Society of Trauma Nurses
Continuing Education Provider Unit
Policy and Procedure Manual

Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.


I. Continuing Education Provider Unit (CEPU) 3

II. Requirements and responsibility of CEPU members 4

III. CEPU member responsibilities: 5

IV. Principles of High Quality Education Design 6

V. Definition of CNE 6

VI. Educational Design Process 6

VII. Ensuring Independence and Content Integrity 10

VIII. Joint Providership 12

IX. Accredited Provider Statement 12

X. Required Information Provided to the Learner 13

XI. Ongoing Evaluation 15

XII. Demonstrating positive outcomes 15

XIII. Record Keeping 16

XIV.Attachment 1 18

XV. Attachment 2 19

XVI. Attachment 3 Society of Trauma Nurses 25

I. Continuing Education Provider Unit (CEPU)

A. The Continuing Education Provider Unit (CEPU) is defined by the Society of Trauma Nurses Board Policy 4.2.

B. Purpose of the CEPU is to

1. Support the delivery of continuing nursing education activities

2. Assure that STN provides educational activities according to the ANCC Commission on Accreditation criteria.

3. Set policy within the guidelines of the ANCC Commission on Accreditation and the Society of Trauma Nurses Board of Directors.

4. Monitor the quality and consistency of the Provider Unit program.

C. The CEPU is responsible for participating in the planning of developing individual education activities and providing contact hours to nurses for use in fulfilling their own goals for professional development, licensure, and certification.

1. Each educational activity is led by a Nurse Planner in collaboration with at least one other planner.

2. Contact hours may not be provided for CNE activities developed without the direct involvement of a Nurse Planner.

3. Provider Units may jointly provide activities with other non-commercial interest organizations.

4. Provider Units may not approve educational activities that have been planned by other organizations or individuals or without the involvement of a STN Continuing Education Provider Unit Nurse Planner.

D. The CEPU will consist of a minimum of six (6) Nurse Planners, one being the Lead Nurse Planner.

1. Nurse Planner for ATCN

2. Nurse Planner for TOPIC

3. Nurse Planner for Annual Conference

4. Nurse Planner for EAST

5. Nurse Planner for Certification Preparation (Update) Course

6. Lead Nurse Planner

7. Other Nurse Planners as required as STN develops new CE opportunities

II. Requirements and responsibility of CEPU members

A. Nurse Planner

1. Requirements

a. The Nurse Planners will meet the educational and licensure requirements of the ANCC.
b. Be a registered nurse who holds a current, unencumbered nursing license
c. Hold a baccalaureate degree or higher in nursing
d. In addition to the ANCC requirements the CEPU members will:
e. Be an STN member in good standing
f. Possess an interest in trauma nursing CE that enriches the trauma nurses’ contribution to health care
g. Have knowledge of CE development, program criteria and guidelines
h. Have strong communication and organizational skills

2. Responsibility

a. The Nurse Planner is to be actively involved in all aspects of planning, implementation, and evaluation of each CNE activity.
b. The Nurse Planner is responsible for assessing whether appropriate educational design principles are used and processes are consistent with the requirements of the ANCC Primary Accreditation Program.

B. The Lead Nurse Planner requirements and responsibilities

1. The Lead Nurse Planner will be appointed by the STN Board of Directors.

2. The Lead Nurse Planner must have the educational and licensure requirements of the ANCC.

a. Is a registered nurse with a current, unencumbered nursing license
b. Holds a graduate degree
c. Holds a baccalaureate degree or higher in nursing

3. Responsibilities

a. The Lead Nurse Planner has the authority within the CEPU to ensure compliance with the ANCC Accreditation Program criteria that pertain to the operations of the organization as a CEPU
b. Has responsibility for ensuring that the CEPU adheres to the ANCC Accreditation Program criteria for all operational aspects of providing continuing nursing education activities and criteria that pertain to the operations of the organization as a CEPU

c. Has responsibility for the orientation of all Nurse Planners in the organization with respect to the ANCC Accreditation Program criteria. See Attachment 1 in this document.

d. Has responsibility for ensuring each Nurse Planner understands the ANCC Accreditation Program criteria and is responsible for appropriately evaluating compliance with those criteria

e. Has responsibility for submitting annual report to ANCC.

f. The Lead Nurse Planner may also function as Nurse Planner for a CNE product when necessary or appropriate.

C. The CEPU will be responsible to an assigned member of the STN Board of Directors.

D. Appointment to CEPU and notification of appointment to the STN Board of Directors will be in accordance with STN by-laws.

III. CEPU member responsibilities:

A. Prepare for and attend monthly CEPU conference calls

B. Participate in CNE program reviews.

C. Assigned Nurse Planner to prepare Activity Planning Document and Educational Activity Plan as their CNE product is being developed or modified.

D. Assigned Nurse Planner is to collaborate with STN management staff to assure all mandatory disclosures are disclosed, appropriate course evaluations are prepared and necessary Conflict of Interest forms (COI’s) are obtained and available.

E. Assigned Nurse Planner will provide updates on their CNE product during each conference call as appropriate.

F. Assigned Nurse Planner will prepare a summary of evaluations of their CNE product according to the annual schedule.

G. Lead Planner will chair monthly conference call

H. Lead planner is responsible to oversee STN Management Group maintains all records according to ANCC requirements.

I. The CEPU will evaluate summary of evaluations prepared by STN management staff of all CE presentations for opportunities for improvement and suggestions for future programs.

IV. Principles of High Quality Education Design

A. Addresses a professional practice gap (change in standard of care, problem in practice, or opportunity for improvement).

B. Incorporates the active involvement of a Nurse Planner in the planning process.

C. Analyzes educational needs (knowledge, skills, and/or practices) of registered nurses and/ or health care team members that underlie the problem or opportunity (why the problem or opportunity exists).

D. Identifies one or more learning outcomes to be achieved by learners participating in the activity.

E. Uses strategies that engage the learner in the educational activity and are congruent with the educational needs and desired learning outcomes.

F. Chooses content based on evidence-based practice or best available evidence.

G. Evaluates achievement of learning outcomes.

H. Plans independently from the influence of commercial interest organizations.

V. Definition of CNE

A. CNE is defined as “learning activities intended to build upon the educational and experiential bases of the professional RN for the enhancement of practice, education, administration, research, or theory development, to the end of improving the health of the public and RNs’ pursuit of their professional career goals.”

VI. Educational Design Process

A. The Nurse Planner, as a member of the planning committee, documents on the Continuing Education Planning Document (found as Attachment 2 in this document and in the CEPU Committee section of the STN Web Site.)

1. Activity Type

a. Provider-directed, provider-paced- The provider controls all aspects of the learning activity. The provider determines the desired learning outcome based on a needs assessment and gap analysis, selects content based on best available evidence, chooses strategies to facilitate learning, and identifies methods for collecting and analyzing evaluation data. (Examples include live activities and live webinars.)

b. Provider-directed, learner-paced: The provider determines the desired learning outcome based on a needs assessment and gap analysis, selects content based on best available evidence, chooses strategies to facilitate learning, and identifies methods for collecting and analyzing evaluation data. The learner determines the pace at which he/she engages in the learning activity. (Examples include print articles, online courses, e-books, and self-learning modules/independent studies.)

c. Enduring activities are provider-directed, learner-paced activities. Enduring materials have an expiration date after which no contact hours may be awarded.

· The expiration date of enduring material should be based on the content of the material.
· Providers must review content of enduring materials at least once every three years, or more frequently if indicated by new developments in the field specific to the enduring material.
· Review of enduring material content should be conducted for accuracy of content, current application to practice, and evidence-based practice.
· Upon completion of the enduring material review and appropriate revisions, a new expiration date should be established.
· Expiration/end date of enduring material: This is determined by the planning committee based upon the content and the potential for information to become outdated within a certain amount of time. The maximum length of time for enduring materials prior to expiration is 3 years.

2. Considerations for Live and Enduring Formats

a. Live educational activities, whether in-person or on-line, are provider-directed, provider-paced activities. There is no expiration date for a live activity; however, the provider is expected to evaluate repeated activities as needed to determine that the practice gap still exists, that the underlying educational needs are still relevant for the target audience, and that content is still based on current evidence.

b. Live activities, or portions of live activities, may be repurposed for enduring materials. If repurposed, an expiration date is assigned to the enduring activity.

B. Professional Practice Gap

1. A professional practice gap is a change that has been made to a standard of care, a problem that exists in practice, or an opportunity for improvement.

2. Professional practice gaps are not limited to clinical practice and may also exist in areas of professional work such as administration, education, and research.

3. Identify and document the difference between current state and desired state.

4. Identify if CNE can be developed to close the professional practice gap.

5. Provide a summary of evidence gathered validating the need for this educational activity

C. The Nurse Planner and Planning Committee evaluate

1. What registered nurses or members of the health care team do not know (knowledge deficit),

2. Do not know how to do (skill deficit),

3. Or are not able to do in practice (practice deficit),

4. Then plan the best type of educational activity to achieve the desired state.

D. Identify the target audience

1. The target audience is defined as the specific registered nurse learners or health care team members the educational activity is intended to impact. The target audience is defined as the specific registered nurse learners or health care team members the educational activity is intended to impact.

E. The Nurse Planner and Planning Committee determine and document the learning outcome.

1. A learning outcome is written as a statement that reflects what the learner will be able to do as a result of participating in the educational activity.

2. The learning outcome must be observable and measurable.

3. The outcome addresses the educational needs (knowledge, skills, and/or practices) that contribute to the professional practice gap, and achieving the learning outcome results in narrowing or closing the gap.

4. The learning outcome may be assessed over the short term or long term. There may be more than one learning outcome for an educational activity.

F. Content of Activity will be documented on the Education Activity Plan (EAP). The EAP is found as Attachment 3 to this document and on the CEPU committee section of the STN web site.

1. The Nurse Planner should begin the EAP by completing the top of the form including Title, Gaps, Current State, Desired State, and Learning Objectives using the information from the Continuing Education Planning Document.

2. The content outline, presenter and teaching methods and learner engagement strategies table should be completed by the speaker/author.

3. The evidence based references should be completed by the presenter/author.

4. It is the responsibility of the Nurse Planner and Planning Committee to ensure that content is based on the most current evidence, which may include but is not limited to evidence-based practice, literature/peer-reviewed journals, clinical guidelines, best practices, and content experts’ opinion.

5. To be considered current, written materials should be less than 6 years old unless the reference is considered a seminal/classic source.

G. Method of calculation number of contact hours:

1. If Live (in person or live webinar):

a. Time spent evaluating the learning activity may be included in the total time when calculating contact hours.

b. Total Minutes divided by 60= number of contact hours.

2. If Enduring: Method of calculating contact hours may include:

a. Pilot Study

b. Historical Data

c. Complexity of Content

d. Other as appropriate

3. If rounding is desired in the calculation of contact hours, the provider must round down to the nearest 1/10th or 1/100th (e.g., 2.758 should be 2.75 or 2.7, not 2.8). Educational activities may also be conducted “asynchronously” and contact hours awarded at the conclusion of the activities.

H. Evaluation of educational activity

1. Evaluation may be formative and integrated within the educational activity

2. Evaluation may also summative at the conclusion of the educational activity.

3. Evaluation should assess for change in knowledge, skills or practice.

4. Evaluation may be self reported or objective measures of change.

5. Short-term evaluation options include

a. Intent to change practice

b. Active participation in learning activity

c. Post-test

d. Return demonstration

e. Case study analysis

f. Role-play

g. Other

6. Long-term evaluation options include

a. Self reported change in practice

b. Change in quality outcome measure

c. Return on investment (ROI)

d. Observation of performance

e. Other

7. Review summative evaluation and

a. Assess impact of educational activity

b. Modify current educational activity

c. Guide future educational activity

VII. Ensuring Independence and Content Integrity

A. Conflict of Interest

1. A conflict of interest exists when an individual is in a position 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.

2. The Nurse Planner is responsible for ensuring that all individuals who have the ability to control or influence the content of an educational activity disclose all relevant relationships with any commercial interest, including but not limited to members of the Planning Committee, speakers, presenters, authors, and/or content reviewers.

3. Relationships with commercial interest organizations are considered relevant if they existed within the past twelve months.

4. Relationships of the individual’s spouse/partner may be considered relevant and must be reported, evaluated, and resolved.