ucdhs center for nursing education€¦ · web viewcontinuing education course planning form...

CONTINUING EDUCATION COURSE PLANNING FORM Information Sheet

California Board of Registered Nursing Provider No. CEP26

INFORMATION/INSTRUCTIONS: PLEASE READ CAREFULLY

Processing may take up to 30 days. Please plan accordingly. CPPN will not advertise or take registrations for any educational activity until planning form is completely

processed.

COURSE REQUIREMENTS:

When planning form is completed, submit to [email protected] All components of the planning form are required to be submitted to start processing. CPPN will not publish or take registration for a course until the planning form has been endorsed. Continuing Education contact hours are provided for a three-year period. To offer the same course after that

date, the coordinator must submit a new C.E. planning form.

IF ANCC COURSE CREDIT DESIRED:

If you wish for your course to be considered for ANCC credit, you will need to meet the following criteria:

CPPN Nurse Planner needs to be involved in the planning of the course from the beginning. Please contact [email protected] to discuss. ANCC credit cannot be awarded if CPPN Nurse Planner is not involved in planning from the beginning.

Content must be beyond the basics of general nursing information. Cannot be a skills day or unit-based class. All ANCC required information must be included in planning form.

SIMULATION TRAINING

• A CPPN Course utilizing the Center for Simulation and Education Enhancement and the Center for Health and Technology (CHT) should be coordinated through CPPN.

COURSE CONTENT

• The content of all continuing education courses must be relevant to the practice of registered nursing.

• Course offerings must be at least 60 minutes (1 hour) in length.

• Credit cannot be offered for completing part of a course.

• Blended Learning or e-Learning must have expiration dates for the enduring or on-line materials.

• Course content may include basic and advanced courses in the physical, social and behavioral sciences, and advanced nursing in general or specialty areas.

o Examples of acceptable courses include advanced nursing theory, pathophysiology, or planning form of content areas related to specialized nursing; i.e. ACLS, chemotherapy, recent scientific knowledge, direct patient care such as; patient education strategies, certification/re-certification skills, cultural aspects, or indirect patient care such as; nursing administration, publishing for professional journals or books, current trends in nursing care, and legal aspects of nursing

o Examples of non-acceptable courses include CPR, orientation programs, equipment in-services, basic nursing skills or review of basic nursing care procedures courses focusing on self-improvement (i.e., self-awareness, yoga, weight loss, etc.), economic courses geared for personal

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CONTINUING EDUCATION COURSE PLANNING FORM Information SheetCalifornia Board of Registered Nursing Provider No. CEP26

financial gain (i.e., preparing resumes, job interviewing techniques, etc.), and courses for the lay public (i.e., parenting courses, etc.).

TWO LEVELS OF CPPN SUPPORT:

CPPN-based courses, which means that the class is on the CPPN website and open to all (internal and/or external) who wish to attend. CPPN handles the registration, evaluation, printing of course materials (if received 10 days prior to the class), questions concerning, etc. CPPN personnel will be on hand to open and close the class, supply AV equipment, and support as needed.

Unit-Based courses, which means opened to only a select group/unit of staff only to attend, and no pre-registration. CPPN supplies in advance blank rosters and evaluation forms only.

For all CPPN courses, there is a base deposit of $25 for UCDH employees and $10/hour for non-employees. Cost varies depending on length, catering needs, honorariums, etc. This is determined by CPPN.

COURSE FEES

Course fees are dependent on multiple factors and are thus at the discretion of CPPN.

‒ All CPPN courses have a minimum of a $25 deposit for UCDH employees.

‒ If non-UCDH employee, there is a fee for all contact hours awarded.

Return entire form and direct questions to:

[email protected]

document.docxRevision 2020-August

Return entire form and direct questions to [email protected]

CONTINUING EDUCATION COURSE PLANNING FORM California Board of Registered Nursing Provider No. CEP26

Title of Activity: Click here to enter text.

TO BE COMPLETED BY CPPNDate received: Click here to enter a date.

Consent to provide course date:Click here to enter a date.

Renewal date: (3 years from consent to provide course)

Click here to enter a date.

Course Code: Click here to enter text.

Contact Hours: Click here to enter text.

Type: ☐ CPPN Course ☐ Unit-Based Course

Planning form reviewed and meets BRN regulatory criteria.

CPPN Consent to provide course: Click here to enter text.

Planning form reviewed and meets ANCC regulatory criteria.

CPPN Nurse Planner Consent to provide course: Click here to enter text.ANCC Course

CPPN Nurse Planner:

Click here to enter text.

CPPN Coordinator:

Click here to enter text.

CPPN Nurse Planner and Analyst Notes:



CONTINUING EDUCATION COURSE PLANNING FORM - GAP ANALYSIS WORKSHEETCalifornia Board of Registered Nursing Provider No. CEP26

Required for ANCC CoursesSuggested for all coursesFor more information on GAP ANALYSIS, see worksheet information at end of planning formTitle of Activity: Click here to enter text.

Describe Desired State Current StateData that Supports Current State

Identified Gap (Knowledge, Skills, and/or Practice) Educational Goal

Outcome Measure(s)(A quantitative statement as to how the outcome will be measured)




Title of Activity: Click here to enter text.Course Code: (entered by CPPN)Submitter’s Contact InformationSubmitted By (Name, Degree, Credentials, Title): Click here to enter text.Department: Click here to enter text.Telephone: Click here to enter text. UCDH email address: Click here to enter text.

ANCC – CPPN Nurse Planner: Click here to enter text.

CPPN Course Coordinator: Click here to enter text.

Location: Click here to enter text.Maximum # participants for Activity: Click here to enter number.Activity Type: (Choose one that applies)☐Provider-directed, provider-paced: Live (in-person or webinar)

• Initial Date of live activity: Click here to enter a date.

• Additional Dates: Click here to enter text.

☐Provider-directed, learner-paced: Enduring material (i.e.; e-course or journal review)• Start date of enduring material: Click here to enter a date.

• Expiration/end date of enduring material: Click here to enter a date.

☐Blended activity• Date(s) of enduring materials (e.g. prework): Click here to enter a date.

• Date of live portion of activity: Click here to enter a date.

Course Start Time: Click here to enter text. Course End Time: Click here to enter text.

Brief Course Description for website posting. Include attendance requirements, need to wear scrubs/work attire, prerequisites, etc.: Click or tap here to enter text.

Professional Practice Gap: (required for ANCC courses)A. Identified Gap: (What learning need are you fulfilling?) Click or tap here to enter text.

• Evidence to validate the professional practice gap (check all methods/types of data that apply):

☐ Survey data from stakeholders, target audience members, subject matter experts, or similar☐ Input from stakeholders such as learners, managers, or subject matter experts☐ Evidence from quality studies and/or performance improvement activities to identify opportunities for improvement☐ Evaluation data from previous education activities☐ Trends in literature, law, and health care☐ Direct observation☐ Other—Describe: Click here to enter text.

Educational need that underlies the professional practice gap (e.g. knowledge, skill, and/or practice)

☐ Gap in Knowledge☐ Gap in Skills☐ Gap in Practice

Audience




Title of Activity: Click here to enter text.B. Description of Target Audience (RNs, Adv Pract. RNs, MDs, Resp Ther., etc.): Click here to enter text.Registration opened to: ☐Open to all who match target audience ☐UC Davis Employee only ☐Unit (Group), specify:

Outcomes Measure(s): (required for ANCC courses)C. Desired outcome measure for activity: Click here to enter text.Learner Engagement StrategiesD. Select from list the learner engagement strategies that will be employed:

☐ Lecture☐ Blended Learning/Flipped Classroom☐ Group Work☐ Case Study☐ Self-Learning Module☐ Reflection☐ Role Play☐ Return Demonstration☐ Gaming☐ Simulation☐ Storytelling/Narrative☐ Socratic Questioning☐ Other - Describe Click or tap here to enter text.

Criteria for Awarding Contact HoursE. Criteria for awarding contact hours for live and enduring material activities include:

☒ No contact hours awarded if late to activity as described in course description; must attend all sessions (required for all CPPN courses)

☐ Successful completion of a post-test (attendee must score Click here to enter text. % or higher)☐ Successful completion of a return demonstration☐ Successful completion of required eLearning (i.e.; Pre-Study)☐ Completion/submission of evaluation form (must collect evaluation form from every participant)☐ Other - Describe: Click here to enter text.

Description of evaluation methodEvidence that change in knowledge, skills, and/or practices of target audience was assessed:

F. Short-term evaluation options:

☐ Intent to change practice☐ Active participation in learning activity☐ Post-test☐ Return demonstration☐ Case study analysis☐ Role-play☐ Other – Describe: Click here to enter text.

G. Long-term evaluation options:

☐ Self-reported change in practice☐ Change in quality outcome measure☐ Return on investment (ROI)☐ Observation of performance☐ Other - Describe: Click here to enter text.




Title of Activity: Click here to enter text.List of Individuals in a Position to Control Content

Complete the table below for each person in a position to control content of the educational activity (e.g., planners, speakers/presenters, and content reviewers). For each individual, include name, credentials, educational degree(s), and role in the activity. Each person must submit a complete Biographical and Conflict of Interest form that validates their expertise to fulfill their respective role.

Required for ANCC courses:• There must be one Nurse Planner from CPPN who is knowledgeable of the continuing nursing professional development processes and is

responsible for adherence to ANCC criteria. There must be one Nurse Planner and one other planner to plan each educational activity

• At least one planner needs to have appropriate subject matter expertise for the educational activity being offered (Content Expert).

• The individuals who fill the roles of Nurse Planner and Content Expert must be identified.

Every person on list must complete a Biographical and Conflict of Interest (COI) form.

Name of individual and credentials

(i.e., John Smith, MSN, RN, CCRN)

Individual’s role in activity

Nurse Planner, Content Expert, Presenter

Planning committee member?

(Yes/No)

Name of commercial interest

Nature of relationship to the commercial interest

(i.e., speaker bureau, stockholder, CEO, etc.)

CO

I form

completed



Center for Professional Practice of Nursing

CONTINUING EDUCATION COURSE PLANNING FORM EDUCATIONAL DESIGN

California Board of Registered Nursing Provider No. CEP26Title of Activity: Click here to enter text.

Educational Planning TableContent (Topics)Provide a short outline of the content/topic presented.

Include reference/resources used to develop content (may be as additional reference sheet)

ObjectivesMinimum of 2, Maximum of 5, learning objectives for content. Use Bloom’s Taxonomy to write objectives.

Time Framein minutes

Must match course agenda

PresenterList presenter(s) name, credentials, degrees for each topic/content area.Each presenter must submit a COI/Bio form

Learning StrategiesList the learning strategies for each topic or content area. Include learner engagement strategies.

Right click on last row to insert additional rows below as needed 1.

1.

1.

1.






Educational Planning TableContent (Topics)Provide a short outline of the content/topic presented.

Include reference/resources used to develop content (may be as additional reference sheet)

ObjectivesMinimum of 2, Maximum of 5, learning objectives for content. Use Bloom’s Taxonomy to write objectives.

Time Framein minutes

Must match course agenda

PresenterList presenter(s) name, credentials, degrees for each topic/content area.Each presenter must submit a COI/Bio form

Learning StrategiesList the learning strategies for each topic or content area. Include learner engagement strategies.

Right click on last row to insert additional rows below as needed 1.

1.

1.

1.

References (list here or provide additional reference sheet when submitting form; required for ANCC courses):



ATTACHMENTS

All the following should be sent to CPPN for attachment to final course document.Attachment 1 Agenda (for each course date if changes)Attachment 2 All Conflict of Interest formsAttachment 3 Commercial Support Agreement with signatures and date, if applicableAttachment 4 Course Materials/All Presentations (with repeated classes, note version if changed from initial)Attachment 5 Course Advertisements (save the dates/course flyers/PDF of web page)Attachment 6 Course Evaluation formsAttachments to be supplied by CPPNAttachment 1 Document of completion certificateAttachment 2 Summative evaluationAttachment 3 Evidence of required information provided to learners: Materials associated with the activity (marketing

materials, advertising, agendas, and certificates of completion) must clearly indicate the Provider awarding contact hours and responsible for adherence to ANCC criteria)

1. Accreditation statement of provider awarding contact hours2. Criteria for awarding contact hours3. Presence or absence of conflicts of interest for all individuals in a position to control content (e.g.

the Planning Committee, presenters, faculty, authors, and content reviewers)4. Commercial support (if applicable)5. Expiration date (enduring materials only)6. Joint Providership (if applicable)




Course General Information Sheet

This form is required to be given to attendees prior to the start of any educational activity

Requirements for completion of this program Participant must sign in on official roster and be present for content presentation. C.E. credit will not be awarded for this program session if the participant is more than:

5 minutes late for a course of 4 hours or less in duration or 20 minutes late for a course of more than 4 hours in duration

Specific requirements for individual course:

Conflict of interest Conflict of interest can exist when an individual has an opportunity to affect continuing nursing professional

development content in relation to a commercial interest in which they have a financial interest. Unless indicated below, all planners and presenters associated with this program have signed forms stating

that no conflict of interest exists for them or their spouse/partner with relation to the content of this program.

Off label use This educational activity does not include any unannounced information about off label use of a product for a

purpose other than that for which it was approved by the Food and Drug Administration (FDA).

Potential Conflict of Interest Notification to Course Attendees Click or tap here to enter text.

Course Attendance Requirements/COI Informationdocument.docx

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Information to Complete Gap Analysis FormGap analysis is a useful tool in taking you from “I think I know what the problem is” to an idea of potential solutions and outcomes. Gap Analysis a tool that helps to determine your current state and desired state as well as the tasks that are needed to close the identified gap. Used at the beginning of a program, a Gap Analysis will assist you in planning your educational activity.

1st. Determine what is the Desired State, the best practice, or where you want to be. The desired state is the level that the planners would like the learners to achieve due to the educational activity.

2nd. What your current state? Current State refers to the current level of practice of the target audience.3rd. Describe the current state with Data that Supports Current State. Planners should use data and

evidence to determine and validate the current state. Data gathering may include surveying stakeholders, reviewing quality data, direct observation, and evaluations of other educational activities, trends in healthcare or literature, etc.o Now ask: What knowledge of the problem is missing? What skill is not being performed to best

practice? Are both knowledge and skill lacking? What pieces are missing?4th. The missing pieces are the Identified Gap in the target audience. This could be knowledge (don’t know),

skill (don’t know how to do), and/or practice (not able to show or do in practice). 5th. Based on the Identified Gap and Desired State, develop your Educational Goal (what you want your

learners to gain from the activity) and plan to meet the goal. Learning strategies should reflect the learning gap that was identified, i.e., lack of test taking skills would align with a variety of strategies including reviewing common test taking errors and use of practice testing environments.

6th. Using the same data measures that support your current state, develop an Outcome Measure that is specific, measurable, and attainable. Write the outcome measure as a quantitative statement as to how the outcome will be measured.

Title of Activity: EXAMPLE

1. Describe Desired State 2. Current State

3. Data that Supports Current State

4. Identified Gap (Knowledge, Skills, and/or Practice) 5. Educational Goal

6. Outcome Measure

75% of the Peri-Anesthesia Nurses will obtain a specialty certification by passing examination after completing an exam preparation course and engaging in appropriate study based on their individual needs.

Only 30% of the Peri-Anesthesia Nurses have obtained a recognized specialty certification.

Survey of Peri-Anesthesia Nurses both with certification and without identified that >75% of Nurses feel unprepared to sit for and pass the required examination (knowledge) and 60% state they lack test taking skills.Current literature trends show that employer-supported program increase passage rates.

Nurses lack the knowledge and skills to pursue a certification exam.

Using a variety of tools, the Peri-Anesthesia Nurse will successfully pass a certification exam within 24 months.

Within 12 months, the number of Peri-Anesthesia nurses with a specialty certification will increase by 10%.

Informational sheetdocument.docx

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Information to complete Educational Planning Form

Title of Activity: Click here to enter text.

Completed by CPPN

Explanation of planning form requirements – please direct any questions to [email protected]

Title of Activity: Should be specific to content; if course is part of a series should be differentiated by day (i.e., Day 1, Day 2, Part 1, Part 2., Pediatric Critical Care Day 1).

Professional Practice Gap Analysis: Should be complete for all courses (required for those requesting ANCC credit). Information concerning how and why course came about and the learning gap (knowledge, skills, and/or practice) to which the course is aligned.

Audience: Who the course is targeted towards, and any restrictions on that audience (i.e., only from NICU, only RNs, only UC Davis employees, etc.)

Outcome Measure(s): What is the purpose of the learning, what outcome measures will be affected, or skill enhanced. Should be specific, measurable, and attainable. Should reflect PCS or UCD Health strategic goals (i.e., the learners will increase their practice of post-cardiac catheterization patient care). Include quantitative statement.

Quantitative Statement example: After the learning activity has initiated, there will be a decrease in length of stay for post-cardiac catheterization patients by 10%.

Content of Activity: A brief description of the content that will be presented and where information was chosen from. This should be completed in greater detail in the Educational Planning Table.

Brief Course Description for website posting: This is what CPPN will post on the website for course advertisement. If there are any prerequisites or attendance requirements, please state clearly.

Learner Engagement Strategies: List strategies you plan to use to engage learners.

Criteria for Awarding Contact Hours: List any criteria beyond attending the class.Description of Evaluation Method: Mark what type of evaluation, short- and long-term, that will reflect the change

in knowledge, skills, and/or practice of the learner.Conflict of Interest: All persons in a position to control the content of the educational activity are required to

complete the Biographical and Conflict of Interest Form.

Planning forms will not be processed until all forms are completed and attached to planning form.

Educational Design:Content/Topics – What information will be covered by presenter? Include references either with content or on

separate reference sheets.Objectives – Written as to what the learner should be able to do, not what the speaker is going to talk about. “At the

end of this session the learner will be able to…” (Understand is not an acceptable learning objective).Each 60 minutes of content should have minimum of 2 and maximum of 5 learning objectives.Use Bloom’s Taxonomy to assist you with writing learning objectives.If you need assistance with writing your objectives, contact: [email protected]

Time Frame – Amount of time in minutes to present topic: 60. Not specific clock time 0800-0900. Specific times should be reflected in the class agenda.

Presenter/Speaker – Name, Credentials, and Title of person(s) presentingLearner Strategies – How is the information going to be presented? Lecture only, Demonstration, Case Study

Discussion, Group brainstorming, etc. Including learner engagement strategies is a best practice and will positively affect the activity and resulting knowledge, skills, practice change(s).

Informational sheetdocument.docx

Version 8/13/2020


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