Montana Nurses Association

What’s an example of a role description for the Primary Nurse Planner (PNP) and Nurse Planner (NP)?

When you complete your provider application, you are asked to provide us with position descriptions for two roles in your provider unit: PNP and NP. Many people who fill those roles also have other formal position descriptions within their organizations – some of you, for example, are department directors as well as PNPs. For purposes of assessing adherence to ANCC Accreditation Criteria for continuing education, our reviewers need to know the qualifications and roles specific to your functioning as primary or NP, regardless of other positions you may hold in your organizations. Please do not submit your formal “job description” unless it is specific to the PNP or NP role.

Here are generic examples of the two position descriptions. You can use these as guidelines, but please be sure to modify them to fit your own unique circumstances.

Approved Provider Unit PNP

• Description: The PNP is a member of the Education Department staff who is responsible for the management of continuing nursing education activities delivered by the organization. The PNP is responsible for leadership of the approved provider unit, including adherence to requirements and criteria related to the provider unit itself (structural capacity and quality outcomes) as well as ensuring that the organization consistently meets or exceeds criteria for the educational design process. The PNP chairs the organization’s Education Committee and facilitates the work of other NPs and key personnel in the provider unit.
• Qualifications: The PNP must have a minimum of a baccalaureate degree in nursing and a current, unrestricted nursing license. An advanced degree in nursing, education, and/or administration is highly preferred. The incumbent must have experience in adult learning (patient teaching, staff development, or faculty roles, for example) and knowledge of ANCC accreditation program criteria for continuing nursing education. Certification in nursing professional development is required at time of hire or within 2 years of assuming the PNP role.
• Accountability: As the leader of the Approved Provider Unit, the PNP is accountable to the Accredited Approver Program Director of the Montana Nurses Association, our accredited approver. As a member of the education department staff and Chair of the Education Committee, the PNP reports to the VP of Professional Development. Collateral accountability addresses ad hoc relationships with other areas, such as administration, quality improvement, human resource development, and finance as needed to carry out and evaluate the work of the Approved Provider Unit.

Approved Provider Unit NP

• Description: The NP is a member of the organization’s Education Committee with authority to serve as the person accountable for planning, implementation, and evaluation of a continuing nursing education (CNE) activity. This authority is granted by the PNP after the NP completes an orientation to the role of NP and is satisfactorily precepted by a tenured NP. The NP is either a member of the Education Department staff or a clinician representing a clinical practice area on either the Education Committee or the Quality Improvement Committee of ABC Healthcare System. In addition to responsibility for his/her role at the individual activity level, the NP also participates in collection and evaluation of data relative to the effectiveness of the Approved Provider Unit.
• Qualifications: A NP must have a minimum of a baccalaureate degree in nursing and a current, unrestricted nursing license. Experience in adult education is highly preferred. The nurse must have participated actively in at least three educational activities given by the Approved Provider unit within the past year and must have an interest in supporting the professional development of his/her colleagues. The incumbent must either have familiarity with or be willing to learn ANCC accreditation program criteria related to learning activity development and operation within an approved provider unit. Certification in nursing professional development or in a clinical practice specialty is expected at time of hire or within two years of assuming this role.
• Accountability: In the NP role, the incumbent is accountable to the PNP. It is recognized that the person in this position may also have another title and position within the organization. However, reporting relationships within the formal organizational structure are separate from those of the Approved Provider Unit. The PNP evaluates the effectiveness of the NP and shares evaluation data with the NP’s clinical or administrative manager as part of the total evaluation plan for that employee.

What are tips for completing the Structural Capacity section (SC1, SC2, SC3)?

SC1 and 2 are from the PNP’s perspective, while SC3 is from either the PNP or NP’s perspective.

SC1 is the PNP’s commitment to learner needs, including how the approved provider unit processes are revised based on aggregate data, which may include but is not limited to individual educational activity evaluation results, stakeholder feedback, and learner/customer feedback.
This criterion focuses on commitment to learners in the big picture of the provider unit’s operations, not on how you collect data for a particular education. The description of your process may include what feedback the PNP uses to change or improve provider unit processes. This may include items such as learning styles, learning modalities, etc. and how you revised processes based on this information.

SC2 highlights how the PNP ensures that all NPs in the provider unit are appropriately oriented and trained to implement and adhere to the ANCC Accreditation Criteria. Included is the orientation of new NPs, updating, and ongoing monitoring. If you have not had any new NPs, you can include what your orientation process would entail. For provider units with only one NP, you may want to include succession planning, how you maintain and incorporate criteria changes.

SC3 highlights how the PNP and/or NP provides direction and guidance to others involved with the activity in compliance with Accreditation Criteria. The focus of this criteria is on others involved, like planning committee members, presenters, or other stakeholders. You may want to include how the PNP/NP role models maintenance of standards, how the PNP/NP makes expectations clear to those involved, and how the PNP/NP ensures compliance with Accreditation criteria.

For the EDP section, do you need to use examples from one activity or different activities?

You may use one activity or multiple activities to address examples for EDP 1 through 7. If you use one activity, you will address how criteria applies to the entire process from assessing a practice gap to evaluating the activity.

What’s the difference between EDP1 and EDP2?

The intent of educational design process (EDP) is to clearly show the process you use to conduct each step of the activity planning for any given learning activity and a specific example of how you addressed the criteria for one of your planned activities.

EDP 1: The process used to identify a problem in practice or an opportunity for improvement (professional practice gap). This criterion addresses WHAT. What is the issue that needs attention and has created the request for the educational activity? What are people not doing that they could/should be doing or perhaps doing something that should not be done? What sources of data might alert you to the existence of the professional practice gap?

Identification of a professional practice gap is a critical first step in developing an effective educational activity. Your response to EDP 1 will address the process used to determine the professional practice gap. One strategy is to ask – where is the learner now and where should the learner be related to knowledge, skill, and/or application in the practice setting. You might consider including types of questions the NP asks, types of data analyses that are completed, or an explanation of the critical thinking process used by the NP to evaluate requests for educational activities. In addition to sources of data, you will want to focus on how a gap is determined using that data. The example will show a specific instance of steps taken by the NP to determine what professional practice gap exists.

EDP 2: How the NP identifies the underlying educational needs (knowledge, skills, and/or practices) that contribute to the professional practice gap. This criterion addresses WHY. Why does the professional practice gap exist between where the learner is now and where he/she should be in relation to the issue? What factors are contributing to this gap? Are there knowledge deficits? Skills deficits? Difficulty in transferring what the nurse knows and is able to do into the practice setting? It is important to identify the evidence to support the problem for this specific activity and not the long-term goal.

This critical step helps to assure that the educational intervention is targeted at the appropriate level to address the gap and therefore improve practice. Your response to EDP 2 will address the process used by activity NPs to analyze data related to why a professional practice gap exists. You might consider including examples of questions NPs ask, information about stakeholders who provide input into the reason for an existing problem, types of resources and references that are used to substantiate findings, or mechanisms for collecting needs assessment data at levels of knowledge, skill, or practice. The other issue is that the needs assessment may show that the issue is not educational at all – it’s related to an individual compliance or competency issue. The example will show a specific instance where the NP made a determination of the appropriate educational intervention based on verification of a learner deficit in knowledge, skill, or practice.

What’s a sample process description of how the Nurse Planner identifies and measures change in knowledge, skills and/or practices that are expected to occur as a result of participating in the educational activity (EDP3)?

The educational design process is focused on determination of gap analysis, targeted learning needs assessments, and development of outcome measures to demonstrate that gaps have been closed as a result of implementation of knowledge, skill, and/or practice improvement.

Subjective data from learners and objective data from post-tests, skills return demonstrations, or other evidence support achievement of outcomes. Specific measures for evaluating success of activities in achieving outcomes to narrow or close a practice gap are determined during the activity planning process, congruent with the identified gap and the evaluation method by which data are collected to determine whether the outcome has been achieved.

Our provider unit collects data in a variety of ways to measure change in nursing practice or nursing professional development as a direct result of engagement in our learning activities. Examples of evaluation of knowledge acquisition includes post-activity evaluation forms, end-of-session roundtables or report-outs, case studies, return demonstrations, and free-text responses on audience response systems. Examples of evaluation of skills acquisition includes return demonstration or role play. Evaluation of longer-term change in practice is assessed infrequently by observation of behaviors in the practice setting. Regardless of the method, learners are encouraged to reflect on the learning experience and develop their own specific implementation-in-practice plans.

What’s a sample EDP4 description?

EDP4 description is the process used to identify and mitigate AND disclose all relevant financial relationships for all individuals in a position to control educational content.
Here is the generic example of the process to identify, mitigate, and disclose relevant financial relationships. You can use these as guidelines, but please be sure to modify them to fit your own unique circumstances.
It is the responsibility of the NP to identify, mitigate, and disclose all relevant financial relationships with ineligible companies for those with the ability to control the content of the activity. An ineligible company is entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. Financial relationships are relevant if the following three conditions are met for the prospective person who will control content of the education:
• A financial relationship, in any amount, exists between the person in control of content and an ineligible company
• The financial relationship existed during the past 24 months
• The content of the education is related to the products of an ineligible company with whom the person has a financial relationship

Our process begins with the NP determining if the content will only address a nonclinical topic such as communication skills training, leadership, preceptor development, etc. If the content will only address a nonclinical topic, then the NP does not need to identify, mitigate, or disclose relevant financial relationships. The activity information provided to the learners prior to the start of the activity would not include absence of a relevant financial disclosure statement.

If the content addresses a clinical topic, then the NP will first complete the “Financial Disclosure Form” specific to the activity. If the NP reports a financial relationship with an ineligible company, then another member of the planning committee familiar with ANCC criteria review would complete the “Mitigation Worksheet” for the NP. The NP cannot mitigate their own financial relationships.

The NP collects and reviews the “Financial Disclosure Form” from for all those with the ability to control the content including planning committee members, speakers, and content reviews, before they can participate. Any individual refusing to complete the required disclosure will not be allowed to participate in the activity. For individuals with financial relationships noted on the “Financial Disclosure Form”, the NP completes the “Mitigation Worksheet”. The NP excludes owners or employees of ineligible companies from participating as planners or speakers unless one of the three exceptions apply:
• When the content of the activity is not related to their business lines or products
• When the content is limited to basic science or research, and they do not make care recommendations
• When they are participating as technicians to teach the safe and proper use of medical devices, and do not recommend whether or when a device is used

If the NP determines that a financial relationship is relevant, the NP will choose a mitigation strategy appropriate to their role in the activity. Mitigation strategies may include:
• Recusal from controlling aspects of planning and content with which there is a financial relationship (Remove/revise the role of the individual so that the relationship is no longer relevant)
• Peer review of planning decisions by persons without relevant financial relationships-
• Peer review of content by persons without relevant financial relationships (NP, planning committee member, content reviewer, etc.)
• Attest that clinical recommendations are evidence-based and free of commercial bias (e.g., peer-reviewed literature, adhering to evidence-based practice guidelines)
• Divest (sell) the financial relationship
• Other methods
For activities with relevant financial relationships, the NP discloses the name(s) of the individuals, name of the ineligible company(ies) with which they have a relevant financial relationship(s), the nature of the relationship(s), and a statement that all relevant financial relationships have been mitigated. The NP will provide absence or presence of relevant financial information for each person with the ability to control the content prior to the start of the educational activity.
The PNP consults with the Accredited Approver Program Director with any questions related to identifying, mitigating, and disclosing relevant financial relationships.

What’s an example of a summative evaluation (EDP7)?

A summative evaluation is completed for each activity as part of the activity file to analyze achievement of the outcome and provide future recommendations. Accreditation criteria require that you evaluate at the level of the outcome expected. For example, if the identified practice gap was knowledge, the expected outcome of the activity was knowledge gain, the evaluation strategy should be focused on whether or not knowledge of the learners actually improved. Similarly, if the identified gap was in skill, there should be evidence collected that learners improved their skills – or if not, why not. Writing a “NP summary” provides an opportunity for you to reflect on what value that activity added, what your “lessons learned” were, and what adjustments you might want to make in the future.
Although not required, an SBAR format may be helpful in completing a summative evaluation and might read like this:

• Situation – RNs were not aware of the effects of overprescribing opioids.
• Background – A 1-hour activity was designed based on updated guidelines to address the knowledge gap related to best practices in opioid prescription including opioid abuse and strategies to decrease adverse outcomes. The predetermined outcome was that 100% of learners would achieve at least 80% on the post-test.
• Assessment – 26 RNs participated in the full hour and several people asked relevant questions of the speaker during the Q & A session. The outcome was achieved with all learners completing a 10-question post-test scoring 85% or higher.
• Recommendation – Based on how well this activity was received, we plan to offer it again next month at a different time, so more nurses can attend.

Please remember that an “evaluation form” is not necessary – what’s required is an “evaluation process”.

How does the process for evaluating the effectiveness of the provider unit relate to development of outcomes (QO1, QO2, QO3)?

Before you develop provider unit quality outcomes (QO2a and QO3a), it is important to describe the process for evaluating the overall effectiveness of the approved provider unit (QO1). In your description of QO1, there are several key questions that may be considered:

• How does your approved provider unit align with your stakeholder goals?
• How often does your provider unit evaluation process occur?
• Who is involved with this process?
• Why is it important that you conduct this type of evaluation?

After your provider unit evaluation process is clearly identified, you can then align your quality outcome measures with your organization and provider unit goals. 

QO2 and QO3 evaluate the value and benefit to nursing professional development to look at the data in the aggregate and not individual activity data over the past 12 months. QO2a is a measurable component of the structure or process of a provider that contributes to effectiveness of the provider unit while QO3a relates to improvement in practice and/or professional development of nurses. You are not required to meet your identified provider unit outcome(s) but does provides an opportunity for analysis on why the goal was chosen, how you planned to measure it, and what prevented you from achieving the goal. Although not required, outcomes may be written in measurable format like a SMART goal:

• S-Specific/strategic
• M-Measurable/Meaningful
• A- Attainable
• R: Relevant
• T: Time-oriented

Below are examples of provider unit quality outcomes. You can reflect on these as you are developing your outcomes, but please identify outcomes based on YOUR process for evaluating the overall effectiveness of YOUR unique provider unit.

Examples of outcomes related to improvement in provider unit operations (QO2a):

• Increase the number of virtual offerings by 5 webinars in the next 12 months.
• Maintain budget neutral status for all activities for the current fiscal year.
• Develop at least 6 microlearning activities in the next year.
• Complete and share a cost analysis of at least 5% of all activities annually.
• Increase the number of NPs to at least one in each service line area.
• Onboard, orient and train a professional development associate by then end of next year.

Examples of outcomes related to improving the practice or the professional development of nurses (QO3a):

• All NPs will achieve at least 90% accuracy on quarterly audits of activity files.
• 80% of nurses participating in state nurse association events related to political activism will identify at least one way they plan to use knowledge gained in practice.
• 2-point average increase in the pre/post readiness perception for leadership role in participants in leadership activities.
• Increase in the number of certified nurses in the organization by 10%.
• 75% of participants in activities related to evidence-based practice will describe intent to apply content in practice and/or how the activity validated their current practice.
• All of the new clinical educators in the College of Nursing will accurately complete student evaluations and feedback processes by the end of the spring semester.

Remember that quality outcomes answer the questions, “So what?” and “What difference did our approved provider make?”. This provides an opportunity to show the importance of your provider unit based on evidence following a deliberate process.

What’s the difference between SC1 (primary nurse planner revises provider unit processes based on aggregate data) and QO1 (process for evaluating the overall effectiveness of the provider unit)?

SC1 focuses on how the primary nurse planner demonstrates commitment to learner needs in revising provider unit processes based on aggregate data.  QO1 focuses on the process for collecting and evaluating data for the overall effectiveness of the provider unit.