COLORADO NURSES ASSOCIATION/ANCC

Nursing Continuing Education Activity Application Journal Clu !"y #olicy R"$uir"%"nts& '( A UC) approv"d nurs" plann"r *UST " a l"ad in any CNE activity( +( All progra%s *UST go t,roug, t,is approval proc"ss -E.ORE activity ta/"s plac"( 0#"r ANCC1 r"troactiv" approval is pro,i it"d(2 Dir"ctions& 1. Complete each question in all sections by using your mouse to move around and type. To check a box, simply move your mouse pointer to the box and perform a single left click action. !epeat either of these actions to uncheck the box if you need to do so. ". TO INSERT ADDITIONAL TEXT# Click on !$%&$' T() !estrict $diting button. Then, click on *top +rotection , no pass-ord is on this form. .ou can easily copy and paste after this option is completed. /. +lease submit a C01+2$T$3 application and (22 required forms via email to# 4C5 (6CC (pplications7uch.edu 20 days prior to Journal Club date &ncomplete applications -ill be returned. 8. Any request for UC to award contact hours for an education activity planned by others without UCH involvement will not be considered. &nquiries -ill be referred to the Colorado 6urses (ssociation for approval process information. Fees 9:.:: , 4C5 planned and provided activities

!" De#o$rap%i& Data

0rgani;ation# 4niversity of Colorado 5ospital Title of C6$ (ctivity# <ournal Club =(nalgesia and pulmonary function after lung surgery# is a single intercostal nerve block plus patient controlled intravenous morphine as effective as patient controlled epidural anesthesia> ( randomi;ed non inferiority clinical trial? 3ate of $vent# *unday @ebruary "/rd, ":18 Contact 5ours# 1.: Type of (ctivity# 2ive <ournal Club %irtual <ournal Club

2" 'u#an Resour&es

A" Contact person +rovide the follo-ing information for the contact person for this activity. This person is the individual that Colorado 6urses (ssociation -ill communicate -ith regarding the application. 6ame A Credentials# <o(nn 3el1onte, !6 )C, 1*6 0rgani;ation# 4niversity of Colorado 5ospital (ddress# 1"8:1 $. 1Bth (ve 3aytime +hone 6umber including extension# B": C8C DDE8 @ax 6umber# B": C8C B/BB $mail address# <o(nn.3el1onte7uch.edu

(" Planning Committee: 1ust include a designated 2ead 6urse +lanner and a minimum of one other planner# 0ne F1G !6 -ith a baccalaureate degree in nursing or a higher degree in nursing and education or experience in the field of education or adult learning. The lead 6urse +lanner has responsibility for adherence to C6(H(6CC accreditation criteria. (t least one other planning committee member. $ach member of the planning committee must represent at least one of the follo-ing areas# relevant content expertise, the target audience, or adherence to C6(H(6CC accreditation criteria. @or each person listed on the +lanning Committee, please list name, degrees A credentials here. 1. ". /. <ournal Club @acilitator# 1iranda )ishop !6, )*6 4C5 (&+ +(C4 Clinical 6urse 2evel " <ournal Club !esearch 1entor# )arb Irumbach !6, 1*6, C6*, C+(6, CC!6, +erianesthesia Clinical $ducator C6*H$ducator F3esignated 2ead 6urse +lanner# )arb Irumbach !6, 1*6, C6*, C+(6, CC!6, +erianesthesia Clinical $ducator

60T$# ( bio form -ith the additional required information including expertiseHexperience and conflict of interest is !$J4&!$3 for (22 individuals listed on the planning committee. 'hich personFsG listed above has the relevant content expertise> 1iranda )ishop !6, )*6 'hich person FsG represents the target audience> 1iranda )ishop, !6, )*6, (&+ +(C4 'ho is the identified <ournal Club facilitator# 1iranda )ishop !6, )*6,

)" Edu&ational A&ti*ity (a&+$round Data A" Tar$et Audien&e and Needs Assess#ent
1. &dentify the target audience expected to attend# !6 0ther# &dentify =0ther? personnelK e.g., !T, +T, +harmacy, etc. . 60T$# it is required that !6 be checked since you are applying for nursing continuing education approval.

". Check best description of typeFsG of needs assessment used# FCheck all that applyG 'ritten 6eeds (ssessment 2earnersH1anagement !equested $vent Juality *tudiesH+erformance &mprovement (ctivities Trends in 2iterature, 2a- A 5ealth Care 0ther# 3escribe# ( <ournal Club is an important method for critiquing the research literature to advance nursing practice. /. @indings from needs assessment# Clinical registered nurses and other healthcare professionals need continued education on ho- to critique literature through Lournal club activities 8. (reas of needs assessment the activity -ill address# Maps in Ino-ledge *kills Maps in +ractice 0ther

,urpose o- edu&ational a&ti*ity This activity is for registered nurses and may include other healthcare
professionals to provide an opportunity to discuss a Lournal article and critique article content relevant to current practice.

(" Co.,ro*ider Status &f not co providing, initial N1K if yes, ans-er N" and N/.
". 1. This activity -ill not be co provided. &nitial# 1!) Co +rovidersship of this activity has been arranged -ith# F2ist organi;ation nameG "

/. (s the approved provider, -e -ill maintain responsibility for determination of obLectives and content, selection of content specialists and faculty, a-arding of contact hours, record keeping, evaluation and management of any sponsorship or commercial support. & have included a -ritten agreement -ith the co providerFsG -hich outlines the above and is signed by both parties.

D" Sponsors%ip and Co##er&ial Support &f no, initial N1. &f yes, complete items " "d belo-.
1. ". This activity has no commercial support. &nitial# 1!) Sponsorship or Commercial support has been provided by the follo-ing# F2ist name of organi;ationFsG providing commercial support.G a. Commercially supplied funds that are given in the form of an educational grant or in kind assistance are ackno-ledged Fplease provide a copyG )rochures +rinted 1aterial b. Content integrity has beenH-ill be maintained by# FCheck all that applyG 0ur commercial support policyHprocedure has been discussed -ith those providing commercial support. 0ur commercial support policyHprocedure has been shared in -riting -ith those providing commercial support. @aculty has been informed of our policyHprocedure re# commercial support. The session -ill be monitored A violators of policy -ill not be asked to present again. 0ther# 3escribe# c. The follo-ing precautions have been taken to prevent bias in the educational content. 0ur position on commercial support and bias has been discussed -ith each presenter. $ach presenter has signed a statement that says sHhe -ill present information fairly and -ithout bias. The session -ill be monitored A violators of policy -ill not be asked to present again. 0ther# 3escribe# d. *igned sponsorshipHcommercial support agreement attached.

E" Re&ord /eepin$

(ll correspondence# complete copy of documentation form, all attachments, records of attendance, summative evaluations, and contact hours -ill be maintained in a retrievable file -hich is accessible to only authori;ed personnel for six years according to policy. !ecords -ill be filed and stored at Flist locationG +rofessional !esources

0" Edu&ational Desi$n Data

(. @acultyHpresentersHauthors , in addition to listing names belo- A on p. O per obLectiveHcontent area, attach the
completed bio form for each presenterHauthor. 1. <ournal Club @acilitatorH+resenter, degrees and credentials#

1iranda )ishop, !6, )*6, 4C5 (&+ +(C4 clinical nurse

". <ournal Club !esearch 1entor, degrees and credentials#

)arb Irumbach !6, 1*6, C6*, CC!6, C+(6, +erianesthesia Clinical $ducator
/. 8. )io forms -ith expertise, conflict of interest, conflict resolution A off label use declaration for each presenterHfacilitator has been attached. 6eeded qualifications of selected faculty -ere ensured by# !evie- biographical data information &ntervie- or revie- of publications /

0ther

). $ducation 3esign @orm F(ppendix 3 page CG#

1. !" Ob1e&ti*es &ndicate -hat the learner -ill be able to do at the conclusion of the activity. (n average of 1 " obLectives per hour is realistic. &ndicate applicability to each member of the target audience if the obLective deals -ith hands on clinical practice Fi.e. demonstrate, etc.G. +lease number each obLective consecutively" Ob1e&ti*es #ust use be%a*ioral 2ords3 su&% as 4re*ie235 or 4dis&uss5" ,lease re-er to t%e -or# in&luded in t%is se&tion t%at outlines 2%at are t%e proper be%a*ioral ob1e&ti*e lan$ua$es" Content 2ist the content for each obLective. &t must be more than a restatement of the obLective and must flo- from the obLective. 6umbering should be consistent -ith the related obLective.

".
a.

)" Ti#e Fra#e D: ,minutes 0" Tea&%in$.Learnin$ Strate$ies 0pen forum discussion and revie- of article in group discussion 6" Fa&ulty 1iranda )ishop !6, )*6, 4C5 (&+ +(C4 clinical nurse level "K )arb Irumbach !6, 1*6, C6*, CC!6, C+(6, +erianesthesia Clinical $ducator PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP.

C. $valuation#
1. Check or describe the methods of evaluation to be used# FCheck all that applyG $valuation @orm +re andHor +ost test !eturn 3emonstration Structured Interview Direct Observation of skill performance 0ther# 3escribe# (ttach a copy of the evaluationFsG tool to be used for this event. The evaluation tool should include all of the ob ectives on the !ducation "esign #orm$ and evaluation of each faculty member. %see sample at the end of this section& The category of evaluation to be used for this activity# FCheck all that applyG 2earner satisfaction Ino-ledge enhancement *kill and attitude change Change in practiceHperformance !elationship of the practice change to quality of service Check the best description or describe ho- evaluation data -ill be used# !efine future presentations of this course. Create ne- programs. 3iscontinue the activity. 3ecide -hether or not to change this faculty or facility. 0ther# 3escribe# 2earner @eedback# Check the best description or describe ho- learners -ill be provided feedback. Juestion and ans-ers during activity. !eturn results of testing +rovide certificate @ollo- up communication 0ther# 3escribe# 8

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8.

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3. %erifying +articipation and *uccessful Completion

1. ". (ttendanceHparticipation -ill be verified at the event through sign in sheetsHregistration form. 0ther# 3escribe#

Criteria for successful completion include# FCheck all that applyG (ttendance at entire event (ttendance at least C:Q of event CompletionHsubmission of evaluation form (chieving passing score on post test 0ther# 3escribe# 3. Rationale for judging successful completion Session is one hour in length. It is e!pected that participants will stay for the entire presentation for successful completion.

$. 3ocumentation of completion
4pon approval, the 3epartment of +rofessional !esources -ill provide a copy of the certificate, -hich -ill include the name of the learner, number of contact hours a-arded, name and address of the provider of the educational activity, title, expiration date, and date of the activity.

@. 3isclosures to $ducational (ctivity +articipants

1. 2earners -ill be informed of criteria for successful completion by# &nformation on advertising material %erbal statement at beginning of activity 'ritten information on handouts 0ther# 3escribe# 2earners -ill be informed of conflicts of interest or lack thereof for planners and presenters by# F60T$# 6ot applicable is not an acceptable responseG (nnouncement at beginning of session This option must be documented in -riting that it occurred by a representative of the provider -ho attended the event. 6ame of the person -ho -ill do this# 1iranda )ishop, !6 )*6 Clinical 6urse 2evel " &nformation provided on advertising. &nformation provided on handouts. *igns placed inside or outside of presentation room. 0ther# 3escribe# 2earners are informed of sponsorshipHcommercial support by# (nnouncement at beginning of session Itemi"e the content of the disclosed information This option must be documented in -riting that it occurred by a representative of the provider -ho attended the event. 6ame of the person -ho -ill do this# &nformation provided on advertising. &nformation provided in handouts. *igns placed inside or outside of presentation room. 2earners are informed of non endorsement of products if commercial support received. 6o commercial support being received for this event. &nformation provided on advertising. &nformation provided in handouts. %erbal statement made at the beginning of the session. 0ther# 3escribe# $earners are made aware of any relevant financial relationships %o financial relationships e!ist O

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8.

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%ame of individual&s'( nature of relationship with commercial interest D. 2earners are informed of discussion of off label use by faculty by# @aculty has attested that they -ill not discuss off label usage of products. F6o statement needs to be madeG @aculty -ill state at the beginning of their session that there -ill be discussion of off label use of products. &nformation -ill be provided in the handouts. 0ther# 3escribe# $xpiration 3ate for (-arding Contact hours for endurable and educational documents. This must appear on all marketing and educational material. @inal 3ate contact hours -ill be a-arded )*)3*+,

B.

H M. Contact 5our Calculation#

&f live Lournal club, the time frames content outline pages must match and must support the number of contact hours requested. Calculation is based D: minutes equals one contact hour. D: minutesHD: R 1.: &f virtual Lournal club# this is a packaged program. Contact hours -ere calculated by piloting the time a participant takes to read the article, complete the critique form and participate in the blog. The participant has one month to complete the Lournal club. 'hen the participant completes the critique form and is identified as completing the Lournal club, an evaluation form is submitted to presenter, and presenter sends the C$ Certificate via return email. D: minutesHD: R 1.:

5. (dvertising 1aterial
(ttach a copy of the advertising material including relevant pages of the -eb site Fif applicableG. Type of advertising# @lyerHbrochure 1emoH2etter 1eeting 6otice $ mail 'eb site 0ther# 3escribe#

Course Evaluation Form Title: Journal Club: =(nalgesia and pulmonary function after lung surgery# is a single intercostal nerve block plus patient controlled intravenous morphine as effective as patient controlled epidural anesthesia> ( randomi;ed non inferiority clinical trial? Date: 2/23/2014 Location: UC !"# #!CU Journal Club $eetin%

"nstructions: #lease com&lete t'e (ollo)in% statement b* circlin% t'e one number t'at +escribes *our ratin%. T'e ratin% scale ran%es (rom 1 to 4, )'ere 1 - &oor. 2 - (air. 3 - %oo+. an+ 4 - e/cellent. #ur&ose/0oal o( t'is activit*: This activity is for registered nurses and may include other healthcare professionals to provide an opportunity to discuss a Lournal article and critique article content relevant to current practice. #oor 1. To )'at e/tent +i+ t'e ob1ectives relate to t'e overall &ur&ose2 2. To )'at e/tent 'ave *ou ac'ieve+ t'e overall ob1ectives o( t'is course2 a. Discuss t'e article ri%or an+ relevance (or learnin%. b. 3evie) in(ormation &rovi+e+ in t'e 1ournal article an+ a&&lication to current UC &ractice. 1 1 2 2 3 3 4 4 1 Fair 2 0oo+ 3 E/cellent 4

3. Evaluate $iran+a 4is'o& on t'e (ollo)in% criteria. a. E/&ertise o( sub1ect matter b. !&&ro&riate use o( teac'in% strate%ies

1 1

2 2

3 3

4 4

4. T'e overall &ro%ram )as2 Comments:

C5U36E DE6C3"#T"57 F53$ EDUC!T"57!L 6E66"57 T"TLE: =(nalgesia and pulmonary function after lung surgery# is a single intercostal nerve block plus patient controlled intravenous morphine as effective as patient controlled epidural anesthesia> ( randomi;ed non inferiority clinical trial? 54JECT"8E6 C57TE7T 9To&ics: T"$E F3!$E F!CULT; TE!C "70 $ET 5D96:
List 91, 2, 3, etc.: ob1ectives in com&etenc* or be'avioral terms. 5b1ectives s'oul+ be measurable. List 91, 2, 3, etc.: eac' to&ic area to be covere+ an+ &rovi+e a +etaile+ outline o( t'e content to be &resente+. "76E3T T;#E 5F J5U37!L CLU4 ;5U !3E 5LD"70 9e.%. s*stematic revie), Aualitative or Auantitative researc', non?researc' revie): 3evie) a Auantitative article. 8irtual Journal Club : Facilitator )ill &ose Auestions (or an interactive virtual +ialo%ue Cloc< re(erence+, inclu+in% 43E!=6 an+ LU7C 9i.e., 0>00? 0>1@:. 1300?1330 List t'e (acult* &erson or &resenter (or eac' to&ic. #LE!6E C EC= TE!C "70 $ET 5D T !T !##L"E6 T5 ;5U3 !CT"8"T;.

1.: Discuss t'e article ri%or an+ relevance (or learnin%.

$iran+a 4is'o& 37, 467 Clinical 7urse Level 2

3 Live Journal Club : Facilitator )ill &ose Auestions (or an interactive +ialo%ue

3evie) in(ormation &rovi+e+ in t'e 1ournal article an+ a&&lication to current UC &ractice.

T "6 6ECT"57 $U6T 4E C5$#LETED B"T ! 6 53T DE6C3"#T"57 5F =E; #5"7T6. a.Conce&ts o( anal%esia an+ &ulmonar* (unction a(ter lun% sur%er* b.3evie) o( literature c. 3esults o( stu+* : intercostal nerve bloc< )it' #C! vs. #CE! +. !&&lication to current UC &ractice

1330?1400

$iran+a 4is'o& 37, 467, Clinical 7urse Level 2

3 Live Journal Club 3evie) : Facilitator )ill monitor an+ summariCe +iscussion an+ recommen+ations base+ on &artici&ant +iscussion. 8irtual Journal Club 3evie) : Facilitator )ill monitor blo% an+ &ost a summar* o( t'e blo% +iscussion an+ recommen+ations (or &ractice base+ on &artici&ant blo%s.

SO*E #OSSI-LE 4ER-S .OR USE IN DE4ELO#IN5 -E)A4IORAL O-JECTI4ES ! leaner ob1ective +escribes t'e be'avior o( t'e learner at t'e com&letion o( a Continuin% E+ucation !ctivit*. T'e ob1ective must be measurable an+ +emonstrate T'at learnin% 'as ta<en &lace, i.e. 1. List 3 reasons (or t'e nee+ (or &ersonal mal&ractice insurance. 2. "+enti(* 2 e((ective listenin% tec'niAues. 3. 6tate t'e 4 &riorities (or care in t'e mana%ement o( a &atient ma1or trauma.
Evaluation Synt,"sis Analysis Application Co%pr","nsion !no6l"dg" +e(ine re&eat list recall name relate un+erline translate restate +iscuss +escribe e/&lain e/&ress i+enti(* locate re&ort revie) tell inter&ret a&&l* em&lo* use +emonstrate +ramatiCe &ractice illustrate o&erate sc'e+ule s'o& s<etc' +istin%uis' anal*Ce +i((erentiate a&&raise calculate e/&eriment test com&are contrast criticiCe +ia%ram ins&ect +ebate inventor* Auestion relate solve e/amine cate%oriCe com&ose &lan &ro&ose +esi%n (ormulate arran%e assemble collect construct create set u& or%aniCe mana%e &re&are 1u+%e a&&raise rate com&are revise score select c'oose assess estimate measure

-",avior 7ords t,at Ar" Not *"asura l" <no) un+erstan+ a&&reciate become a)are o( %ras& t'e si%ni(icance o( learn increase en1o* reco%niCe communicate im&lement believe motivate