This article explores the American Nurses Credentialing Center (ANCC, 2015) primary accreditation educational design process (EDP) criteria that corresponds with the Association for Nursing Professional Development (ANPD) Scope and Standards of Practice (Harper & Maloney, 2016). According to Dickerson and Graebe (2018, p. 4),“utilization of the criteria and standards is recommended when planning any educational interventions, as they provide a sequential process for content development” including ensuring content integrity. This article provides knowledge for the nurse planner (NP)/nursing professional development (NPD) practitioner to apply content integrity principles when identifying and resolving conflicts of interest (COI) for all individuals in a position to control educational content per the ANCC primary accreditation criteria and the ANPD Scope and Standards of Practice.
Understanding Conflict of Interest
As described in the January and February (2018) articles of this Administrative Angles series, the first step in the Educational Design Process (EDP 1) is identification of the practice gap; which is the “distance between where things are now and where they could or should be” (Dickerson & Graebe, 2018, p. 4). The second step is identification of the appropriate educational need (knowledge, skill, and practice) that validates the established practice gap (Moyer & Graebe, 2018). The third step is “identify and resolve all COI for all individuals in a position to control educational content” (ANCC, 2015, p. 39).
EDP 3 focuses on ensuring components of the ANCC Content Integrity Standards (2016) are adhered to within educational activity planning that is related to identifying and resolving COI. Content integrity is a comprehensive principle that obligates an NP to ensure educational content is free of bias and influence, is fair and balanced, and is based on the best available evidence. Content integrity also requires content to be designed free of commercial interest bias and influence. The ANPD Scope and Standards addresses COI under Standard 7: Ethics (Harper & Maloney, 2016). This standard specifies that the NPD practitioner “maintains procedures for monitoring the integrity of educational activities including screening for potential or actual unethical behavior, commercial bias, compromise of intellectual property rights or conflict of interest” (Harper & Maloney, 2016, p. 38).
Conflict of Interest and Commercial Interest Organization Defined
The NP is responsible for ensuring that all individuals involved in the educational activity understand the definition of COI and commercial interest organizations in order to identify a relationship with a commercial interest organization. COI occurs when an individual on the planning committee or others involved with an educational activity can control or influence the content of the activity and has a financial relationship with a commercial interest organization whose products or services are relevant to the content of the activity. Identifying COI is vital and is a hallmark of the primary accreditation criteria (Dickerson & Chappell, 2015). The NP must understand the definition of terms to demonstrate adherence to this criterion. The ANCC (2015, p. 27) defines COI as existing when:
- An individual who could control content of an educational activity has a relationship with a commercial interest organization, the products, and services of which are related to the content of the educational activity.
- ANCC considers relationships to be relevant if they existed within the past 12 months. Relationships of an individual's spouse or significant other are also considered relevant.
ANCC (2015, p. 27) defines an organization as a commercial interest organization if it:
- Produces, markets, sells, or distributes health care goods or services consumed by or used on patients.
- Is owned or operated, in whole or in part, by an organization that produces, markets, sells, or distributes health care goods or services consumed by or used on patients.
- Advocates for use of the products or services of commercial interest organizations.
Understanding the Principles
Being able to understand and operationalize the principles of identifying and resolving COI is critical in ensuring that educational activities are designed and implemented independent from commercial interest (Dickerson & Chappell, 2015). Before NPs can operationalize these principles, they must understand who the individuals are that control or influence the content of an educational activity. An individual who could control or influence content is anyone who is directly involved in the planning or implementation of the activity. These individuals can be, but are not limited to, the NP, content expert, content reviewer, and speakers and presenters. The NP is responsible for satisfying EDP 3 by implementing a process to identify COI when planning educational activities (Table). Steps to resolve a COI are also outlined in the Table and must be evidenced, if applicable, in the activity planning. Disclosures are then made to the learners prior to providing the activity. Disclosures may be made on marketing material, at the time of registration, or right before the activity commences.
Criteria for Identifying and Resolving Conflict of Interest
Applying the Principles
The NP uses three key questions to determine whether COI exists. The questions are consistent with the criteria for identifying and resolving conflict of interest (Table). Of note, all three questions must be answered yes for a COI to exist. The following scenario is an example of how to apply the principles for identifying and resolving COI. An NP learns that one of the speakers for a planned activity, not yet provided, is a nurse educator for a cardiac device company. The content is related to care of the patient with a cardiac device. The speaker has also written a book on his experience as a cardiac NP.
- First question: Does the individual involved in the planning of the educational activity have the ability to control or influence content? In this case, the answer is yes.
- Second question: Does the individual have a relevant employee or nonemployee relationship with a commercial interest organization? In this case, the answer requires the NP to ask more questions of the individual. Upon investigation, the NP finds out that the speaker is not an employee of the device company but is currently an independent contractor.
- Last question: Does the content of the educational activity related to the products and services of a commercial interest (per the ANCC definition)? In this case, the answer is yes.
In this scenario, all three questions were answered yes, indicating that a conflict exits. However, the speaker has a nonemployee financial relationship with the commercial interest entity; therefore, it would be permissible for the speaker to continue in the role, presuming the conflict is appropriately resolved. The NP must employ resolution processes to ensure the content and speaker remain fair, balanced, and free of commercial interest bias and influence. In addition, the NP may review the content or have someone else review the content or arrange a speaker agreement. The NP in this scenario would disclose the speaker's name, the type of relationship, and the name of the commercial interest entity.
If the individual was an employee of the commercial interest entity, the NP would remove the speaker, not award contact hours, or, if applicable, revise the individuals role. In many cases by asking the last question first, the NP can save time and energy. For example, if the content in the scenario was related to leadership, the content would not have a relationship with the products and services of a commercial interest; therefore, individuals in a position to control or influence content would not have a COI. The NP can simply document this in the activity planning file.
It is important to note that authorship of a book is not a COI, because the book publisher is not a commercial interest entity. However, the NP may review content to ensure freedom from bias and influence and use of best available evidence.
ANCC Primary Accreditation Criteria Implications
EDP 3 requires the provider unit to have an operational process that evidences adherence and compliance to identify and resolve all COI for all individuals in a position to control educational content. The provider unit must evidence their process for identification, resolution and disclosure of COI in the self-study and in educational activity files. Some provider units may have policies that prohibit employees from having relationships with commercial interest organizations. Regardless, understanding and applying the ANCC content integrity standards in activity planning makes certain that learners participate in educational activities that are fair and balanced.
- American Nurses Credentialing Center. (2015). ANCC primary accreditation provider application manual. Silver Spring, MD: Author.
- American Nurses Credentialing Center. (2016). ANCC content integrity standards for industry support in continuing nursing educational activities. Retrieved from http://www.nursecredentialing.org/Accreditation-CEContentIntegrity.pdf.
- Dickerson, P. & Chappell, K. (2015). Content integrity, conflict of interest, and commercial support. Journal of Nursing Professional Development31, 225–230. doi:10.1097/NND.0000000000000182 [CrossRef]
- Dickerson, P. & Graebe, J. (2018). Analyzing gaps to design educational interventions. The Journal for Continuing Education in Nursing, 49, 4–6. doi:10.3928/00220124-20180102-02 [CrossRef]
- Harper, M. & Maloney, P. (2016). Nursing professional development: Scope and standards of practice. Chicago, IL: Association for Nursing Professional Development.
- Moyer, A. & Graebe, J. (2018). Identifying the underlying educational needs that contribute to the professional practice gap. The Journal for Continuing Education in Nursing, 49, 52–54. doi:10.3928/00220124-20180116-02 [CrossRef]
Criteria for Identifying and Resolving Conflict of Interest
Identify all individuals in a position to control content of the educational activity.
Collect and document any relationships that individuals in a position to control content have with commercial interest organizations.
For individuals who have relationships with commercial interest organizations, evaluate whether the products and services of the commercial interest organization are relevant to the content of the educational activity.
If relevant, the relationship must be resolved and disclosed to learners. Resolution processes include:
Removing the individual with conflict of interest from participating in all parts of the educational activity.
Revising the role of the individual with conflict of interest so that the relationship is no longer relevant to the educational activity.
Not awarding continuing education contact hours for a portion or all of the educational activity.
Undertaking review of the educational activity by the nurse planner to evaluate for potential bias, balance in presentation, evidence-based content, or other indicator of integrity and absence of bias and monitoring the educational activity to evaluate for commercial bias in the presentation.
Undertaking review of the educational activity by the nurse planner to evaluate for potential bias, balance in presentation, evidence-based content, or other indicator of integrity and absence of bias AND reviewing participant feedback to evaluate for commercial bias in the activity.