INFORMATION/INSTRUCTIONS: PLEASE READ CAREFULLY

Processing may take up to 30 days. Please plan accordingly.

CPPN will not advertise nor take registrations for any educational activity until planning form is completely processed.

COURSE REQUIREMENTS:

When planning form is completed, submit to hs-cppn@ucdavis.edu

All components of the (1) planning form, (2) course agenda, and (3) all biographical/conflict of interest forms for presenters and planning committee members are required to be submitted to start processing.

CPPN will not publish nor take registration for a course until the planning form has been endorsed.

Continuing Education (CE) contact hours are provided for a three-year period. To offer the same course after that date, the coordinator must submit a new CE planning form.

IF ANCC COURSE CREDIT DESIRED:

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

CPPN Nurse Planner needs to be involved in the planning of the course from the beginning. Please contact hs-cppn@ucdavis.edu to discuss. ANCC credit cannot be awarded if CPPN Nurse Planner is not involved in planning from the beginning.

Content must be beyond the basics of general nursing information.

Cannot be a skills day or unit-based class.

All ANCC required information must be included in planning form.

SIMULATION TRAINING

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

COURSE CONTENT

The content of all CE courses must be relevant to the practice of registered nursing.

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

Credit cannot be offered for completing part of a course.

Blended Learning or e-Learning must have expiration dates for the enduring or online materials.

BRN Requirement (NEW): all CE courses that contain any direct patient care component must include curriculum on implicit bias (“implicit bias” is defined as the attitudes or internalized stereotypes that affect our perceptions, actions, and decisions in an unconscious manner, that exist and often contribute to unequal treatment of people based on race, ethnicity, gender identity, sexual orientation, age, disability, and other characteristics that contribute to health disparities). CPPN cannot provide CE credit for courses that fail to meet this requirement. Courses with a direct patient care component must address at least one, or a combination, of the following:

Examples of how implicit bias affects perceptions and treatment decisions of licensees, leading to disparities in health outcomes.

Strategies to address how unintended biases in decision-making may contribute to health care disparities by shaping behavior and producing differences in medical treatment along lines of race, ethnicity, gender identity, sexual orientation, age, socioeconomic status, or other characteristics.

Course content related to direct patient care can include but is not limited to: patient education strategies; therapeutic interpersonal relationship skills with patients/clients; certification/recertification skills (e.g., advanced life support, audiology, etc.); skills courses (stoma care, etc.); advanced courses on any type of patient monitoring equipment (fetal, cardiac, respiratory, etc.); cultural and ethnic diversity; foreign languages (conversational) and sign language; and courses in any specialty area of nursing practice including occupational health nursing, school nursing, office nursing, etc.

Content related to indirect patient care can include but is not limited to: nursing administration or management, nursing education, or nursing research; statistics; quality assurance; legal aspects of nursing; assertiveness; teaching multi-ethnic students and staff; retention of nurses in the health care delivery system, including cross training; current trends in nursing and health care; publishing for professional journals or books; and instructor courses in CPR, basic life support (BLS), and advanced life support (ALS).

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

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

Examples of non-acceptable courses include CPR, orientation programs, equipment in-services, basic nursing skills or review of basic nursing care procedures courses focusing on self-improvement (i.e., self-awareness, yoga, weight loss, etc.), economic courses geared for personal financial gain (i.e., preparing resumes, job interviewing techniques, etc.), and courses for the lay public (i.e., parenting courses, etc.).

TWO LEVELS OF CPPN SUPPORT:

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

Note: For all CPPN-based courses, there is a base deposit of $25 for UCDH employees and a fee per hour charged for non-employees. Registration cost varies depending on length, catering needs, honorariums, etc. This is determined by CPPN.

Unit-based courses, which means opened to only a select group/unit of staff only to attend, and no pre-registration nor deposit required. CPPN supplies in advance blank rosters and evaluation forms only.

COURSE FEES

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

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

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

Return entire form and direct questions to:

hs-cppn@ucdavis.edu

Title of Activity: Click here to enter text.
TO BE COMPLETED BY CPPN
Date received: Click here to enter a date.	Consent to provide course date: Click here to enter a date.	Renewal date: (3 years from consent to provide course) Click here to enter a date.
Course Code: Click here to enter text.
Contact Hours: Click here to enter text.
Type: ☐ CPPN Course ☐ Unit-Based Course
Planning form reviewed and meets BRN regulatory criteria. CPPN Consent to provide course: Click here to enter text.
Planning form reviewed and meets ANCC regulatory criteria. CPPN Nurse Planner Consent to provide course: Click here to enter text.
ANCC Course CPPN Nurse Planner: Click here to enter text.	CPPN Coordinator: Click here to enter text.

CPPN Nurse Planner and Analyst Notes:

Required for ANCC Courses

Suggested for all courses

For more information on Gap Analysis, see worksheet information at end of planning form

Title of Activity: Click here to enter text.
Desired State (or best practice)	Current State (current practice, target audience)	Data that Validates Professional Practice Gap and Current State (gap is difference between desired and current state)	Underlying Educational Need (knowledge, skills, and/or practice)	Outcome Measure(s) (specific, attainable, quantitative statement as to how the outcome will be measured)	Evaluation Method(s) (aligned with Professional Practice Gap, underlying need, and outcome)

Course Code: (entered by CPPN)
Submitter’s Contact Information
Submitted By (Name, Degree, Credentials, Title): Click here to enter text.
Department: Click here to enter text.
Telephone: Click here to enter text.	UCDH email address: Click here to enter text.
ANCC – CPPN Nurse Planner: Click here to enter text.
CPPN Course Coordinator: Click here to enter text.
Location: Click here to enter text.
Maximum # participants for Activity: Click here to enter number.
Activity Type: (Choose one that applies) ☐ Provider-directed, provider-paced: Live (in-person or webinar) Initial Date of live activity: Click here to enter a date. Additional Dates: Click here to enter text. ☐ Provider-directed, learner-paced: Enduring material (i.e.; e-course or journal review) Start date of enduring material: Click here to enter a date. Review/expiration date of enduring material (maximum: 3 years after creation): Click here to enter a date. ☐ Blended activity Date(s) of enduring materials (e.g. prework): Click here to enter a date. Date of live portion of activity: Click here to enter a date. Review/expiration date of enduring material (maximum: 3 years after creation): Click here to enter a date.
Course Start Time: Click here to enter text.	Course End Time: Click here to enter text.
Brief Course Description for website posting. Include attendance requirements, need to wear scrubs/work attire, prerequisites, etc.: Click or tap here to enter text.
Professional Practice Gap: (required for ANCC courses) Identified Professional Practice Gap: (What learning need are you fulfilling?) Click or tap here to enter text. Data/Evidence to validate the Professional Practice Gap (check all methods/types of data that apply): ☐ Survey data from stakeholders, target audience members, subject matter experts, or similar ☐ Input from stakeholders such as learners, managers, or subject matter experts ☐ Evidence from quality studies and/or performance improvement activities to identify opportunities for improvement ☐ Evaluation data from previous education activities ☐ Trends in literature, law, and health care ☐ Direct observation ☐ Other—Describe: Click here to enter text. Educational need that underlies the Professional Practice Gap (e.g., knowledge, skill, and/or practice) ☐ Gap in Knowledge ☐ Gap in Skills ☐ Gap in Practice
Audience Description of Target Audience (RNs, Adv Pract. RNs, MDs, Resp Ther., etc.):
Registration opened to:	☐ Open to all who match target audience	☐ UC Davis Employee only	☐Unit (Group), specify:
Level of CPPN support requested: Review “Two Levels of CPPN Support” on page 2 of form	☐ CPPN-based course	☐ Unit-based course
Outcomes Measure(s): (required for ANCC courses) Desired outcome measure(s) for activity: Click here to enter text.
Description of Evaluation Method Evidence that change in knowledge, skills, and/or practices of target audience was assessed: Click here to enter text.
Short-term evaluation options: ☐ Intent to change practice ☐ Active participation in learning activity ☐ Post-test ☐ Return demonstration ☐ Case study analysis ☐ Role-play ☐ Other – Describe: Click here to enter text.	Long-term evaluation options: ☐ Self-reported change in practice ☐ Change in quality outcome measure ☐ Return on investment (ROI) ☐ Observation of performance ☐ Other – Describe: Click here to enter text.
Implicit Bias Inclusion into Content: (NEW requirement for ALL courses) Select from list how this course will meet the BRN requirement of including curriculum on implicit bias into all courses that contain any direct patient care component. At least one box must be selected AND description provided. ☐ Course does NOT contain any direct patient care component (i.e., solely leadership, research, etc.) ☐ Provides examples of how implicit bias affects perceptions and treatment decisions of healthcare providers, leading to health outcome disparities. Describe: Click here to enter text. ☐ Provides strategies to address how unintended biases in decision-making may contribute to healthcare disparities (by shaping behavior and producing differences in medical treatment along lines of race, ethnicity, gender identify, sexual orientation, age, socioeconomic status, or other characteristics. Describe: Click here to enter text.
Learner Engagement Strategies Select from list the learner engagement strategies that will be employed:
☐ Discussion ☐ Question/Answer or Socratic Questioning ☐ Storytelling/Narrative ☐ Reflection ☐ Demonstration/Return Demonstration ☐ Group Work ☐ Case Study Analysis ☐ Role Play	☐ Gamification ☐ Simulation ☐ Problem-based Learning ☐ Self-Learning Module ☐ Blended Learning/Flipped Classroom ☐ Concept mapping ☐ Other – Describe: Click or tap here to enter text.
Criteria for Awarding Contact Hours Criteria for awarding contact hours for live and enduring material activities include: ☒ No contact hours awarded if late to activity as described in course description; must attend all sessions (required) ☐ Successful completion of a post-test (attendee must score Click here to enter text. % or higher) ☐ Successful completion of a return demonstration ☐ Successful completion of required eLearning (i.e.; Pre-Study) ☐ Completion/submission of evaluation form (must collect evaluation form from every participant) ☐ Other - Describe: Click here to enter text.

List of Individuals in a Position to Control Content
Complete the table below for each person in a position to control content of the educational activity (e.g., nurse planners, planning committee members, speakers/presenters, and content reviewers). For each individual, include name, credentials, educational degree(s), and role in the activity. Each person must submit a complete Biographical and Conflict of Interest form that validates their expertise to fulfill their respective role (annually for ongoing courses). Required for ANCC courses: There must be one Nurse Planner from CPPN who is knowledgeable of the nursing continuing professional development processes and is responsible for adherence to ANCC criteria. There must be one Nurse Planner and one other planner to plan each educational activity. At least one planner needs to have appropriate subject matter expertise for the educational activity being offered (Content Expert). The individuals who fill the roles of Nurse Planner and Content Expert must be identified. Every person on list must complete a Biographical and Conflict of Interest (COI) form.
Name of individual and credentials (i.e., John Smith, MSN, RN, CCRN)	Individual’s role in activity Nurse Planner, Planning Committee, Content Reviewer, Presenter	Planning committee member? (Yes/No)	Name of commercial interest	Nature of relationship to the commercial interest (i.e., speaker bureau, stockholder, CEO, etc.)	COI form completed

Educational Planning Table
Content (Topics) Provide a short outline of the content/topic presented. Include reference/resources used to develop content (may be as additional reference sheet)	Objectives Minimum of 2, Maximum of 5, learning objectives for content. Use Bloom’s Taxonomy to write objectives (i.e., describe, discuss, apply, analyze, evaluate, examine, etc.).	Time Frame in minutes Must match provided course agenda	Presenter List presenter(s) name, credentials, degrees for each topic/content area. Each presenter must submit a COI/Bio form	Learning Strategies List the learning strategies for each topic or content area. Include learner engagement strategies.
Right click on last row to insert additional rows below as needed

References (Required for ANCC courses: content must be based on best available current evidence to foster achievement of desired outcomes)

List here or provide additional reference sheet when submitting form):

All the following should be sent to CPPN for attachment to final course document.
Attachment 1	Agenda (for each course date if changes)
Attachment 2	All Conflict of Interest forms
Attachment 3	Commercial Support Agreement with signatures and date, if applicable
Attachment 4	Course Materials/All Presentations (with repeated classes, note version if changed from initial)
Attachment 5	Course Advertisements (save the dates/course flyers/PDF of web page)
Attachment 6	Course Evaluation forms
Attachments to be supplied by CPPN
Attachment 1	Document of completion certificate
Attachment 2	Summative evaluation
Attachment 3	Evidence of required information provided to learners: Materials associated with the activity (marketing materials, advertising, agendas, and certificates of completion) must clearly indicate the Provider awarding contact hours and responsible for adherence to ANCC criteria) Accreditation statement of provider awarding contact hours Criteria for awarding contact hours Presence or absence of conflicts of interest for all individuals in a position to control content (e.g., the planning committee, presenters, faculty, authors, and content reviewers) Commercial support (if applicable) Expiration date (enduring materials only) Joint Providership (if applicable)

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

Requirements for completion of this program

Participant must sign in on official roster and be present for content presentation.

C.E. credit will not be awarded for this program session if the participant is more than:

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

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

Specific requirements for individual course:

Conflict of interest

Conflict of interest can exist when an individual has an opportunity to affect nursing continuing professional development content in relation to an ineligible company (previously termed commercial interest) in which they have a relevant financial relationship.

Unless indicated below, all planners and presenters associated with this program no relevant financial relationships with ineligible companies with relation to the content of this program.

Off label use

This educational activity does not include any unannounced information about off label use of a product for a purpose other than that for which it was approved by the Food and Drug Administration (FDA).

Potential Conflict of Interest Notification to Course Attendees (select one and describe as needed)

☐	There are no relevant financial relationships with ineligible companies (previously termed commercial interests) to disclose among planners, faculty, and everyone in control of content.

☐	Relevant financial relationships exist and are disclosed to learners below, including the names of individuals with relevant relationships, names of ineligible companies (previously termed commercial interests), the nature of relationships, and a statement that all relationships have been mitigated.

Click or tap here to enter text.

A gap analysis is an important tool during the beginning of an educational plan to take you from “I think I know what the problem is” to planning relevant professional development activities targeted to specifically address a clearly established professional practice gap, resulting in measurable outcomes. Analyzing a professional practice gap determines the gap between a current and desired state, underlying educational need(s), and activities needed to close the identified gap.

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

Describe the Current State, which is the current level of practice of the target audience.

Summarize the Data that Validates the Professional Practice Gap, or the difference between the current and desired state. Planners should use evidence to validate and support the need for an educational activity. This may include surveying stakeholders, reviewing quality data, direct observation, evaluations of other activities, trends in healthcare or literature, change in practice, etc. There should be analysis and not just data sources nor solely stating there is a “need” or “request” for the activity.

Now ask: What is underlying reason causing the gap? Is knowledge missing? Is a skill not being performed correctly? Is there a practice issue? What pieces are missing in the target audience?

The missing piece is the Underlying Educational Need to bridge between the current and desired state. Why do the learners need the education? The underlying need could be due to knowledge (don’t know), skill (don’t know how to do), and/or practice (not able to show or do in practice). This should align with the professional practice gap, evidence, and outcome measure(s).

Develop an Outcome Measure that is specific, measurable, and attainable, written as a quantitative statement. What should the learner know, show, and/or be able to do at the end of the activity? This should be aligned to the current state, underlying educational need, and evaluation method. For instance, if the underlying need is knowledge, the outcome should be related to measuring a change in the learner’s knowledge.

Describe the Evaluation Method, or how the activity’s outcome will be measured, including how evaluation data will be obtained and analyzed. This should be aligned with the professional practice gap, underlying need, and outcome measure(s). This can include short-term and/or long-term methods. For instance, you can use post-tests or discussion to assess knowledge; return demonstrations or case study analysis can assess skill; and simulation, observation in practice, or quality measure tracking can assess practice.

Title of Activity: EXAMPLE
Desired State (or best practice)	Current State (current practice, target audience)	Data that Validates Professional Practice Gap (gap is difference between desired and current state)	Underlying Educational Need (knowledge, skills, and/or practice)	Outcome Measure(s) (specific, attainable, quantitative statement as to how the outcome will be measured)	Evaluation Method(s) (aligned with Professional Practice Gap, underlying need, and outcome)
At least 50% of perioperative nurses in health system will hold a recognized specialty certification by passing exam	30% of the perioperative nurses have obtained a recognized specialty certification.	Survey of perioperative nurses both with certification and without identified that >75% of nurses state they are unprepared to sit for and pass the certification exam (knowledge) and 60% state they lack test taking skills. Current literature trends show that employer-supported preparation programs increase passage rates.	Lack of knowledge and skills to pass a perioperative specialty certification exam.	Within 12 months, the number of perioperative nurses with a specialty certification will increase by at least 10%.	Knowledge and skill will be evaluated during the learning activity through active participation in discussion, case study analysis, and polling (short-term, formative evaluation) and through completing the specialty certification exam (long-term, summative evaluation).

Title of Activity: Click here to enter text.
Completed by CPPN	Explanation of planning form requirements – please direct any questions to hs-cppn@ucdavis.edu
Title of Activity: Should be specific to content; if course is part of a series should be differentiated by day (i.e., Day 1, Day 2, Part 1, Part 2., Pediatric Critical Care Day 1).
Location, Maximum Number of Participants, Course Start/End Time: Should be specific. This is what CPPN will post on the website and learning management system for course advertisement and participant communication.
Brief Course Description for website posting: This is what CPPN will post on the website for course advertisement. If there are any prerequisites or attendance requirements, please state clearly.
Professional Practice Gap Analysis: Should be complete for all courses (required for those requesting ANCC credit). Information concerning how and why course came about, the underlying educational gap (knowledge, skills, and/or practice), the outcome measure(s), and evaluation method(s) to which the course is aligned.
Audience: Who the course is targeted towards, and any restrictions on that audience (i.e., only from NICU, only RNs, only UC Davis employees, etc.). Indicate level of CPPN support requested.
Outcome Measure(s): What is the purpose of the learning, what outcome measures will be affected, or skill enhanced. Should be specific, measurable, attainable, aligned to practice gap, relevant, and time bound. Should reflect PCS or UCD Health strategic goals (i.e., the learners will increase their practice of post-cardiac catheterization patient care). Include quantitative statement. Quantitative Statement example: After the learning activity has initiated, there will be a decrease in length of stay for post-cardiac catheterization patients by at least 10% within 12 months.
Description of Evaluation Method(s): Indicate what type of evaluation, short- and/or long-term, that will reflect the change in knowledge, skills, and/or practice of the learner.
Implicit Bias Inclusion into Content: (NEW requirement for ALL courses) All CE courses that contain any direct patient care component must include curriculum on implicit bias. Select and describe how this course will meet this BRN requirement (i.e., does not contain any direct patient care component, will provide examples of how implicit bias affects perceptions and treatment decisions of licensees, leading to disparities in health outcomes, and/or will provide strategies to address how unintended biases in decision-making may contribute to healthcare disparities (by shaping behavior and producing differences in medical treatment along lines of race, ethnicity, gender identify, sexual orientation, age, socioeconomic status, or other characteristics).
Learner Engagement Strategies: List strategies you plan to use to engage learners.
Criteria for Awarding Contact Hours: List any criteria beyond attending the class in full.
Conflict of Interest: All persons in a position to control the content of the educational activity are required to complete the Biographical and Conflict of Interest Form. Planning forms will not be processed until all forms are completed and attached to planning form.
Educational Design: Content/Topics – What information will be covered by presenter? Include references either with content or on separate reference sheets. Objectives – Written as to what the learner should be able to do, not what the speaker is going to talk about. “At the end of this session the learner will be able to…” (Understand is not an acceptable learning objective). Each 60 minutes of content should have minimum of 2 and maximum of 5 learning objectives. Use Bloom’s Taxonomy to assist you with writing learning objectives. If you need assistance with writing your objectives, contact: hs-cppn@ucdavis.edu Time Frame – Amount of time in minutes to present topic: 60. Not specific clock time 0800-0900. Specific times should be reflected in the class agenda. Presenter/Speaker – Name, Credentials, and Title of person(s) presenting Learner Strategies – How is the information going to be presented? Lecture only, Demonstration, Case Study Discussion, Group brainstorming, etc. Including learner engagement strategies is a best practice and will positively affect the activity and resulting knowledge, skills, practice change(s).