes as defined by nursing scope of practice, policy, coed of ethics, standards, guidelines, and benchmarks that ensure safe performance of professional activities. Continuing Nursing Education (CNE): Systematic professional learning experiences designed to augment the knowledge, skills, and attitudes of nurses and therefore enrich the nurses contributions to quality health care and their pursuit of professional career goals. Continuing Education Unit: (CEU) A specific, standard measure (10 clock hours) of educational achievement used by many universities and professional organizations under the criteria of the International Association for Continuing Education and Training (IACET) to attest to clock hour completion of continuing education activities. The ANCC Commission on Accreditation or the Montana Nurses Association does not authorize this terminology. Co-providership: Planning, developing, and implementing an educational activity by two or more organizations or agencies. When educational activities are coprovided and one of the providing entities is ANCC-accredited [MNA approved], the ANCC-accredited [MNA approved] provider unit retains responsibility for particular aspects of the process to assure adherence to all the ANCC [MNA] criteria. If collaborating providers are all ANCCaccredited [MNA approved], one is designated to retain the provider responsibilities by mutual, written agreement. The unit designated to retain these responsibilities is referred to as the Montana Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This document adheres to the 2009 ANCC Accreditation Criteria. (Revised 7/2011) Page 27 of 33

28 provider, and the other collaborating providers are referred to as co-providers. If neither entity is approved as a provider, one takes the lead and is referred to as the provider of the activity; the other is the coprovider. Criteria: Relevant, measurable indicators of the standards. Deferral or Deferred: A decision made to delay action on an application. Denial: A decision not to approve an application. Distance Learning: A formal educational activity in which most of the instruction occurs when the learner and the educator are not in the same place. The instruction may take place either synchronously (at the same time) (e.g., interactive video) or asynchronously (at different times) (e.g., online/internet or correspondence courses). Education Activity: A planned, organized effort aimed at accomplishing educational objectives. Educational Design: A plan for instruction documenting a needs assessment, description of the target audience, educational objectives, content outline, teaching methods, evaluation strategies, and designation of appropriate physical facilities and resources. Educational Objective: A statement of learner outcome(s) of an educational activity that is measurable and achievable within the designated time frame. Enduring Materials: A non-live continuing nursing education activity that endures over time. Examples of enduring materials include programmed texts, audio tapes, videotapes, monograph or computer assisted learning materials that are used along or with printed or written materials. Enduring materials can also be delivered via the Internet. The learning experience by the nurse can take place at any time in any place, rather than only at one time, on place, like a live CME activity. Montana Nurses Association Evaluation: A systematic process by which a judgment is made about consequences, results, effects, or merit of a continuing education provider unit or continuing education program in order to make subsequent decisions. The process of determining significance or quality by systematic appraisal and study. Evidence: Specific indicators that document compliance with criteria and rules. Gift: in-kind : Non-monetary support (e.g. marketing assistance, meeting room, event registration assistance, etc.) provided by the giver to the taker. (In the Accreditation community, the taker is the provider of the continuing education.) Goal: A statement of broad direction or general intent. In-service Education: Learning experiences provided in the work setting to assist staff members in performing their assigned functions in that particular agency or institution. In addition: Inservice education consists of planned instruction or training programs to assist the nurse perform in the work setting. Inservices are provided to maintain or increase competency in promoting compliance with institutional policies and procedures, the demonstration of new equipment, the explanation of procedures and the practice of previously learned skills. Key Element: Essential components or basic principles of each criterion. Lead Nurse Planner / Role: The Lead Nurse Planner is responsible for ensuring that all Nurse Planners are performing in a manner consistent with the policies, procedures, position descriptions, and expectations of the accredited [approved] provider unit and with the ANCC [MNA} criteria. All nurse planners contribute oversight and must be actively involved in Montana Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This document adheres to the 2009 ANCC Accreditation Criteria. (Revised 7/2011) Page 28 of 33

29 both the planning and the analysis of evaluation data for the educational activity. Qualifications: The lead nurse planner of a Provider must Be a registered nurse and hold a baccalaureate or higher degree in nursing. Have education or experience in education or adult learning..competence is evaluated by review of the curriculum vitae, biographical data form, and/or professional portfolio. Information should demonstrate the presence of the following knowledge and skills: o knowledge of the MNA Approver Unit Program and its requirements, o knowledge of adult learning theory o ability to analyze/synthesize information related to meeting the criteria and key elements (as evidenced by having planned, implemented and evaluated continuing nursing education activities), o understanding of the policies / procedures of the MNA Approver Unit; o knowledge of the Scope and Standards of Practice for Nursing Professional Development. Learner Directed Activity: A learning activity in which the learner takes the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes. Learner directed activities may be developed with or without the help of others, but only one individual engages in them. Learner-Paced: A continuing nursing education activity where the learner determines the pace at which s/he engages in the learning activity. Learning Package: Materials and description of resources and requirements of the process for completing an independent study. Learning Goal: A statement describing why and for whom an educational program has been designed. (Synonym: Purpose) Montana Nurses Association Monitor: To periodically assess and evaluate continuing compliance with the criteria and operational requirements. Multidisciplinary: To relate to or include several disciplines at once, e.g., a multidisciplinary approach to planning a continuing education activity; also may be referred to as interdisciplinary or transdisciplinary. Multi-Focused Organization: The multifocused organization exists for more than the purpose of providing education. Need: Discrepancy between what is desired and what exists. Needs Assessment: Process by which a discrepancy between what is desired and what exists is identified. Nurse Planner: The Nurse Planner is actively involved in all aspects of planning, implementation and evaluation of the continuing nursing education activity. Typically, the Nurse Planner is responsible for ensuring appropriate educational design principles are used and processes are consistent with the requirements of the ANCC Accreditation Program. See also Lead Nurse Planner Nursing Professional Development: The lifelong process of active participation by nurses in learning activities that assist in developing and maintaining their continuing competence, enhance their professional practice, and support achievement of their career goals. Objective: see Educational Objective. Off-label: Using products for a purpose other than that for which it was approved by the Food and Drug Administration (FDA). Organization: The overall administrative and functional structure that includes the provider unit, e.g., hospital, college, association or private business. Organizational Chart: A diagram or other schematic used to depict informal and formal lines of communication and relationships within the overall Montana Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This document adheres to the 2009 ANCC Accreditation Criteria. (Revised 7/2011) Page 29 of 33

30 organization as well as the approver and/or provider unit. Orientation: The process of introducing new staff to the philosophy, goals, policies, procedures, role expectations and other factors needed to function in a specific work setting. Orientation takes place both for new employees and when changes in nurses roles, responsibilities and practice settings occur. Outcome: The end result of a learning activity usually a change in knowledge, practice or patient care - measured by written evaluation or change in practice. (The overall learning goal (purpose) of a learning activity is different from measured outcomes. An outcome may measure whether an activity s learning goal (purpose) is met, but may also address other elements of learning.) Peer Review: Professional judgment on the quality of the continuing education offered based on designated standards, criteria and rules for continuing education. Philosophy: A statement of beliefs. Pilot Study/Testing: The process of assessing the capability of an activity or product to achieve the intended purpose(s). Pilot testing of an educational activity guides the determination of the effectiveness of the teaching/learning materials and contact hour credit to be awarded. Planning Committee: A group of knowledgeable individuals, including potential participants from or representatives of the target audience, who design continuing education. Policy: A written statement defining "what" determines actions or decisions. Portfolio: A collection of documents, articles and exhibits that summarizes an individual s abilities, skills, achievements and specific accomplishments attained over an extended period of time. Procedure: A written statement defining "how" a particular policy is implemented. Provider: An individual, institution, organization, or agency responsible for the Montana Nurses Association development, implementation, evaluation, financing, record keeping, and quality of CE activities. Provider-Directed Activity: The provider controls all aspects of the learning. The provider determines the learning objectives based on needs assessment, content of the learning activity, the presentation method, number of contact hours, evaluation and evaluation methods. Provider directed activities may be presented in a number of different vehicles - electronic, journal, lecture, etc. Provider Unit: Within the organization, the distinct body responsible for coordinating all aspects of continuing education activities. Purpose: A statement describing why and for whom an educational program has been designed. Note: In a CE activity, the purpose is the statement(s) of intent that describe how this activity will enrich the learner's contribution to quality health care and his or her pursuit of professional career goals. (Activities intended to assist the participant to acquire, maintain, and/or increase the level of competence in fulfilling his or her assigned responsibilities specific to the expectations of the employer are considered in-service education or orientation and do not qualify as continuing education). Reconsideration: A process that allows an applicant to obtain a review of an adverse decision on an application for approval by submission of clarifying materials to the original decision-making body. Also a process that allows for a review of a revocation decision. Relevant Financial Relationships: ANCC defines financial relationships as those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Montana Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This document adheres to the 2009 ANCC Accreditation Criteria. (Revised 7/2011) Page 30 of 33

31 ANCC considers financial relationships in any amount occurring within the past 12 months as relevant in terms of creating a conflict of interest. ANCC considers relationships of the person involved in the CNE activity to include financial relationships of a family member. ANCC defines an entity that has a commercial interest as any proprietary entity producing health care goods or services, with the exception of non-profit or government organizations. Financial relationships can also include contracted research where the institution gets the grant and manages the funds and the individual is the principal or named investigator on the grant. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received or expected. Resources: Individuals, materials, facilities, equipment and funds needed to implement educational activities. Resubmission: A process that provides for review and action on applications that had been previously submitted and withdrawn prior to action. Retroactive Approval: Peer review and approval of an activity that has already taken place; not authorized in the ANCC Commission on Accreditation and MNA systems. Review Team: Consists of 2 RNs who are members of the MNA Council on Continuing Education, Approver Unit, who independently review applications. Revoke: To rescind approved status. Sentinel Event: A sentinel event is one of high risk and high impact related to the improper or inappropriate provision of continuing nursing education in compliance with the ANCC Accreditation Program criteria. Examples include, but are not Montana Nurses Association limited to misuse of accredited [approved] status, illegal actions perpetrated or experienced by the accredited unit or its approved entities. Single-focused Organization: The single-focused organization exists for the single purpose of providing education. Sister Company: A subsidiary of an accredited [approved] organization /unit s parent company but which maintains a governance structure and activities separate from the accredited [approved] organization/unit. The sister company does not control or direct, in whole or in part, the operations of the accredited [approved] organization/unit. Site Visit: An on-location review of an applicant to verify, clarify, and amplify documentation of a written application and thus to establish the applicant's capacity to meet the criteria. Sponsorship: Support (monetary or inkind ) furnished to the provider of the education activity. Sponsorship must be acknowledged to learners. A written agreement is completed. When an educational activity is supported by more than one entity, each entity is a cosponsor. Sponsors and co-sponsors do NOT participate in planning, developing, and implementing the educational activity. Staff Development: Those learning activities that facilitate the nurse's jobrelated performance. The systematic process of assessment, development and evaluation that enhances the performance or professional development of healthcare providers and their continuing competence (NNSDO 1999; ANA, 2000, p.25) Standard: Authoritative statement, promulgated by the profession, by which the quality of practice, service or education can be judged. Target Audience: Group for which an educational activity has been designed. Teaching Strategies: Methods and techniques used in accord with principles of adult learning. Montana Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This document adheres to the 2009 ANCC Accreditation Criteria. (Revised 7/2011) Page 31 of 33

32 Withdrawal: Termination or cancellation of an application, without prejudice to future applications, prior to when an official decision is made. Montana Nurses Association Thank you for reviewing this manual! Montana Nurses Association is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This document adheres to the 2009 ANCC Accreditation Criteria. (Revised 7/2011) Page 32 of 33

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