COLORADO NURSES ASSOCIATION/ANCC

Nursing Continuing Education Activity Application Journal Clu

!"y #olicy R"$uir"%"nts&
'( A UC) approv"d nurs" plann"r *UST " a l"ad in any CNE activity(
+( All progra%s *UST go t,roug, t,is approval proc"ss -E.ORE activity ta/"s plac"( 0#"r ANCC1
r"troactiv" approval is pro,iit"d(2
Dir"ctions&
1. Complete each question in all sections by using your mouse to move around and type. To check a box, simply move
your mouse pointer to the box and perform a singleleft click action. !epeat either of these actions to uncheck the box
if you need to do so.
". TO INSERT ADDITIONAL TEXT# Click on !$%&$' 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# Translating an $vidence)ased (lgorithm to 3ecrease $arly +ost0perative 4rinary !etention after
4rogynecologic *urgery
3ate of $vent# <ebruary "/, ":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 > Credentials# =o(nn 3el1onte, !6)C, 1*6
0rgani;ation# 4niversity of Colorado 5ospital
(ddress# 1"8:1 $. 1?
th
(ve
3aytime +hone 6umber including extension# ?":@8@AAB8 <ax 6umber# ?":@8@?/??
$mail address# =o(nn.3el1onte7uch.edu
1
(" Planning Committee: 1ust include a designated 2ead 6urse +lanner and a minimum of one other planner#
0ne C1D !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(E(6CC accreditation
criteria.
(t least one other planning committee member. $ach member of the planning committee must represent at least one of
the follo-ing areas# relevant content expertise, the target audience, or adherence to C6(E(6CC accreditation criteria.
<or each person listed on the +lanning Committee, please list name, degrees > credentials here.
1. =ournal Club <acilitator# !aelyn 6icholson !6, )*6, +CC6
". =ournal Club !esearch 1entor# )arbara Frumbach 1*6, !6, C+(6, CC!6
/. C6*E$ducator C3esignated 2ead 6urse +lanner# )arbara Frumbach 1*6, !6, C+(6, CC!6
60T$# ( bio form -ith the additional required information including expertiseEexperience and conflict of
interest is !$G4&!$3 for (22 individuals listed on the planning committee.
'hich personCsD listed above has the relevant content expertiseH !aelyn 6icholson !6, )*6, +CC6
'hich person CsD represents the target audienceH
!egistered 6urses in the (&+ +ost (nethesia Care 4nit, !aelyn 6icholson !6, )*6, +CC6
'ho is the identified =ournal Club facilitator# !aelyn 6icholson !6, )*6, +CC6
)" Edu&ational A&ti*ity (a&+$round Data
A" Tar$et Audien&e and Needs Assess#ent
1. &dentify the target audience expected to attend# !6 0ther# &dentify I0therJ personnelK e.g., !T, +T,
+harmacy, etc. .
60T$# it is required that !6 be checked since you are applying for nursing continuing education approval.
". Check best description of typeCsD of needs assessment used# CCheck all that applyD
'ritten 6eeds (ssessment
2earnersE1anagement !equested $vent
Guality *tudiesE+erformance &mprovement (ctivities
Trends in 2iterature, 2a- > 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 need continued education on ho- to critique literature through Lournal club activities.
8. (reas of needs assessment the activity -ill address#
Maps in Fno-ledge
*kills
Maps in +ractice
0ther

,urpose o- edu&ational a&ti*ity This activity is for registered nurses to provide an opportunity to discuss a
Lournal article and critique article content relevant to current practice.
(" Co.,ro*ider Status &f not coproviding, initial N1K if yes, ans-er N" and N/.
1. This activity -ill not be coprovided. &nitial# !6
". Co+rovidersship of this activity has been arranged -ith# C2ist organi;ation nameD

/. (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 coproviderCsD -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# !6
". Sponsorship or Commercial support has been provided by the follo-ing# C2ist name of organi;ationCsD
providing commercial support.D

a. Commercially supplied funds that are given in the form of an educational grant or inkind assistance are
ackno-ledged Cplease provide a copyD
)rochures
+rinted 1aterial
b. Content integrity has beenE-ill be maintained by# CCheck all that applyD
0ur commercial support policyEprocedure has been discussed -ith those providing commercial support.
0ur commercial support policyEprocedure has been shared in -riting -ith those providing commercial
support.
<aculty has been informed of our policyEprocedure re# commercial support.
The session -ill be monitored > 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.
$ach presenter has signed a statement that says sEhe -ill present information fairly and -ithout bias.
The session -ill be monitored > violators of policy -ill not be asked to present again.
0ther# 3escribe#
d. *igned sponsorshipEcommercial support agreement attached.
E" Re&ord /eepin$
(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 Clist locationD +rofessional !esources
0" Edu&ational Desi$n Data
(. <acultyEpresentersEauthors , in addition to listing names belo- > on p. O per obLectiveEcontent area, attach the
completed bio form for each presenterEauthor.
1. =ournal Club <acilitatorE+resenter, degrees and credentials#
!aelyn 6icholson, !6, )*6, +CC6
". =ournal Club !esearch 1entor, degrees and credentials#
)arbara Frumbach 1*6, !6, C+(6, CC!6
/. )io forms -ith expertise, conflict of interest, conflict resolution > offlabel use declaration for each
presenterEfacilitator has been attached.
8. 6eeded qualifications of selected faculty -ere ensured by#
!evie- biographical data information
&ntervie- or revie- of publications
0ther
/
). $ducation 3esign <orm C(ppendix 3page @D#
!" Ob1e&ti*es &ndicate -hat the learner -ill be able to do at the conclusion of the activity. (n average of 1" obLectives per
hour is realistic. &ndicate applicability to each member of the target audience if the obLective deals -ith handson clinical
practice Ci.e. demonstrate, etc.D. +lease number each obLective consecutively" Ob1e&ti*es #ust use be%a*ioral 2ords3 su&%
as 4re*ie235 or 4dis&uss5" ,lease re-er to t%e -or# in&luded in t%is se&tion t%at outlines 2%at are t%e proper be%a*ioral
ob1e&ti*e lan$ua$es"
2" Content 2ist the content for each obLective. &t must be more than a restatement of the obLective and must flo- from the
obLective. 6umbering should be consistent -ith the related obLective.
)" Ti#e Fra#e 2ist number of minutes for each obLective Cunless this is a packaged program or independent studyD. &nclude
breaks.
0" Tea&%in$.Learnin$ Strate$ies 2ist the delivery methods, strategies, learner feedback mechanisms, materials and
resources to be used by facultyEauthor to cover each obLective.
6" Fa&ulty 2ist the faculty -ho -ill be teaching each segment. .ou do not need to list the credentials since faculty has been
identified -ith credentials and bio forms in previous section.
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP.
C. $valuation#
1. Check or describe the methods of evaluation to be used# CCheck all that applyD
$valuation <orm
+re andEor +osttest
!eturn 3emonstration
Structured Interview
Direct Observation of skill performance
0ther# 3escribe#
". (ttach a copy of the evaluationCsD tool to be used for this event. The evaluation tool should include all of the obectives
on the !ducation "esign #orm$ and evaluation of each faculty member. %see sample at the end of this section&
/. The category of evaluation to be used for this activity# CCheck all that applyD
2earner satisfaction
Fno-ledge enhancement
*kill and attitude change
Change in practiceEperformance
!elationship of the practice change to quality of service
8. 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#
O. 2earner <eedback# Check the best description or describe ho- learners -ill be provided feedback.
Guestion and ans-ers during activity.
!eturn results of testing
+rovide certificate
<ollo-up communication
0ther# 3escribe#
8
3. %erifying +articipation and *uccessful Completion
1. (ttendanceEparticipation -ill be verified at the event through sign in sheetsEregistration form.
0ther# 3escribe#
". Criteria for successful completion include# CCheck all that applyD
(ttendance at entire event
(ttendance at least @:Q of event
CompletionEsubmission of evaluation form
(chieving passing score on posttest
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 $ducational (ctivity +articipants
1. 2earners -ill be informed of criteria for successful completion by#
&nformation on advertising material
%erbal statement at beginning of activity
'ritten information on handouts
0ther# 3escribe#
". 2earners -ill be informed of conflicts of interest or lack thereof for planners and presenters by#
C60T$# 6ot applicable is not an acceptable responseD
(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# .04! 6(1$ 5$!$
&nformation provided on advertising.
&nformation provided on handouts.
*igns placed inside or outside of presentation room.
0ther# 3escribe#
/. 2earners are informed of sponsorshipEcommercial 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.
8. 2earners are informed of nonendorsement 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
%ame of individual&s'( nature of relationship with commercial interest
A. 2earners are informed of discussion of offlabel use by faculty by#
<aculty has attested that they -ill not discuss offlabel usage of products. C6o statement needs to be madeD
<aculty -ill state at the beginning of their session that there -ill be discussion of offlabel use of products.
&nformation -ill be provided in the handouts.
0ther# 3escribe#
?. $xpiration 3ate for (-arding Contact hours for endurable and educational documents. This must
appear on all marketing and educational material. <inal 3ate contact hours -ill be a-arded )ebruary *3( *+,-
M. Contact 5our Calculation#
&f live Lournal club, the time frames content outline pages must match and must support the number of contact hours
requested. Calculation is based A: minutes equals one contact hour.
A: minutesEA: R 1.:
&f virtual Lournal club# this is a packaged program. Contact hours -ere calculated by piloting the time a participant takes
to read the article, complete the critique form and participate in the blog. The participant has one month to complete the
Lournal club. 'hen the participant completes the critique form and is identified as completing the Lournal club, an evaluation
form is submitted to presenter, and presenter sends the C$ Certificate via return email.
A: minutesEA: R 1.:
5. (dvertising 1aterial
(ttach a copy of the advertising material including relevant pages of the -eb site Cif applicableD.
Type of advertising#
<lyerEbrochure
1emoE2etter
1eeting 6otice
$mail
'eb site
0ther# 3escribe#
A
Course Evaluation Form
Title: Translating an Evidence-Based Algorithm to Decrease Early Post-Operative rinary !etention a"ter
rogynecologic #urgery
Date: Fe$raury %&' %()* +ocation: )),() East Cornell Circle
Aurora' CO ,(()*
-nstructions: Please complete the "ollo.ing statement $y circling the one num$er that descri$es your rating. The
rating scale ranges "rom ) to *' .here ) / poor0 % / "air0 & / good0 and * / e1cellent.
Purpose23oal o" this activity: 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.
Poor Fair 3ood E1cellent
). To .hat e1tent did the o$4ectives relate to the overall purpose5 ) % & *
%. To .hat e1tent have you achieved the overall o$4ectives o" this
course5
a. Discuss the article rigor and relevance "or learning.
) % & *
$. !evie. in"ormation provided in the 4ournal article and
application to current C6 practice.
) % & *
/. Evaluate !aelyn 7icholson on the "ollo.ing criteria.
a. E1pertise o" su$4ect matter
) % & *
$. Appropriate use o" teaching strategies
) % & *
*. The overall program .as5 ) % & *
Comments:
?
CO!#E DE#C!-PT-O7 FO!8
EDCAT-O7A+ #E##-O7 T-T+E: Translating an Evidence-Based Algorithm to Decrease Early Post-Operative rinary !etention a"ter rogynecologic #urgery
OB9ECT-:E# CO7TE7T ;Topics< T-8E F!A8E FAC+T= TEAC6-73 8ET6OD;#<
+ist ;)' %' &' etc.< o$4ectives in competency
or $ehavioral terms. O$4ectives should $e
measura$le.
+ist ;)' %' &' etc.< each topic area to $e covered and
provide a detailed outline o" the content to $e
presented.
Cloc> re"erenced'
including B!EA?# and
+7C6 ;i.e.' (@((-
(@)A<.
+ist the "aculty person or
presenter "or each topic.
P+EA#E C6EC? TEAC6-73
8ET6OD T6AT APP+-E# TO
=O! ACT-:-T=.
Discuss the article rigor and relevance "or
learning.
-7#E!T T=PE OF 9O!7A+ C+B =O A!E
6O+D-73 ;e.g. systematic revie.' Bualitative or
Buantitative research' non-research revie.<
!evie. a Buantitative research article.
)%((-)%&( !aelyn 7icholson !7' B#7'
PCC7
Liv" Journal Clu &
Facilitator .ill pose Buestions "or
an interactive dialogue
:irtual 9ournal Clu$ :
Facilitator .ill pose Buestions "or
an interactive virtual dialogue
!evie. in"ormation provided in the 4ournal
article and application to current C6
practice.
T6-# #ECT-O7 8#T BE CO8P+ETED C-T6 A
#6O!T DE#C!-PT-O7 OF ?E= PO-7T#.
a. A"ter implementing an algorithm' there .as a
statistically signi"icant improvement in voiding
e""iciency and a reduction o" urinary retention in
the studyDs urogynecologic population.
$. The study .as limited due to insu""icient
num$ers and reBuires ongoing analyses.
c. #tandardiEing practice creates consistency and
possi$ly improves patient outcomes.
d. Application to current practice.
)%&(-)&(( !aelyn 7icholson !7' B#7'
PCC7
Liv" Journal Clu R"vi"3 &
Facilitator .ill monitor and
summariEe discussion and
recommendations $ased on
participant discussion.
:irtual 9ournal Clu$ !evie. :
Facilitator .ill monitor $log and
post a summary o" the $log
discussion and recommendations
"or practice $ased on participant
$logs.
@
SO*E #OSSI-LE 4ER-S .OR USE IN DE4ELO#IN5 -E)A4IORAL O-JECTI4ES
A leaner o$4ective descri$es the $ehavior o" the learner at the completion o" a
Continuing Education Activity. The o$4ective must $e measura$le and demonstrate
That learning has ta>en place' i.e.
). +ist & reasons "or the need "or personal malpractice insurance.
%. -denti"y % e""ective listening techniBues.
&. #tate the * priorities "or care in the management o" a patient ma4or trauma.
Evaluation
Synt,"sis
Analysis 4udge
Application compose appraise
Co%pr","nsion distinguish plan rate
!no3l"dg" interpret analyEe propose compare
translate apply di""erentiate design revise
de"ine restate employ appraise "ormulate score
repeat discuss use calculate arrange select
list descri$e demonstrate e1periment assem$le choose
recall e1plain dramatiEe test collect assess
name e1press practice compare construct estimate
relate identi"y illustrate contrast create measure
underline locate operate criticiEe set up
report schedule diagram organiEe
revie. shop inspect manage
tell s>etch de$ate prepare
inventory
Buestion
relate
solve
e1amine
categoriEe
-",avior 6ords t,at Ar" Not *"asural"
>no. learn communicate
understand increase implement
appreciate en4oy $elieve
$ecome a.are o" recogniEe motivate
grasp the signi"icance o"
B