Listed below are tips and frequently asked questions for nursing continuing education. If you have a CE question, email us at firstname.lastname@example.org.
Conflict of Interest
Check this page for updates and changes to criteria from American Nurses Credentialing Center's Commission on Accreditation.
"In the past we had to have a Bio form/COI form on everyone on the planning committee. Do we still need that or one just for the presenter?"
ANCC is trying to reduce unnecessary documentation burden and the 2015 ANCC revisions have two BIO/COI changes:
A. The Biographical sketch is no longer required for presenters by ANCC.
Approved Providers no longer need a BIO - i.e. biographical sketch for planners or presenters
Exception -- Individual Activity Applicants must provide "BIO" qualifications for the nurse planner and content expert(s) on the planning committee. [This is documented in the Individual Activity Application at the end of the table of "Individuals in a Position to Control Content."]
B. Fewer Conflict of Interest (COI) forms required by ANCC.
The assessment for COI by the nurse planner is not different, just the requirement for obtaining and maintaining dozens of unnecessary COI forms is removed when the nurse planner has assessed that no potential for COI exists. The new documentation requirements for the nurse planner for COI assessment for all individuals in a position to control content is based on 3 questions:
1. Is the activity content relevant to a commercial interest organization (by ANCC definition):
- If no, the nurse planner must document in the activity file why the content is not relevant to any commercial interest, then no COI forms are needed for anyone - planners or presenters. [This is Item H in the new NE-MSD Provider Activity Planning Form and the new NE-MSD Individual Activity Application form.]
- If yes, potential for COI exists, move to Question #2
2. Do the planners or presenters (or their spouses/significant others) have a financial relationship in the last 12 months with a commercial interest organization relevant to the content?
- NE-MSD Documentation Options:
- The nurse planner requires COI forms be completed by all planners and presenters, signed by the nurse planner and attached to the activity file and completes the Item I table.
- OR the nurse planner personally asks each person in a position to control content if they have a financial relationship with any commercial interest relevant to the content. If the answer is no, she documents 'no' on the new table [Item I on the NE-MSD forms] "Individuals in a Position to Control Content" and she does not need to obtain a COI form because no further assessment or resolution is needed. If they answer yes, she moves to Question #3 and a COI form is needed for documentation in the activity file.
3. What is the name of the commercial interest organization and the nature of financial relationship?
- Individuals in a position to control content (planners and presenters) who answered "yes" in Question #2 must complete the COI form disclosing the name of the Commercial Interest organization(s) and the nature of their financial relationship (or that of their spouse/significant other) and the nurse planner assesses the relationship and determines what resolution, if any, would allow participation in the activity.
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Providers must utilize a logical and defensible method to award ANCC contact hours. Providers have flexibility in determining what method works best for the particular setting or circumstances of the activity. Here are some suggested methods that may be considered:
- Pilot test the number of posters that can be reviewed during a time period and award contact hours based on the pilot test data. Participants attest to the time they spent reviewing the posters using an attestation form. Regularly evaluate the pilot test data to validate accuracy.
- Require participants to review and complete an evaluation form for the poster session. The Provider may choose to require an evaluation form for each poster reviewed or for the full poster session. Pilot test the time required to review each poster or full poster session and award contact hours accordingly. Regularly evaluate pilot test data to validate accuracy.
- Hold the poster presentation session over a set period of time and log participants into and out of the session. Award contact hours based on the set period of time.
- Require participants to review each poster and/or a set number of posters and complete a post-test. Successful completion based on passing the post-test. Pilot test amount of time required to review posters and complete post-test. Regularly evaluate pilot test data to validate accuracy.
There may be other options to use to award contact hours for poster presentation sessions. As long as the method is logical and defensible (and documented in the activity planning), the Provider may give participants the opportunity to earn contact hours for poster sessions. They are great learning activities!
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Content for educational activities should be selected based on the most current available evidence. Choosing evidence, however, can sometimes present a challenge for planners. What constitutes "best available evidence?" For those planning educational activities, it is helpful to understand a basic evidence hierarchy, or a classification system of evidence based on the rigor and strength of the research process used to obtain the evidence. There are many different types of evidence hierarchy tables that are available in research textbooks, in articles or through web resources. Here are some great options:
An evidence hierarchy is often shown graphically as a pyramid, with the strongest levels of evidence at the top of the pyramid and the weaker levels of evidence below. One example of an evidence hierarchy is http://ebp.lib.uic.edu/nursing/node/12 .
In this evidence hierarchy, a systematic review is considered the highest level of evidence. A systematic review is a synthesis of all available, high quality research that exists about a particular subject. Next, is evidence obtained through randomized control trials followed successively by cohort studies, case control studies, case series/case reports and finally editorials or expert opinion at the bottom of the pyramid.
While it is not necessary that everyone planning educational activities be a researcher, it is important for all planners to have a basic understanding of the quality of evidence. This is foundational for nursing practice that is based on evidence, as opposed to practice based on tradition or opinion.
So, what resources should a planner use when choosing content for an educational activity? A planner should search for evidence in resources that are based on the quality of evidence available. For example, looking for evidence in peer-reviewed journals or peer-reviewed textbooks ensures that the article or content has been critically evaluated by experts in the field. Content from web-based resources that require peer review or only allow content that has been peer-reviewed ensures that readers have access to high-quality evidence. Organizations such as the Agency for Healthcare Research and Quality (AHRQ), National Quality Forum (NQF), or Centers for Disease Control (CDC) regularly post evidence related to particular diseases or treatment of disease. Evidence-based clinical guidelines are posted on sites such as www.guidelines.gov. Content for educational activities should also be chosen from resources that have been recently published. One guideline is to look for articles that have been published within the past 5 – 7 years, or as appropriate for the content area.
Not all content for educational activities in nursing has a robust evidence-base. Some evidence is not feasible to obtain through research, or is not a priority area for funding thereby limiting the number of researchers available and/or interested in conducting research, for example.
Planners should always, however, seek to obtain content for educational activities based on the best available evidence that currently exists in the topic area.
Accredited continuing nursing education activities promote professional development for registered nurses. Using current evidence is important regardless of whether the nurse is providing direct care to patients, is functioning as a clinical resource for other nurses or students, or working administratively as a Director or Manager.
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ANCC defines an organization as having a commercial interest (known as a Commercial Interest Organization)* if it:
- Produces, markets, sells or distributes health care goods or services consumed by or used on patients;
- Is owned or operated, in whole or in part, by an organization that produces, markets, sells or distributes health care goods or services consumed by or used on patients; or
- Advocates for use of the products or services of commercial interest organizations.
- Commercial Interest Organizations are ineligible for accreditation and may not be a provider or joint-provider of an educational activity.
An organization is NOT a Commercial Interest Organization* if it is:
- A government entity
- A non-profit (503(c)) organization
- A provider of clinical services directly to patients, including but not limited to hospitals, health care agencies and independent health care practitioners
- An entity the sole purpose of which is to improve or support the delivery of health care to patients, including but not limited to providers or developers of electronic health information systems, database systems, and quality improvement systems
- A non-healthcare related entity whose primary mission is not producing, marketing or selling or distributing health care goods or services consumed by or used on patients
- Liability insurance providers
- Health insurance providers
- Group medical practices
- Acute care hospitals (for profit and not for profit)
- Rehabilitation centers (for profit and not for profit)
- Nursing homes (for profit and not for profit)
- Blood banks
- Diagnostic laboratories
Accreditation Council for Continuing Medical Education (ACCME) Standards of Commercial Support, August 2007. The ANCC definition is intended to ensure compliance with Food and Drug Administration Guidance on Industry-Supported Scientific and Educational Activities and consistency with the ACCME definition.
ANCC Website - www.nursecredentialing.org/AccredDefinitionsFAQ
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Evaluating Conflicts of Interest Flow Chart [pdf]
Conflict of Interest exists when an affiliation or relationship of a financial nature with a Commercial Interest Organization might bias a person's ability to objectively participate in the planning, implementation, or review of a learning activity. Understanding what constitutes Conflict of Interest begins with knowing that a Commercial Interest Organization is defined by ANCC as any entity either producing, marketing, reselling, or distributing healthcare goods or services consumed by or used on patient or an entity that is owned or controlled by an entity that produces, markets, resells, or distributes healthcare goods or services consumed by or used on patients. Exceptions are made for nonprofit or government organizations and non-healthcare related companies.
Conflict of interest is evaluated for all Planning Committee members, presenters, or faculty associated with an educational activity.
Conflict of interest is evaluated
- in the planning process and
- Again prior to presentation of the educational activity.
- Conflict of interest is assessed through review of information collected in biographical data forms and conflict of interest disclosure statements completed by each individual associated with an educational activity.
- Evaluating an individual for potential or actual conflict of interest relative to an educational activity is the responsibility of both the individual completing the forms and the Nurse Planner. If an actual or potential conflict of interest is identified, the Nurse Planner is responsible for documenting the details including a description of the conflict of interest as well as how the conflict of interest was resolved.
- Each individual who is in a position to control the content of an education activity must disclose all relevant relationships with any entity in a position to benefit financially from the success of the educational activity.
- The relevant relationship includes the relevant 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.
- All information disclosed must be shared with the participants/learners on program handouts, advertising and/or audiovisual presentation.
- Examples of relevant relationships include (but are not limited to) those relationships in which the individual benefits by receiving any of the following:
- intellectual property rights
- consulting fee
- ownership interest (e.g., stocks, stock options, or other ownership interest, excluding diversified mutual funds)
- other financial benefits often associated with roles such as:
- management position
- independent contractor
- membership on advisory committees or review panels
- board membership
Relevant relationships can also include ‘contracted research' where the organization receives a grant and manages the grant funds and the individual is the principal or a named investigator on the grant.
Resolution of conflict of interest may include, but is not limited to, the following:
- Documentation that the individual with conflict of interest
- has reviewed the provider's policy/procedure related to conflict of interest
- has received a copy of the provider's policy/procedure related to conflict of interest
- has agreed to present an unbiased presentation
- will not promote the commercial interest or sponsorship organization or products of the organization
- Monitoring of the educational activity to evaluate adherence to policy/procedures
- Removing the individual with conflict of interest from participating in the educational activity
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Evaluating Conflicts of Interest Flow Chart [pdf]
The potential for conflicts of interest exists when an individual has the ability to control or influence the content of an educational activity and has a financial relationship with a commercial interest,* the products or services of which are pertinent to the content of the educational activity. The Nurse Planner is responsible for evaluating the presence or absence of conflicts of interest and resolving any identified actual or potential conflicts of interest during the planning and implementation phases of an educational activity. If the Nurse Planner has an actual or potential conflict of interest, he or she should recuse himself or herself from the role as Nurse Planner for the educational activity.
*Commercial interest, as defined by ANCC, is any entity producing, marketing, reselling, 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, resells, or distributes healthcare goods or services consumed by or used on patients. Nonprofit or government organizations, non-healthcare-related companies, and healthcare facilities are not considered commercial interests.
- Employees of commercial interest organizations are not permitted to serve as planners, speakers, presenters, authors and/or content reviewers if the content of the educational activity is related to the products or services of the commercial interest organization.
- Employees of commercial interest organizations are permitted to serve as planners, speakers, presenters, authors and/or content reviewers if the content of the educational activity is NOT related to the products of the commercial interest organization.
- Individuals who have non-employee relationships with commercial interest organizations (see bullet 2 below) are permitted to serve as planners, speakers, presenters, authors and/or content reviewers as long as the Provider has implemented a mechanism to identify, resolve and disclose the relationship as outlined in these standards.
Now test yourself!
Jane Smith is being considered to serve as a content expert on your planning committee. She is also on the speaker's bureau with a commercial entity, which produces drugs for diabetes. The conference is about the latest research in diabetes management.
Lisa Taylor is being considered to serve as a content expert on your planning committee. Her husband is vice president of a company that produces pacemakers. The topic for the conference is horizontal violence.
Jack Williams is a sales representative with a pharmaceutical entity and is being considered to serve on your planning committee.
The individual being considered as the keynote speaker is an expert in the topic of women's health and wrote a best-selling book on the topic. The conference is about implementing the latest research findings on women's health.
The author of a web-based learning activity on special considerations for people with arthritis has declared no conflict of interest on his biographical data form. When his assistant sends you a copy of the author's publicity statement, you discover he wrote multiple books on arthritis and produced a topical ointment for patients with arthritis.
Scroll Down for the Answers!
PLANNING COMMITTEE CONTENT EXPERT ON SPEAKER'S BUREAU FOR A COMMERCIAL INTEREST ORGANIZATION:
According to accreditation criteria, "financial benefits may be associated with employment, management positions, independent contractor relationships, other contractual relationships, consulting, speaking, teaching, membership on an advisory committee or review panel, board membership, and other activities from which remuneration is received or expected from the commercial interest."
Based on this definition, Jane Smith has a conflict of interest because she is a member of a speaker's bureau for a company that produces drugs for diabetes and the content of the educational activity is relevant to the products or services of the commercial interest organization (management of diabetes).
Jane could be a speaker for the conference if the Nurse Planner/planning committee believes she is knowledgeable in the topic and appropriate to be a speaker. Steps to resolve Jane's actual conflict of interest must be taken. For example, the Nurse Planner/planning committee might ask a content reviewer to evaluate Jane's presentation for any bias towards the pharmaceutical company and its products, for balance in the presentation, and for other indicators of integrity. The Nurse Planner or designee could then monitor Jane's presentation to ensure no bias is introduced during the session.
The Nurse Planner/planning committee might also include a question on the evaluation form asking if the presentation was presented free of bias. It might be beneficial to include a definition of bias on the evaluation form so learners are aware of what to evaluate. For example, rather than, "Was the learning activity free of bias?" the question could be worded as "Was the learning activity free of product promotion?"
Prior to the start of the presentation, the Nurse Planner/planning committee must also ensure that Jane's conflict of interest is disclosed to the learners. This could be done on the advertising, on the agenda, or on the first page of handouts, or on the first slide of the presentation.
PLANNING COMMITTEE MEMBER WITH SPOUSE EMPLOYED BY A COMMERCIAL INTEREST ENTITY:
The topic for this conference is not related to pacemakers therefore, Lisa would not have a conflict of interest. (Note: Lisa would have a COI if the topic was related to pacemakers, such as treatment of cardiac dysrhythmias.)
SALES REPRESENTATIVE ON PLANNING COMMITTEE:
There is insufficient information to make a decision about whether Jack has an actual or potential conflict of interest. Questions to consider include: What is the topic of the CE activity? What is the purpose of including Jack on the planning committee?
KEYNOTE SPEAKER WITH BOOK:
This speaker can influence learners but does not appear to have a financial relationship with a commercial interest organization related to the content of this educational activity. To be sure, the Nurse Planner/planning committee should closely evaluate the speaker's Biographical/Conflict of Interest disclosure form.
Note: A publishing company does not fit the definition of a commercial entity.
While this particular scenario does not appear to present a conflict of interest in relation to a commercial interest organization, the speaker does have the ability to benefit financially from promoting his book. The Nurse Planner/planning committee will need to ensure the presentation is evidence-based, free from promotion, and advances the professional development of registered nurses.
Book sales may only be conducted if separated from the educational activity. Sales may not be part of an educational activity.
AUTHOR AND RELATIONSHIP WITH A COMMERCIAL INTEREST ORGANIZATION:
It appears this author does have an actual conflict of interest. The Nurse Planner/planning committee must evaluate the discrepancy between the conflict of interest declaration by the author and the materials forwarded from the assistant. If an actual conflict of interest exists, it is the responsibility of the Nurse Planner to resolve the identified conflict prior to the start of the educational activity.
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Effective January 1, 2015, The ANCC Commission on Accreditation has voted to change the term "Co-Providership" to "Joint Providership." This change in language reflects our ongoing efforts to help nurses, physicians, pharmacists and all healthcare continuing education providers and regulatory agencies to standardize terms and create a common language. This language will now also be used by the Accreditation Council for Continuing Medical Education (ACCME and the Accreditation Council for Pharmacy Education (ACPE) to reflect that two or more organizations are working collaboratively to plan, implement and evaluate continuing education activities. The change may be implemented immediately.
Joint-providing an educational activity is an opportunity for organizations to share both expertise and workload! It is important, however, that the ANCC accredited organization understands the requirements for joint-providership to maintain adherence to the Accreditation criteria.
When two organizations joint-provide an educational activity and one is ANCC accredited, the ANCC accredited organization is responsible for ensuring adherence to the criteria. The ANCC Accredited organization is termed the provider and the other organization is termed the joint-provider. Documentation and communication including marketing materials must clearly demonstrate the joint-provider relationship.
When two organizations joint-provide an educational activity and both are ANCC accredited, one organization is designated as the provider and other organization is the joint-provider.
The provider in a joint-provider relationship is responsible for the following:
- Determination of educational objectives and content
- Selection of content specialist planners and activity presenters
- Awarding of contact hours
- Evaluation methods and categories
- Management of any commercial support or sponsorship
The Accreditation Council for Continuing Medical Education (ACCME) and Accreditation Council for Pharmacy Education (ACPE) use the term "joint-sponsorship" to describe two or more organizations providing an educational activity. The term "sponsor" or "sponsorship" has a different meaning for ANCC accredited organizations. When organizations are ANCC accredited and ACCME or ACPE accredited, the terms can be combined to demonstrate that the organization understand the difference between the terms. For example, communication may be written as such: This educational activity is co-provided/co-sponsored by ABC Hospital and XYZ Association.
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Approved Providers are required to provide and sign an attestation statement that the approved provider unit (PU) complies with all applicable local, regional, state, or national laws and regulations and operates its business in an ethical manner. Initially, NE-MSD reviewers determine whether the attestation statement is present and is signed and dated.
Next, NE-MSD reviewersevaluate the organization related to the components of the attestation statement, which may include but are not limited to:
- Complaints about the applicant organization as an entity, the quality of educational activities offered (accredited provider) or the quality of activities approved (accredited approver).
- The organization's response to complaints about its products or services from stakeholders or customers.
- Congruence between narrative explanations in the self-study documents and evidence found in other documents, web sites, or in verbal descriptions from presenters, learners, customer, etc.? Adherence to laws and regulations such as the Americans with Disabilities Act, Rehabilitation Act, harassment and discrimination laws, and laws and regulations related to copyright, trademarks or intellectual property.
We have provided a brief overview of laws and regulations related to copyright, trademarks and intellectual property below:
Intellectual Property Rights (IPR)—defined by the U.S. Department of Commerce Market Access and Compliance as "Creations of the mind-creative works or ideas embodied in a form that can be shared or can enable others to recreate, emulate, or manufacture them. Patents, trademarks, copyrights, and trade secrets are four of the most common ways to protect intellectual property." Infringement of copyright, trademark or intellectual property rights is a serious offense. It is estimated that more than 33% of the value of a business resides in its IPR, and IPR violations can lead to financial losses and reputation erosion for the intellectual property owner.
When planning an educational activity, be careful to adhere to all requirements related to the use of copyrights, trademarks or intellectual property rights. Just because a document or photograph is available on the web, for example, does not mean that it is available for public use and dissemination. Similarly, an article from a journal may not be copied and distributed without obtaining permission from the journal editor.
The U.S. Patent and Trademark Office (www.uspto.gov) and the U.S. Copyright Office www.copyright.gov) define intellectual property rights as:
Copyright—a form of legal protection provided by U.S. law (title 17, U.S. Code) to the authors of "original works of authorship" fixed in any tangible medium of expression. The manner and medium of fixation are virtually unlimited. Creative expression may be captured in words, numbers, notes, sounds, pictures, or any other graphic or symbolic media. The subject matter of copyright is extremely broad, including literary, dramatic, musical, artistic, audiovisual, and architectural works. Copyright protection is available to both published and unpublished works. The author or creator is protected for their lifetime and for a period of 50 years after their death.
Free copyright training video resources can be accessed at the Copyright Clearance Center at www.copyright.com/content/cc3/en/toolbar/education/resources.html
Trademark—a word, phrase, symbol or design, or a combination of words, phrases, symbols or designs, that identifies and distinguishes the source of the goods of one party from those of others. A trademark is a proprietary term that is usually registered with the Patent and Trademark Office to assure its exclusive use by its owner. A service mark is the same as a trademark, except that it identifies and distinguishes the source of a service rather than a product.
Patent—an intellectual property right granted by the Government of the United States of America to an inventor "to exclude others from making, using, offering for sale, or selling the invention throughout the United States or importing the invention into the United States" for a limited time in exchange for public disclosure of the invention when the patent is granted.
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The above document was amended on August 12, 2014. Changes were made to Section G, Item 8. These changes are noted below:
G. Content of the Educational Activity. Content is the responsibility of the Provider of the educational activity. All materials used for the educational activity must be free from commercial bias. To guard against the presence of commercial bias, the Provider is responsible for ensuring the following:
a. Slides, handouts and other materials presented to the learner related to the educational activity do not display any logos or other trademarks of a Commercial Interest Organization;
b. Live (in-person) educational activities are presented without reference to a Commercial Interest Organization; acknowledgement of commercial support is limited to the name of the entity providing support.
c. Enduring materials do not include logos, trademarks or other insignia of, or references to, a Commercial Interest Organization; acknowledgement of commercial support is limited to the name of the entity providing support
d. Web-based materials do not include logos, other trademarks or other insignia of, or reference to, a Commercial Interest Organization; acknowledgement of commercial support is limited to the name of the entity providing support
e. Evaluations of the educational activity make no reference to a commercial Interest Organization or its products or services; and
f. Learners are not recruited for any purpose during the activity or evaluation.
Maintaining content integrity is a multi-step process involving the Nurse Planner, all members of the planning committee, authors, presenters/speakers and content reviewers.
Maintaining content integrity ensures that
- content for an educational activity is evidence-based or based on the best-available evidence;
- content for an educational activity is presented free from commercial bias or promotion;
- all individuals in the position to control content have been evaluated for relationships with commercial interest organizations that might create a conflict of interest, and any identified COI has been resolved; and
- there has been independence from any organization providing financial support for the activity.
The Nurse Planner of the activity is accountable for ensuring content integrity yet all members of the planning committee as well as any individual in a position to control content must take an active role in ensuring content integrity is maintained.
One issue of ensuring content integrity may occur when an individual who is in a position to control content of an educational activity has a product or service (such as a book or consulting service) that he/she may try to promote through the activity.
- When the product or service is related to a commercial interest organization, the processes used to identify, evaluate and resolve conflicts of interest must be implemented.
- When the products or services are not related to a commercial interest organization, such as the individual who is the author of a book or the business owner of a consulting company, the issue is not one defined as "conflict of interest" (or the relationship that an individual has with commercial interest organizations) but should be evaluated and treated as part of the process of maintaining content integrity of the educational activity.
For example, the Provider must ensure that the educational activity is designed to meet the learning needs of the target audience of registered nurses, the content is evidence-based or based on the best-available evidence, and the activity is delivered free from bias or promotion. Educational activities should not be used as a mechanism to sell a product or service.
Strategies to ensure that activities are not promotional or biased may include but are not limited to:
- Providing speakers/presenters/authors with guidelines stating that the educational activity may not be used to promote an individual's products or services and obtaining signed confirmation of agreement to comply with the guidelines
- Providing speakers/presenters/authors with the overall purpose and objectives of the educational activity to ensure that content supports achieving the desired outcomes
- Ensuring that evidence used to develop content for the educational activity is based on high-quality resources (via a review of the content by the Nurse Planner, content expert, etc.)
- Reviewing presentations prior to the educational activity and monitoring for bias or promotion during and/or after the activity.
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ANCC Accreditation criteria require that providers plan, implement and evaluate quality continuing nursing education activities with integrity, free from the undue influence of commercial interest organizations. A provider may be defined as an Accredited Provider, Approved Provider or Individual Activity Applicant.
The following questions may be used by Providers to evaluate whether an actual or potential conflict of interest exists. A review of the ANCC Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities is recommended (available at the following link: www.nursecredentialing.org/Accreditation-CEContentIntegrity).
The Planning Process
When the planning process for an educational activity is initiated, the first individual who must be evaluated for any potential or actual conflict of interest is the Nurse Planner for the activity. The Nurse Planner may not evaluate her/his own potential for conflicts of interest. An independent party such as the Lead/Primary Nurse Planner or another member of the planning committee must evaluate the Nurse Planner for potential conflicts of interest and document findings appropriately.
Any Nurse Planner with a potential or actual conflict of interest should recuse her/himself from the activity. The potential conflict of interest must be resolved by another Nurse Planner for the educational activity, the Lead/Primary Nurse Planner of the organization, or other independent party.
During the planning process for an educational activity and throughout implementation and evaluation of the activity, it is the responsibility of the Nurse Planner to ensure 1) all actual and/or potential conflicts of interest are identified and resolved; 2) content integrity for the activity is maintained; and 3) learners are aware of all actual and/or potential conflicts of interest prior to participating in the activity.
Therefore, the Nurse Planner must first identify all individuals with the potential ability to control or influence the content of the educational activity. Individuals may include, but are not limited to, members of the planning committee, faculty, presenters, authors, and/or content reviewers.
Questions to evaluate for potential or actual conflicts of interest:
- Which individual(s) has (have) the ability to control or influence the content of the educational activity being planned?
- All planning committee members have the ability to influence or control content of an educational activity through activities such as gathering needs assessment data; identifying the appropriate gap in knowledge, skills or practices; choosing content; and/or recommending faculty/presenters/authors.
- Faculty/presenters/authors have the ability to determine what to include or not include in a presentation.
- Content reviewers can influence content by determining appropriateness of content, if best available or most current evidence was chosen, and the presence or absence of bias.
- Have all individuals with the ability to control or influence the content of the educational activity completed a Biographical/Conflict of Interest disclosure form?
- Is the Biographical/Conflict of Interest disclosure form up to date with current accreditation criteria?
- Requires disclosure of the individual and her/his spouse or partner
- Requires disclosure of all relationships with commercial interest organizations
- Requires disclosure of all relationships within the past 12 months
- Signed by the individual (electronic signature acceptable)
- Reviewed and signed by the Nurse Planner
- Dated (must be within 12 months of the educational activity and reviewed in relation to the educational activity being planned at the time)
- Could the content of the educational activity be related to a product or service of a commercial interest organization? Examples could include but are not limited to:
- Pharmaceutical products used for patients
- Pharmacologic management of diseases
- Devices used on patients
- Products used on patients
- Did any individual with the ability to influence the content of the educational activity disclose a relationship with a commercial interest organization, including relationships of a spouse or partner?
- Is the relationship that was disclosed relative to the content of the educational activity being planned?
- For relevant relationships, how will the Nurse Planner/planning committee resolve the conflict of interest?
- For relevant relationships, how will the Nurse Planner/planning committee disclose the conflict of interest to learners? (Note: only relevant relationships are required to be disclosed).
Making the Link: Gap, Purpose and Outcome
When initially planning an educational activity, it is critical that planners identify the gap in knowledge, skills or practices the educational activity is intended to address. This gap will drive the purpose and outcome of the educational activity.
A gap analysis worksheet is often a useful tool for planners to use when getting started. This type of worksheet helps planners make the link between the gap, the purpose and the outcome of the activity. One example of gap analysis worksheet is included here:
Gap due to Knowledge, Skills or Practice
In this worksheet, "current state" represents the current level of practice for the intended target audience. Practice may be a variety of different types including but not limited to administrative, educational or clinical practice. The "desired state" represents the level of practice that planners would like to achieve through the educational activity. The "identified gap" represents the delta between current and desired states. Planners must then use data to determine if the identified gap is due to knowledge (doesn't know), skill (does not know how), or practice (not able to show or do in practice) in the intended target audience. Data may be collected by different methods which may include surveying stakeholders such as members of the target audience or content experts, reviewing quality data, analyzing data from previous educational activity evaluations or reviewing trends in published literature. When planners have determined the basis for the practice gap, they develop the purpose for the educational activity, stated in terms of what the learner will achieve by the end of the activity, AND how planners will evaluate the outcome of the educational activity, or whether the activity achieved the purpose. These components can then be used as the basis for developing specific objectives and teaching/learning strategies for the activity.
Documenting using this type of tool is not just helpful for activity planners, but also provides a clear picture of the planning process for Accreditation appraisers when reviewing individual activity.
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ANCC Accreditation criteria require that Providers plan, implement and evaluate quality continuing nursing education activities with integrity, free from the undue influence of commercial interest organizations. A Provider may be defined as an Accredited Provider, Approved Provider or Individual Activity Applicant.
ANCC routinely receives questions related to ensuring independence, particularly during the planning process and selection of individuals who may or may not participate on the Planning Committee for an individual activity. As per Accreditation criteria, every educational activity must be planned by at least two people, a Nurse Planner who is responsible for ensuring compliance with Accreditation criteria at the activity level and a content expert. Additional individuals may be asked to participate on a Planning Committee as needed for an individual activity. All individuals, however, who are defined as members of the Planning Committee may not have relationships with commercial interest organizations, the products and services of which are related to the content of the educational activity being planned. Because members of the Planning Committee are able to directly influence the educational activity through activities such as determining objectives, choosing content for the activity and selecting speakers/authors/presenters, independence cannot be ensured if individuals who have relevant relationships with commercial interest organizations, the products and services of which are related to the content of the educational activity being planned, are on the Planning Committee.
The Planning Committee may, however, choose an individual who has a relationship with a commercial interest organization for a role such as a speaker or presenter as long as the Nurse Planner has evaluated the relationship for relevance and implemented a resolution process as outlined in the 2013 ANCC Primary Accreditation Application Manual for Providers and Approvers and in the ANCC Content Integrity Standards for Industry Support in Continuing Nursing Educational Activities. This ensures that the Provider maintains overall control of the educational activity with integrity, free from the undue influence of commercial interest organizations.
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ANCC have removed the requirement that educational activities last a minimum of thirty (30) minutes (0.5 contact hours) effective immediately. Therefore, CE activities can be any length in order to better meet the needs of our accredited organizations and the needs of today's learners. With the explosion in technology, continuing nursing education activities can be delivered using a variety of methods and ANCC wants to ensure that those providing activities have maximum flexibility in developing and delivering high-quality education for professional registered nurses.
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When planning educational activities, Nurse Planners may identify previously developed content that would be appropriate to meet the learning needs of the intended target audience. These guidelines are not intended to bypass the critical role of Nurse Planners in conducting needs assessments and planning, implementing and evaluating educational activities, but rather to allow Nurse Planners to incorporate previously developed educational content in a continuing nursing education activity which relates to the needs assessment and target audience.
Content that has been previously developed may be incorporated into educational activities awarding continuing nursing education credit according to the following guidelines:
- The Nurse Planner and Planning Committee:
- Have conducted an independent needs assessment of the target audience
- Have identified previously developed educational content that meets the learning needs of the target audience
- Have developed learning objectives for the educational activity independent of the learning objectives previously developed for the content or have evidence why previously developed learning objectives did not require modification
- Have evidence that the previously developed content is current, evidence-based, meets current standards or practice guidelines or otherwise should be incorporated into the activity
- Have evidence of revisions/deletions/additions required for the previously developed content OR evidence stating why previously developed content did not require any revisions/deletions/additions
- Ensures that the previously developed content is objective and unbiased; and excludes any promotional influence
- Verifies that the previously developed content meets the definition of "continuing education" as described by the American Nurses Credentialing Center's Accreditation Program.
- The Nurse Planner and Planning Committee may not "approve" a previously developed educational activity and award continuing nursing education credit without complying with these guidelines.
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The process of planning educational activities requires Nurse Planners to systematically gather information then utilize this information to develop educational interventions that are designed to close a gap between what learners currently know or do in practice and what learners should know or do in practice. The process of systematically gathering information is known as needs assessment. Data collected via a needs assessment are used to determine why a gap in practice exists and then an educational activity is designed to address that gap. It is important to note that "practice" should not be inferred to mean "clinical practice" but rather the practice setting of the learner which may be in administration, clinical practice, education, or research.
Method of data collection
The purpose of collecting and then evaluating data is to identify problems or opportunities for improvement that currently exist in practice, determine the reason for the gap in practice, and then design educational interventions to address those problems or opportunities. When choosing a method to collect data, then, it is critical that Nurse Planners utilize one that will result in data that can be used to describe problems or opportunities for improvement in practice.
For example, one method of collecting data is to use end of activity evaluation forms or stakeholder surveys. While there is nothing inherently wrong with using these methods, they often include questions that are similar to the following:
- Please indicate what you would like to know more about in future conferences:
a. Free text response
- Please indicate which of the following topics you would like to know more about:
b. Congestive heart failure
The problem with these types of questions is that they do not elicit responses that address the reason why learners would like to know more about the topic, or the problems in practice that they are facing in relation to these topics. There are more effective strategies for soliciting this information via evaluation forms or survey questions that can easily be integrated into the process of collecting data.
For example, these questions are designed to focus on problems in practice:
- Please describe a problem or issue in practice that you are currently experiencing:
- Please indicate which of the following topics you would like to know more about. Describe a situation you have encountered in practice related to this topic.
- Will this educational activity help you improve your own (administrative, educational, clinical, research) practice? If not, why not?
If a problem or opportunity for improvement in practice is identified through a method such as analysis of a sentinel event or evaluation of performance improvement outcomes, Nurse Planners should implement a similar drill down process to identify the reason why the problem in practice exists.
Consider the following questions:
- Do nurses not know about the problem/opportunity for improvement?
- Are nurses not able to describe what to do and/or demonstrate what to do in relation to the problem/opportunity for improvement?
- Do nurses not implement what they know how to do or are capable of doing in practice in relation to the problem/opportunity for improvement?
- Gap in practice
Or, is there some other reason that the problem/opportunity for improvement exists?
Findings of the needs assessment
Findings of the needs assessment are the data that identify the problem or opportunity for improvement in practice, validate the need for the educational activity, and identify the gap in knowledge, skill and/or practice.
Operationalizing a Provider-Directed, Learner-Paced Performance Improvement (PI) CNE Activity
The opportunity for improving practice and patient outcomes through a Performance Improvement (PI) project is well-documented. The opportunity for learning and growth is also an important outcome for registered nurses and contact hours can be awarded by ANCC Accredited Providers for PI projects as provider-directed, learner-paced CNE activities.
The ANCC Accredited Provider must adhere to the accreditation criteria when planning, implementing and evaluating this type of educational activity.
The planning process starts with assessing learner needs of the target audience. The provider might ask:
- Who is the target audience for the educational activity?
- What assessment data has been or will be collected?
- What do data demonstrate or reveal about my target audience? Is there a gap between the current and the desired practices of my target audience? Why does that gap exist? Is it due to a gap in knowledge, skills and/or practices?
For example, the target audience might be Advanced Practice Registered Nurses (APRNs) working in primary care pediatric clinical settings. Assessment data might demonstrate that APRNs are currently administering vaccinations in compliance with vaccination recommendations for pediatric patients 70% of the time. The desired practice is that APRNs will comply with vaccination recommendations for pediatric patients 100% of the time. The identified gap is presumed to be a knowledge and/or a practice gap (not knowing the vaccination recommendation schedule or not complying with the schedule in the clinical setting).
Now, planning the activity. The provider determines:
- Who is the Nurse Planner for this activity?
- What type of content expertise is needed to plan the activity?
Once the team ("planning committee") is assembled, planning continues.
- What is the purpose of this educational activity and what are the measureable objectives?
- What content will the provider choose for the activity?
- What will be the criteria for successful completion?
- Will contact hours be awarded for meeting the objectives in stages (i.e. able to describe best practices after completing a webinar or reading an article)? OR
- Will contact hours be awarded when the learner meets all objectives including developing an action plan, implementing an action plan, evaluating outcomes and describing changes in practice that were made as a result of the outcomes achieved?
The purpose of the activity might be: Administer vaccinations in compliance with vaccination recommendations for pediatric patients in the primary care pediatric clinical setting.
The objectives might be:
- Describe best practices for ensuring vaccination compliance for pediatric patients in the primary care setting.
- Formulate an action plan to implement best practices within the target audience's clinical setting.
- Implement the action plan within the clinical setting.
- Evaluate outcomes of the action plan including the compliance rate of vaccination recommendations.
The Provider might choose to deliver some content for the activity using evidence-based resources for best practices or developing action plans which could be delivered as an enduring material, live webinar or similar. Other content might include evidence obtained from the clinical setting through chart audits or analysis of process flow.
The evaluation method might be something like submitting examples of changes in practice that were made as a result of participating in the learning activity.
ANCC contact hours could be awarded by a method such as pilot testing steps in the PI process, calculating contact hours for each stage and then awarding contact hours based on pilot data. The Provider would also be responsible for regularly auditing and confirming the number of contact hours awarded for the activity.
In summary, Performance Improvement (PI) projects present great learning opportunities for registered nurses and can be an important strategy to improving practice and/or patient outcomes. By structuring these activities as provider-directed, learner-paced activities, ANCC contact hours can be awarded by Accredited Providers.
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If you are planning a presentation or a program you will need a "nurse planner" in order to apply for CE contact hours. ANCC defines the nurse planner as a "currently licensed RN with a baccalaureate degree or higher who is actively involved in all aspects of planning, implementation, and evaluation of the continuing education activity. The Nurse Planner is responsible for ensuring that appropriate educational design principles are used and processes are consistent with the requirements of the ANCC Primary Accreditation Program."
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ANCC defines conflict of interest as an affiliation or relationship of a financial nature with a Commercial Interest Organization that might bias a person's ability to objectively participate in the planning, implementation, or review of a learning activity. During the planning process for an educational activity, evaluation of the presence or absence of conflicts of interest must occur for all individuals in a position to control or influence the content of the activity. The planning process starts with evaluation of conflict of interest for the Nurse Planner, and an independent party (someone other than the Nurse Planner) must confirm the Nurse Planner has no conflicts of interest that would impact planning the educational activity.
Once confirmed, the Nurse Planner is responsible for evaluating the presence or absence of conflicts of interest for all other members of the planning committee, presenters, speakers, authors, and content reviewers. Relationships with Commercial Interest Organizations are classified as relevant if the products or services of the commercial interest are related to the content of the educational activity.
All individuals completing a conflict of interest form understand the ANCC definition of conflict of interest. It is common for individuals completing a conflict of interest form to disclose all relationships with organizations that might appear to result in benefit of a financial nature. For example, an individual may disclose his/her employer as a relationship that might pose a conflict of interest. If the employer is not classified as a Commercial Interest Organization, however, the relationship is not defined as one that presents a conflict of interest.
When an individual discloses a relationship with an organization on a conflict of interest form, the Nurse Planner must review the information to determine whether the organization meets the definition of a Commercial Interest Organization.
- Failure to recognize an organization as a Commercial Interest Organization may result in an individual having the opportunity to unduly bias the educational activity.
- Failure to recognize an organization as not meeting the definition of a Commercial Interest Organization because an individual may be precluded from participating in the planning process of an educational activity without cause, learners may be told the relationship presents a conflict of interest for the individual when it does not, and it is difficult to determine if the Nurse Planner truly understands the definition of conflict of interest.
In the event that the relationship disclosed is not with a Commercial Interest Organization, the Nurse Planner could simply make a notation in the record such as "organization not commercial interest – not relevant" thus reflecting review and accurate assessment of the situation.
In summary, remember these key points:
- The Nurse Planner may not evaluate his/her relationships with Commercial Interest Organizations and determine whether or not a conflict of interest exists. Another person must make this determination and sign the bio/COI form to indicate that the review has been completed and an appropriate decision made regarding the Nurse Planner's ability to proceed with the planning process.
- The person providing the disclosure does not determine the presence or absence of conflict of interest. He/she simply discloses relationships with Commercial Interest Organizations. It is the responsibility of the Nurse Planner to determine whether or not the relationship represents a conflict of interest for this particular activity. The signature on the bio/COI form validates that the Nurse Planner has completed this process.
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ANCC Accredited Providers are accountable for demonstrating that, in aggregate, the educational activities they provide impact nursing professional development. ANCC Accredited Approvers are accountable for demonstrating that they support Approved Providers and/or Individual Activity Applicants in demonstrating an impact on nursing professional development. What types of quality outcome measures, then, relate to nursing professional development? How are quality outcome measures identified, measured and evaluated?
A continuing nursing education provider - whether an Accredited Provider, Approved Provider or Individual Activity Applicant – should identify quality outcome measures that are appropriate for the organization and/or educational activity. In order to aggregate outcome data, data do need to be collected at the individual activity level then analyzed to evaluate the impact of the educational activity on nursing professional development, or the professional practice of nursing.
The 2015 Primary Accreditation Application Manual for Providers and Approvers includes a suggested list of quality outcome measure categories related to nursing professional development. Providers may choose a quality outcome measure from this suggested list of categories or identify a quality outcome measure that is appropriate for the organization. The quality outcome measure should be specific and measureable, and should be relevant to the organization's overall strategic goals related to the professional practice of nursing. When applying for accreditation or re-accreditation as a provider, the provider lists the chosen quality outcome measures under criterion Organizational Overview (OO) 4, and when applying for accreditation or re-accreditation as an approver, the approver unit. The process utilized for evaluating effectiveness of the Approver Unit is supporting the delivery of quality CNE by Approved Providers and/or Individual Activity applicants in Quality Outcome (QO) 1. How the evaluation process for the Approver Unit resulted in development or improvement of an identified quality outcome measure of the Approver Unit in Quality Outcome (QO) 2.
Examples of quality outcome measures related to nursing professional development:
Accredited/Approved Provider: A hospital identified a strategic goal of improving RN-MD communication. The quality outcome measure might be: improve RN-MD communication by 10% from previous year's satisfaction survey.
Accredited/Approved Provider: A specialty nursing organization in perioperative nursing has a strategic goal to ensure perioperative nurse compliance with a new evidence-based standard. The quality outcome measure might be: by 2015, 75% of member nurses will self-report intent to change practice related to the updated standard in perioperative nursing.
Accredited/Approved Provider: A continuing education provider has a strategic goal to increase interprofessional collaborative practice of its learners. The quality outcome measure might be: At 6 months post-participating in a series of educational activities, 50% of learners will self-report collaborating with members of other professions in the practice setting.
Individual Activity Applicant Provider: A medical education company wants to engage registered nurses and advanced practice registered nurses as part of the target audience for its annual conference on multiple sclerosis. The medical education company understands that to positively impact the care of patients with multiple sclerosis, it will need to engage all members of the team in its educational activities. A quality outcome measure at the individual activity level for learners participating in this conference might be: At the conclusion of the annual conference, learners will self-report intent to engage patients and family members in care planning. The medical education company may also choose to survey learners over time to evaluate whether they self-report actual practice change.
In order to demonstrate an impact on nursing professional development, the provider will need to measure outcomes of its learners at the individual activity level, either at the conclusion of the educational activity, longitudinally after the educational activity, or both. Then, data can be aggregated to measure the overall impact of the provider unit on the identified nursing professional development outcome measure.
Evaluating the impact of continuing education on the professional practice of nursing helps to demonstrate the link between continuing education and outcomes achieved as a result, and demonstrates the value of life-long learning.
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Learners need to receive all required disclosures prior to the start of a learning activity. This is sometimes missed when the activity is provided in print or web based formats. Required disclosures must be visible to learners prior to the start of the educational activity. The purpose of providing learners with all required disclosures is to ensure that they are informed of the following:
- The purpose, objectives and requirements for successful completion of the activity.
- Any influencing financial relationships disclosed by anyone in a position to control content of the activity or lack thereof.
- Any sponsorship or commercial support provided for the activity.
- That accredited status does not imply endorsement by ANCC or the provider.
- Whether the activity will include discussion of a product used for a purpose other than that for which it was approved by the Food and Drug Administration (off label use).
- Expiration of contact hours (enduring materials only).
Placing required disclosures at the end of an educational activity such as at the end of an article or the end of a webinar does not adhere to ANCC Accreditation criteria.
When developing educational activities for print or web formats, it is helpful to pilot test the activity to ensure that someone unfamiliar with the format can locate all required disclosures easily.
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ANCC accreditation and approval is recognized by all BONs with the following exception: the CA and IA BONs will not recognize a provider's CE if that provider enters those states to offer their CE, without the respective BONs approval. If the provider does not go into the states of CA or IA, then those BONs will recognize the provider's contact hours awarded (this is true for internet courses and other home study courses as well). Please contact the CA and IA BON's for their specific regulations.
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From the ANCC Website: www.nursecredentialing.org/PharmacotherapeuticsRequirements
Information for re-certifying ANCC Certified Clinical Nurse Specialists (CNS) and Nurse Practitioners (NP), effective January 1, 2014:
- 25 of the 75 required contact hours must be in pharmacotherapeutics. Important note: If you double category 1, there is NO requirement to double the number of pharmacotherapeutic hours.
- These 25 pharmacotherapeutic hours do not need to be formally ANCC accredited/approved, provided the certified nurse meets the requirements for Category 1 contact hours. (That requirement is: at least 51% of the total number of contact hours must be in your certification role and specialty and at least 50% must be formally ANCC accredited/approved.)
- If an educational program includes pharmacy content, please refer to equivalency tables in above link/brochure to determine the number of pharmacotherapeutic hours that could be counted towards re-certification. Align calculation with the agenda or content (e.g. 60 minutes of a 2 hour presentation was devoted to pharmacotherapeutics = 1 contact hour).
- The educational presentation or conference agenda may be submitted as evidence to validate the contact hour calculation. A narrative note describing pharmacology content within agenda may be necessary to validate content.
- The same hours submitted to renew certification may be submitted to a State Board of Nursing for re-licensure.
- Pharmacotherapeutic content does not need to be presented by a nurse for the hours to be eligible for re-certification however the presenter must have content expertise in pharmacology.
Educational Activity Providers:
- If a provider is developing content to meet the ANCC pharmacotherapeutic hour requirement, content must specifically address pharmacotherapeutics.
- Pharmacotherapeutic content does not need to be presented by a nurse for the hours to be eligible for re-certification however the presenter must have content expertise in pharmacology.
- When developing the content for an educational activity, it is recommended that the provider delineate the number of pharmacotherapeutic contact hours.
- Existing continuing education courses/programs that include pharmacotherapeutic content may be reviewed to calculate the appropriate number of pharmacotherapeutic contact hours.
- When a speaker develops content for an educational activity, it would be advised that pharmacotherapeutic contact hours contained within the presentation be calculated at that time.
**Pharmacotherapeutic content may include but is not limited to drug specific information, safe prescribing practices, safe medication administration, prescribing methodologies, new regulations or similar content.
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ANCC has updated its position regarding "in-service" topics eligible for contact hours!
Now, any content that addresses professional practice gaps for registered nurses may be awarded contact hours as long as the topic meets the usual credentialing standards. ANCC recognizes that educational activities which help ensure that nurses know how to properly use equipment, medications, and/or products on patients in their practice setting enhances the quality of their care to those patients. This perspective expands the definition of the type of content eligible for contact hours.
Thus, CNE activities no longer have to meet the "generalizable" requirement—a now-defunct requirement in which in the past content eligible for contact hours had to be applicable to, and transferrable from, one health care facility to another and could not address “institution-specific” equipment, medications, and/or products.
We were very excited to see this change. What does this mean for you?
It means you now have the opportunity to greatly expand the variety of CNE topics available to your staff! It means you may develop CNE activities specific to processes in your facility or the brand of equipment, medications, and/or products used in your facility (i.e. monitors, IV pumps, EMR applications, etc.). These activities can be specific to the practice gap in your facility and qualify for contact hours under the revised ANCC criteria.
One significant ANCC caveat related to this revised position is this:
If contact hours are to be awarded, no sales reps or their clinical educators, even if they are nurses, who are employees of commercial interest companies (per ANCC's definition) may be on the planning committee or be the presenters of any portion of the activity (including a demonstration).
However, if the company representative teaches your educators about the equipment, medication, and/or product and then your educators plan and present the activity content, that activity can be awarded contact hours.
This new ANCC revised ruling opens up a wide variety of topics that can meet criteria to be awarded contact hours. In addition, re-certifications for BCLS, ACLS, PALS, etc. (where updates to current practice standards and re-validation of practice skills are required) also meet the criteria to award contact hours.
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PROMOTING A PROGRAM PRIOR TO APPROVAL BY THE NE-MSD: Submitted for Approval Statement
This activity has been submitted to the Northeast Multi-State Division for approval to award contact hours. The Northeast Multi-State Division is accredited as an approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Maine, New Hampshire, New York, Rhode Island, Vermont Nurses Associations are members of the Northeast Multi-State Division of the American Nurses Association.
PROMOTING A PROGRAM AFTER APPROVAL BY THE NE-MSD AND ON CERTIFICATES: Approval Statement
This continuing nursing education activity was approved by the Northeast Multi-State Division, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Maine, New Hampshire, New York, Rhode Island, Vermont Nurses Associations are members of the Northeast Multi-State Division of the American Nurses Association.
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