Issues Update

Ensuring Quality in Continuing Education

In the past 10 years, health care has undergone tremendous, unprecedented change. Today's practicing nurses, many who graduated from nursing school 10, 20, or even 30 years ago, may find they need additional education to meet the demands of managed care, hospital restructuring, technological advances, and an aging population.

Continuing education has long been embraced by the nursing profession as an ideal way to build RNs' skills. Legal, ethical, and professional concerns, and those related to clinical and competency-based skills, are among the most pressing in today's nursing environment. Important legal and ethical CE topics include supervision of personnel and RN delegation of tasks. Continuing education is also addressing professional issues such as adapting nursing care and professional duties to managed care settings, multistate licensure, and the encroachment of other disciplines into nursing practice. Among popular clinical topics are skills in advanced intravenous therapy and meeting the needs of high-acuity patients.

The significance of CE to nursing practice is undisputed. Not only does it help a nurse to provide better patient care, it makes her more valued by her employer. (See this month's Vital Signs, page 80.) Continuing education also can enable nurses to comply with the ANA's Code for Nurses, which requires competencies in nursing practice, and assists, in some states, in achieving certification and maintaining licensure. At least 27 state boards of nursing include a continuing education requirement for license renewal, 43 state boards have such requirements for re-entry into practice, and 14 have a designated CE requirement for advanced practice registered nurses.

New technologies are making CE increasingly accessible to all nurses. These technologies include electronic transmissions, Internet access, and audio- and videoconferencing. (See Issues Update, October 1997.) In addition, traditional seminars and large conferences, such as the upcoming biennial ANA convention in San Diego, June 26-July 1, 1998, offer programs addressing trends in professional and practical nursing.

Ensuring CE quality

Just as RNs strive to empower clients to make informed health care choices, they must empower themselves to make informed choices in their own education. What steps can nurses take to ensure the quality of their continuing education?

Accreditation of CE activities by the Commission on Accreditation (COA) of the American Nurses Credentialing Center (ANCC) is one indication of quality CE offerings. Through the ANCC accreditation program, organizations that wish to provide or approve CE offerings participate in an intensive self-examination and external peer review that includes a site visit by COA volunteers. Various organizations, agencies, and institutions that develop and present CE for nurses receive accreditation as providers. Nursing organizations that review and approve CE activities receive accreditation as approvers. An organization may have both a provider unit and an approver unit. Currently, there are 220 COA-accredited providers and approvers in the U.S.

In addition to understanding the accreditation process for CE, nurses should consider the following questions:

• How can I identify CE that meets COA quality standards?
• What questions can I ask about the merits of a specific CE activity and about how COA criteria shape its quality?
• What responsibility do I bear for contributing to the quality?

Nurses can begin by critically evaluating the announcement of a CE activity. Is there a statement that identifies the COA as the accrediting body? For example, it might say, "[Name of provider] is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation."

There also may be a statement indicating that an application is pending approval by a COA-accredited approver. Approval must be obtained in advance for contact hours to be awarded. The brochure also must state the number of contact hours that can be awarded. A contact hour equals 50 minutes of an organized learning activity, such as a lecture with a question-and-answer session, clinical experience, or videoconferencing. The COA awards only contact hours and does not use continuing education unit (CEU) terminology of the International Association of Continuing Education and Training. A CEU represents ten 60-minute hours of learning activity.

Questions to ask

In examining a CE announcement, nurses can ask questions to determine whether an offering reflects COA requirements.

• Q: Does the topic interest me? Is it relevant and timely?
• A: COA criteria require CE planners to conduct needs assessments and to describe how they use assessment findings in determining future activities. The CE needs of nurses include not only topic relevance and timeliness but also a convenient time and place and an effective and user-friendly learning format. CE announcements describe the target audience to help consumers select appropriate activities.
  
  
• Q: Do the objectives for the activity meet my needs as a nurse and a consumer of education?
• A: All CE activities contain specific behavioral objectives to describe what can be achieved through participation. Peer review of proposed activities assures learners that objectives reflect continuing education (professional experiences designed to enrich the nurse's contribution to health care) as opposed to in-service education (activities designed to help the nurse fulfill responsibilities specific to employer expectations). For example, learning a specific computer system used in the workplace would be in-service education, while attending a conference on planning research to meet the health care needs of the geriatric population would be considered continuing education.
  
  
• Q: Is the delivery system satisfactory to me?
• A: The COA defines two types of delivery. Education Design (ED) I refers to CE in which the planner determines the time, place, and learning pace, such as a one-day conference. ED II is learner-paced, as in a written independent-study course or one conducted by videotape. Many of the offerings in nursing journals are of the latter type.
  
  
• Q: Will this activity meet my special learning needs?
• A: COA criteria encourage a variety of learning activities--from in-person presenters to home-study paper-and-pencil courses to interactive videos--so consumers can select activities to match their personal learning styles and preferences for passive or participatory learning.
  
  
• Q: What are the credentials of the CE offering's planners?
• A: COA criteria require that a registered nurse with a graduate degree be responsible for planning, developing, implementing, and evaluating CE activities. One of the nurse's degrees, either the baccalaureate or a graduate degree, must be in nursing.
  
  
• Q: Can I depend on the quality of this CE activity's content?
• A: Applicants for accredited provider status and those seeking approval for one or more CE activity submit detailed educa- tion programs. Volunteer reviewers pay careful attention to applications to ensure that content is appropriate to the learning objective in terms of quality and quantity of hours required to complete the program. Nurse planners, presenters, and preparers of CE materials submit biographical data on their education, professional experience, and expertise in nursing continuing education.
  
  
• Q: How will my completion of this activity be documented?
• A: Participants receive written verification of successful completion of an educational activity. The document includes the number of contact hours awarded, the provider's name and address, an official accreditation statement, and the title and date of completion of the activity. Provider and approver organizations maintain confidential but accessible attendance records for at least five years.

Nurses' responsibility for quality CE

The COA requires that participants be able to evaluate each CE activity's planning and presentation, its objectives and content, and its teaching methods and learning environment.

Specific comments are the most useful. Although presenters enjoy hearing "everything was great" and cringe at "it was awful," identifying the aspects that made a CE activity great or awful gives direction to future planners. Comments are valuable whether they address small concerns or larger issues that affect many learners. A comment such as "use larger type on overheads so those in the back can read them" suggests a specific change helpful to a few, while a suggestion to "incorporate more nursing research findings in CE material" can help improve the overall quality for prospective learners. Participants can register serious concerns about quality directly with the organization offering the CE activity. Unanswered concerns can be addressed to the COA.

An additional opportunity to influence quality is to volunteer for the ANCC's COA. Volunteers participate in all levels of COA activities, including the peer review process. State nurses associations (SNAs) accredited by the COA as CE approvers maintain volunteer peer panels to review applications from groups wishing to award contact hours for educational activities. The COA comprises 14 volunteer commissioners; most are nominated by their state nurses associations. The commissioners, in conjunction with ANCC/COA staff, operate the accreditation program and serve as site visitors. Additional peer volunteers serve as site visitors with the commissioners.

Nurses can contact their SNAs for information about becoming peer review panel members or about eligibility criteria for nomination as COA commissioners. Interested nurses with CE experience may contact the COA directly for an application to become a site visitor.

The assurance of quality in nursing continuing education depends on the efforts of many, and much of the responsibility for quality in nursing CE rests with the nurse consumers who actively participate in the learning process.

Nancy Ryan Macklin is professor of nursing at Maryville University in St. Louis, MO, and a member of the American Nurses Credentialing Center's (ANCC) Commission on Accreditation (COA). Jennifer Hopkins Matthews, is the director of the ANCC's Accreditation and Magnet Programs. COA members Dorothy Bell, MSN, RN, and Sally Russell, MSN, RN, are acknowledged for their help with this article.