Adult - Gerontology Clinical Nurse Specialist Role Delineation Study

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2012

Adult - Gerontology Clinical Nurse Specialist

Role Delineation Study

National Survey Results

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About this Report

This report pertaining to the practice of adult-gerontology clinical nurse specialist was based on the results of a national study of practice of adult-gerontology and pediatric clinical nurse specialists.

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APPENDICIES

WORK ACTITIVIES STATEMENTS ... APPENDIX A DEMOGRAPHIC DATA SUMMARY ... APPENDIX B WORK ACTIVITIES DESCRIPTIVE STATISTICS ... APPENDIX C WORK ACTIVITIES MEAN OVERALL CRITICALITY --RANK ORDER ... APPENDIX D

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Acknowledgements

The American Nurses Credentialing Center (ANCC) wishes to thank a number of content experts who served on the 2012 ANCC Adult-Gerontology Clinical Nurse Specialist and Pediatric Clinical Nurse Specialist Role Delineation Study panels for sustaining this effort and producing a role delineation study of such high caliber. Without their numerous hours of input and feedback, the study would not be possible.

Adult-Gerontology Clinical Nurse Specialist • Amanda Segrest, MSN, ACNS-BC, RN-BC • Elizabeth Bauer, MSN, ACNS-BC

• Julie Ponto, PhD, ACNS-BC

• Mary Francisco, MSN, GCNS-BC, CCRN • Ann Jacobson, PhD, ACNS-BC

• Ann Marie Lazarus, MSN, ACNS-BC • Chanda Harrison, MSN, ACNS-BC • Deborah Messecar, PHD, GCNS-BC • Mary Strickland, MSN-ACNS-BC • Linda Hoke, PhD, ACNS-BC Pediatric Clinical Nurse Specialist • Heidi McNeely, MSN, PCNS-BC

• Patricia Conlon, MS, PCNS-BC, PNP, BC • Maureen O’Brien, PhD, PCNS-BC

• Jerithea Tidwell, PhD, PCNS-BC, PNP-BC • Cynthia Wall, MSN, PCNS-BC

• Angela Scott, MNSc, APN, PCNS-BC • Heather Walsh, MSN, PCNS-BC • Sharon Barton, PhD, PCNS-BC • Rhonda Werner, MS, PCNS-BC

We also would like to thank the ANCC staff who also spent numerous hours working to make this study possible:

• Christine DePascale, MS (Project Manager) • David Paulson, PhD, CAE

• Chie Ohba, PhD • Cheray Jones

Finally, we would like to thank the ANCC-certified clinical nurse specialists who supported this study by completing the survey questionnaire.

The contributions that all of these people made to the study were essential to its success.

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Background

The American Nurses Credentialing Center (ANCC), which was incorporated in 1991 as a subsidiary of the American Nurses Association, is the largest nursing credentialing organization in the United States. Its vision is to drive nursing excellence, quality care and improved

outcomes. Currently, ANCC offers 25 examinations at various levels including diploma and associate degree, baccalaureate, and advanced practice for nurse practitioners, clinical nurse specialists, and other disciplines. More than 14,000 candidates take an ANCC certification examination each year. In addition to certification, ANCC provides services such as the Magnet and Pathways to Excellence recognition programs for hospitals and other facilities that

demonstrate excellence in nursing services, accreditation of continuing education programs, education and consultation services, and outreach to nursing organizations around the globe.

Role Delineation Study Overview

Role delineation or job analysis studies are typically carried out at the national level with the goal of describing current practice expectations, performance requirements, and

environments. ANCC has a current goal of conducting a study of clinical nurse specialists approximately every three years in order to capture changes in work activities and the knowledge and skill areas required to perform those activities. The findings are used to update the content of its respective certification examinations.

The 2012 Adult-Gerontology Clinical Nurse Specialist and Pediatric Clinical Nurse Specialist Role Delineation Study involved two sets of processes or activities that ran more or less concurrently: a national web-based survey and a linking activity. The national survey was designed to collect information on the work activities clinical nurse specialist actually perform in practice, while the linking activity identifies the major knowledge and skill areas required to perform the work activities listed in the survey. The results of both of these processes were used in the updating of the test content outlines for each examination contained within the study.

Updated Test Content Outlines

The results of this role delineation study were used in developing or updating the test content outline for each examination contained within the study. Examination forms produced based on the adult-gerontology clinical nurse specialist test content outline developed through this study are scheduled to go into effect April 17, 2014. A copy of the test content outline is available on the American Nurses Credentialing Center website.

Role of the Content Expert Panels

Throughout the study, ANCC invited professionals in practice and educators who teach courses relevant to clinical nurse specialists to serve on content expert panels for this study. They developed the work activities and demographic items for the survey, linked knowledge and skill areas to the work activities list, and finalized the test content outlines for the respective certification examinations. All of the content experts serving on the panels were certified by ANCC in the clinical nurse specialist population they represented and were invited to serve on the panels based upon expertise in their specialties.

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Survey Methodology

The purpose of the development and administration of the national survey was to collect information on the work activities clinical nurse specialists actually perform in practice. Since the survey instrument that was used for the purposes of this study would be used across two clinical nurse specialist populations, representatives from each of these two population-based role delineation study panels were also asked to serve as members of a ten member initial study workgroup that acted as a sort of steering committee for the panels. This initial workgroup met for three days May 21-23, 2013 to draft a single pilot version of the survey and to construct the initial map of knowledge and skill areas relevant to the work activities included in the survey.

Survey Chronology

The survey development and administration timeline was as follows: May – July 2012

• The initial study workgroup along with staff from ANCC drafted the survey

• The survey was pilot tested and revised. August - September 2012

• The final survey was administered on the web. September – October 2012

• The survey activity results were analyzed, and activity weights were determined.

• Each panel met to review the survey results and activity weights.

Sample Selection

On May 17, 2013, there were 3,554 actively certified ANCC clinical nurse specialists in adult health nursing and 585 actively certified ANCC clinical nurse specialists in gerontological nursing. A random sample of ANCC 559 adult health clinical nurse specialists stratified by region and all ANCC certified gerontological clinical nurse specialists (except 25 who were selected to participate in the pilot survey) were selected from the ANCC certification database. Table 1 presents the numbers of ANCC certified adult health clinical nurse specialists and ANCC certified gerontological clinical nurse specialists that were selected from each region.

Table 1. Number of Surveys Mailed Out per Geographic Region Geographic Region

Number of ANCC Certified Adult Health CNS Selected (percent of total pop.)

Number of ANCC Certified GerontologyCNS Selected (percent of total pop.)

Northeast – NY, CT, MA, NJ, ME, PA, NH, VT, RI 71(12.70) 125 (22.36)

South – TN, MS, TX, FL, LA, AL, GA, AR, OK, VA, MD, SC, DC,

NC, WV, DE, KY 201 (35.96) 155 (27.73)

Midwest – IA, NE, KS, OH, MO, MN, SD, ND, MI, IL, IN, WI 227 (40.61) 206 (36.85)

West – WA, AZ, CA, OR, CO, AK, ID, NM, UT, HI, NV, WY, MT 58 (10.38) 73 (13.06)

Other – AE, AP, APO 2 (0.36) 0 (0.00)

Total 559 (100.00) 559 (100.00)

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Survey Development and Measures

On May 21-23, 2013, the initial study workgroup met in Silver Spring, MD in order to draft the national Adult-Gerontology Clinical Nurse Specialist and Pediatric Clinical Nurse Specialist Role Delineation Study survey for the 2012 role delineation study. The panel members reviewed the work activities which had been used in the ANCC's 2009 Role Delineation Survey of Clinical Nurse Spcialists as well as the following documents:

• Consensus Model for APRN Regulation (2008)

• American Association of Colleges of Nurses Essentials of Master’s Education of Nursing

(2011)

• National Association of Clinical Nurse Specialist Clinical Nurse Specialist Core

Competencies (2008)

• American Association of Critical-Care Nurses Scope and Standards for Acute and Critical

Care Clinical Nurse Specialist Practice (2010)

• American Association of Colleges of Nursing and National Association of Clinical Nurse

Specialists Adult-Gerontology Clinical Nurse Specialist Competencies (2010)

During the meeting, they discussed any additions, deletions, and changes they would make to update the 2009 work activity list to reflect current practice of clinical nurse specialists working within either of the two population areas. The goal of this process was to create a comprehensive list of relevant work activities that were potentially performed by clinical nurse specialist in either of the population areas, regardless of whether it was performed in the other. As a result of this meeting, the panel reached consensus on a list of 124 work activities to be used in the 2012 pilot survey. These work activities were divided into seven domains: Direct Care; Consultation; Systems; Coaching/Education; Collaboration; Evidence-based practice and Research; and Ethical Decision-making, Moral Agency and Advocacy. The complete text of the work activities list is presented in Appendix A. The workgroup also identified and finalized a set of 17

demographic questions. (See Appendix B).

During the same meeting, the workgroup reviewed and approved three scales that respondents would use to rate the work activities listed in the survey — Frequency (the frequency with which a work activity is performed), Performance Expectation (how soon on the job the performance of an activity is expected), and Consequence (the consequence of performing an activity incorrectly). The performance expectation scale was specifically designed to distinguish entry-level skills. These three questions and the instructions for answering them are presented in Table 2.

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Table 2. Survey Questions for Rating Work Activity Statements

In this section, activities potentially performed by clinical nurse specialists working with adult-gerontology and pediatric populations are listed.

As you complete this section of the survey, please respond from the persective of one who is newly certified as a clinical nurse specialist working with the population of patients with whom you are certified to work and has the following qualifications: -- a current, active RN license

-- a master's from a clinical nurse specialist program specific to the population of the certification -- 500 faculty supervised clinical hours

-- Course work in advanced health assessment, advanced pharmacology, and advanced pathophysiology

Please respond to each activity with three separate responses, one response in each category. When considering a response for one category, do not consider the other categories. For example: When considering the consequences of incorrect performance of an activity, do not worry about whether you perform or are expected to perform the activity; the possibility exists that an activity has severe consequences, even if you never perform it.

Performance Expectation: When is a newly certified clinical nurse specialist working with your specific population first expected to perform this activity?

-- Within the first 6 months of working within the role. -- After the first 6 months of working within the role. -- Never expected to perform this activity within the role.

Frequency: How often does a newly certified clinical nurse specialist working with your specialty perform this activity (consider within a one year period)?

-- Frequently -- Often -- Occasionally -- Seldom -- Never

Consequences: Does incorrect performance of this activity cause: -- Little or no harm (i.e. negative consequences)?

-- Mild harm (i.e. negative consequences)? -- Moderate harm (i.e. negative consequences)? -- Severe harm (i.e. negative consequences)?

The study design included combining each respondent’s responses to each of the three rating scales in a hierarchical manner into one overall ranking of criticality. To select a procedure for combining the three scales, importance of each scale to the performance of the work activity was considered. Performance expectation scale was determined to be regarded as more critical than the other two scales for representing entry-level practice. The consequence scale was then regarded as more critical than the frequency scale. Therefore, the scales were combined so that a particular value on the performance expectation scale would outweigh or outrank all values on the consequence and frequency scales. This hierarchical scheme emphasized the work activities that are required of new practitioners immediately on the job and have the greatest impact on public health or safety. Thus this scheme was selected as the organizing mechanism for combining the responses from the three survey scales into an overall measure of criticality.

Data Collection

Pilot Testing. Using the same procedures intended for administering the national data

collection, the survey was piloted in June and July 2012. Twenty-five ANCC certified adult health clinical nurse specialists and 25 gerontological clinical nurse specialists randomly selected from across the nation were included in the sample of 75 ANCC certified clinical nurse specialists

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invited to take the pilot survey. Overall, 24 of the clinical nurse specialists invited to take the pilot survey responded; nine of these respondents were adult health clinical nurse specialists and eight were gerontological clinical nurse specialists.

The respondents of the pilot test in general indicated that the work activities were appropriate and reflective of the job of the clinical nurse specialist.

National Survey. On August 13, 2012, the 1,300 clinical nurse specialists (including 559

adult health clinical nurse specialists and 559 gerontological clinical nurse specialist) selected to take the national web-based survey were sent an alert letter explained the purpose and

importance of the study, the eligibility criteria of the study, and stated how to access the survey via the internet. The letter indicated that the participant’s responses would be kept confidential.

The letter also notified that respondents completing the survey receive a 5 hour reduction of their continuing education requirement for their ANCC recertification.

A follow-up reminder letter was sent approximately two-weeks after the alert letter. It thanked recipients if they had already submitted their completed survey and encouraged them to do so if they had not already.

A final follow-up reminder letter was sent out only to those who had not yet responded to the survey and was sent out approximately two-weeks prior to the end of the survey.

Data Analysis

The three rating scales used in the survey were combined into a single measure of overall criticality using a hierarchical method. As agreed by the initial study workgroup, the three rating scales were combined into a single measure in such a manner that a particular value on the performance expectation scale would outweigh or outrank all values on the consequence and frequency scales, and that a particular value on the consequence scale would outweigh or outrank all values on the frequency scale.

Table 3 displays how the values of the overall criticality rating were constructed according to all the possible survey response patterns that might be given to rate an individual work activity by its frequency, performance expectation, and consequence. For example, if a respondent indicated that a particular work activity was expected to be performed within the first six months of assuming the role of a clinical nurse specialist, could cause severe harm if it was performed incorrectly, and is performed occasionally, the overall criticality rating for that response pattern would be 39. A score of 32 suggests that a work activity is generally expected to be performed within the first six months of assuming the role of a clinical nurse specialist and could cause moderate harm if incorrectly performed. Therefore, work activities with scores of 32 or higher on the overall criticality variable may be considered as highly critical. When a work activity was rated as never expected on the performance expectation scale, it would receive an overall criticality score of 1 as the bottom row in Table 3 indicates.

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Table 3. Construction of the Overall Criticality Variable

Criticality Ranking Performanc Expectations Consequences Frequency

Within the first 6 months of

working within the role Severe Harm Frequently Often 41 40 Occasionally 39

Seldom 38

Never 37

Moderate Harm Frequently 36

Often 35

Occasionally 34

Seldom 33

Never 32

Mild Harm Frequently 31

Often 30

Occasionally 29

Seldom 28

Never 27

Little or no Harm Frequently 26

Often 25

Occasionally 24

Seldom 23

Never 22

After the first 6 months of

working within the role Severe Harm Frequently _Often 21 ₂₀ Occasionally 19

Seldom 18

Never 17

Moderate Harm Frequently 16

Often 15

Occasionally 14

Seldom 13

Never 12

Mild Harm Frequently 11

Often 10

Occasionally 9

Seldom 8

Never 7

Little or no Harm Frequently 6

Often 5

Occasionally 4

Seldom 3

Never 2

Never Expected to perform

this activity within the role 1

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Survey Results

The total sample size of the national survey included 1,118 adult health and

gerontological clinical nurse specialists (559 each per adult health clinical nurse specialist and gerontological clinical nurse specialist). A total of 397 adult health clinical nurse specialist and gerontological nurse specialist responses were returned. Of these 107 respondents indicated they were not currently practicing. The overall response rate was 35.51% percent and a total usable response rate was 28.68% percent.

Table 4 shows the percent of surveys per population returned in each geographic region compared to the number of ANCC certified adult health clinical nurse specialist and

gerontological clinical nurse specialist selected within the region.

Table 4. Number of Surveys Returned per Geographic Region

Geographic Region

Adult Health CNS Gerontological CNS

Number Selected (percent of total pop.) Number Return (percent of total pop.) Number Selected (percent of total pop.) Number Return (percent of total pop.) Northeast – NY, CT, MA, NJ, ME, PA,

NH, VT, RI 71(12.70) 18 (12.77) 125 (22.36) 32 (21.48)

South – TN, MS, TX, FL, LA, AL, GA,

AR, OK, VA, MD, SC, DC, NC, WV, DE, KY

201 (35.96) 40 (28.37) 155 (27.73) 38 (25.50)

Midwest – IA, NE, KS, OH, MO, MN,

SD, ND, MI, IL, IN, WI 227 (40.61) 61 (43.26) 206 (36.85) 62 (41.61)

West – WA, AZ, CA, OR, CO, AK, ID,

NM, UT, HI, NV, WY, MT 58 (10.38) 21 (14.89) 73 (13.06) 17 (11.41)

Other – AE, AP, APO 2 (0.36) 1 (0.71) 0 (0.00) 0 (0.00)

Total 559 (100.00) 141 (100.00) 559 (100.00) 149 (100.00)

Demographic Information

Appendix B details the adult-gerontological clinical nurse specialist survey respondents’

responses to the survey’s 17 demographic questions which included inquiry on the clinical nurse specialist’s background and practice setting.

Demographic Background

Ninety seven percent of the respondents were female and 93 percent reported to be white. Seventy one percent of the adult-gerontological clinical nurse specialist respondents indicated they were between the ages of 45 and 64.

Ninety percent of the adult-gerontological clinical nurse specialists reported having a Masters in Nursing as one of their highest degrees. Seven percent of the respondents indicated having a Masters in a field other than nursing and six percent indicated having a Doctorate in Nursing Research.

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The average number of years of experience that the adult-gerontological clinical nurse specialists had as a registered nurse was 29 years and as a clinical nurse specialist was 13 years.

Practice Settings

Overall, approximately 41 percent of the adult-gerontological respondents indicated that they practiced in cities with populations between 50,000 and 249,999. Metropolitian areas with populations between 250,000 – 999,999 had the second highest percent of respondents (23 percent). Just over one percent of the respondents indicated working in rural communities with populations less than 2,500.

The Hospital, Inpatient setting had the highest percent of adult-gerontological clinical nurse specialist respondents indicating that it was among their primary work setting (50 percent). Outpatient settings, University School or College of Nursing, and Owned Practice (group) came in next with 18, 17, and 16 percent respectively.

Eighty percent of the adult-gerontological clinical nurse specialist respondents indicated that their primary patient/client base included Patients with Chronic Conditions. Sixty two percent of the respondents reported working with Patients with Acute Conditions, while 53 percent reported working with Patients with Geriatric Syndromes. The adult-gerontological clinical nurse specialist respondents also reported spending on average approximately 25 – 28 percent of their time with each of the following age groups: adults (18 – 64 years old); Young-Old (65 to 74 years old); and Middle-Old (75-84 years old). On average, approximately nineteen percent of their time was spent providing care for patients 85 years old or older. When asked what percent of time they spend in direct care, the adult-gerontological clinical nurse specialist indicated on average approximately 33 percent of their time. They reported on average 17 percent of their time in Consultation/Collaboration and 15 percent of their time in

Education/Coaching.

Overall, 54 percent of the adult-gerontological clinical nurse specialist respondents indicated that they are required to have a physician collaborator/supervisor for their practice. Twenty three percent of the respondents indicated that their services are billed directly and 15 percent indicated they are billed under another provider. Finally, 14 percent indicated they have staff privilieges to admit/discharge patients/clients from a facility.

Practice Descriptions

Descriptive statistics (means, standard deviations, and medians) for the three ratings of all 124 work activities—performance expectation, consequence, and frequency—and mean overall criticality are listed in Appendix C. The scales were highly reliable. Cronbach’s

coefficient alpha estimates for the performance expectation, consequence, and frequency scales when applied to all the data were 0.9620, 0.9909, and 0.9777 respectively. (Cronbach's

coefficient alpha, a measure of internal stability, ranges in value between 0 and 1.)

In Appendix D, the overall criticality statistics are presented in rank order of criticality. As indicated in Table 5, six work activity statements were rated by the adult-gerontology clinical nurse specialist respondents as highly critical (with a mean overall criticality rank of 32 or above).

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Table 5. Number of Work Activities by Mean Overall Criticality Range for Adult-Gerontological Clinical Nurse Specialist Mean Overall Criticality Score

37.0 and above Between 32.0 and 36.9 Between 27.0 and 31.9 Between 22.0 and 26.9 Between 17.0 and 21.9 Between 12.0 and 16.9 Between 7.0 and 11.9 Between 6.9 and under Total number above 32.0 Number of Work Activities 0 6 26 21 39 29 3 0 6

Table 6 and 7 displays the 20 highest-ranking and the 20 lowest-ranking work activities by mean overall criticality respectively. The grey shading in Table 6 indicates the six work activities that received criticality ratings of 32 and above. Three of these tasks, including the highest task fell into the domain Ethical Decision-making, Moral Agency and Advocacy. The other three of the highest ranked tasks fell into the domain Direct Care.

The three lowest ranked work activities that received criticality rankings less than 12 are are shaded in grey in Table 7. Two of these three tasks fell into the domain Evidence-base Practice and Research. The other task among these three was part of the Systems domain.

Table 6. Top 20 Work Activities Ranked by Mean Overall Criticality Work Activity Number and Name

Mean Overall Criticality

Std Dev

26 Document in accordance with regulatory requirements 36.29 5.48 110 Advocate for the patient and/or family when there is concern about abuse, neglect or other forms of

violence 35.92 7.96

117 Promote professional accountability in self and others 35.26 7.82 116 Promote a practice climate conducive to providing ethical care 33.68 9.08

4 Interprets values/results of laboratory and diagnostic tests with consideration of age, ethnicity, and

health status 33.66 8.75

2 Perform a problem-focused assessment and examination (e.g., functional assessment, physical

assessment) 33.61 7.09

8 Collaborate with the patient, family and interprofessional team to develop plan of care to achieve

desired outcomes 31.83 7.00

1 Perform a comprehensive, holistic, age-appropriate assessment using advanced assessment

techniques 31.79 8.77

6 Prioritize health problems/needs in collaboration with patient and family, nurse and interdisciplinary

team 31.62 7.82

18 Provide education for patient and/or family with complex learning needs 31.46 7.45 17 Employ evidence-based clinical practice guidelines to guide prevention, screening, diagnosis and

treatment 31.41 9.18

22 Evaluate the plan of care based on patient and family response 31.11 7.80 23 Modify the plan of care based on patient and family response 30.95 8.30 44 Promote compliance with regulatory (i.e. local, state, federal), accreditation (e.g. Magnet, The Joint

Commission) and professional standards 30.92 11.10 122 Address patient-specific ethical and/or moral dilemmas 30.70 10.67 100 Incorporate evidence into clinical practice (e.g., clinical decision-making, policies and

procedures/protocols, standards, guidelines, products and technologies) 30.05 10.49 82 Serve as a role model to colleagues, patients, families, community 29.92 10.26 45 Promote a supportive and healthy work environment (e.g. team development, conflict resolution,

respect, accountability, civility, Just Culture) 29.77 10.67 3 Assess the effects of interactions among the patient, family, community, social systems, and physical

environment on health and illness 29.15 9.08 120 Identify ethical implications of complex care situations, e.g. use of technology and end of life care 29.05 11.34

Grey shading represent work activities that received criticality ranking of 32 and above.

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Table 7. Bottom 20 Work Activities Ranked by Mean Overall Criticality Work Activity Number and Name

Mean Overall Criticality

Std Dev

52 Analyze the impact of social, political, regulatory and economic forces on the delivery of care 15.24 10.78 89 Mentor professional colleagues through the process of quality improvement 15.12 10.61 95 Evaluate the effectiveness of interprofessional, intra-agency, and inter-agency collaboration 14.78 10.73 102 Conduct a study/investigation to evaluate new products, technologies, and techniques 14.70 10.87 43 Evaluate population specific programs/innovative models of practice across the continuum of care 14.61 9.48 106 Establish collaborative relationships with nurse scientists 14.54 11.70 81 Mentor professional colleagues (e.g., nurses, administrators, physicians, therapist) 14.43 9.99 41 Design population specific programs/innovative models of practice across the continuum of care 14.29 9.79 109 Disseminate evidence-based practice and/or research findings locally, nationally, or internationally 14.28 10.63 38 Evaluate impact of CNS and nursing practice on systems of care 14.27 10.17 79 Precept graduate nursing students 14.17 9.39 30 Serve as content expert for legal and/or health policy issues 13.55 9.83 46 Analyze fiscal and budgetary implications of practice and system modifications 13.51 10.63 31 Serve as content expert in the development of population specific documentation systems 13.48 10.14 78 Coach others in creating presentations and generating publications 13.33 10.57 58 Assist in the mobilization of organizational resources for local, state, and national emergencies 12.63 11.90 80 Precept new clinical nurse specialists to the role 12.59 7.74 104 Interact with an institutional review board 11.71 10.76 47 Analyze programs, processes and technologies based on business and economic principles 11.48 9.93 103 Apply for grants or local/organizational research funding 8.67 8.00

Grey shading represent work activities that received criticality rankings less than 12.

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Appendix A

Work Activities Statements

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Task List for Final Survey

I. Direct Care

1. Perform a comprehensive, holistic, age-appropriate assessment using advanced assessment techniques 2. Perform a problem-focused assessment and examination (e.g., functional assessment, physical assessment) 3. Assess the effects of interactions among the patient, family, community, social systems, and physical environment on

health and illness

4. Interprets values/results of laboratory and diagnostic tests with consideration of age, ethnicity, and health status 5. Formulate differential diagnoses

6. Prioritize health problems/needs in collaboration with patient and family, nurse and interdisciplinary team 7. Evaluate the impact of health care delivery options on the plan of care and treatment choices

8. Collaborate with the patient, family and interprofessional team to develop plan of care to achieve desired outcomes 9. Design strategies and therapies to meet the multifaceted needs of the complex patient or a population

10. Prescribe pharmacologic therapies

11. Prescribe non-pharmacologic therapies (e.g., wound care, behavioral therapies, physical therapies) 12. Prescribe durable medical equipment (DME)

13. Prescribe diagnostic and laboratory tests

14. Assist patient and family with making decisions regarding palliative care and/or end-of-life care 15. Provide case management and/or coordination of care

16. Perform advanced clinical procedures (e.g., complex wound management, vascular access management) 17. Employ evidence-based clinical practice guidelines to guide prevention, screening, diagnosis and treatment 18. Provide education for patient and/or family with complex learning needs

19. Provide anticipatory guidance and/or health promotion counseling

20. Provide psychosocial support for patient and/or family with complex emotional needs 21. Refer patient and family to other health care professionals and community resources 22. Evaluate the plan of care based on patient and family response

23. Modify the plan of care based on patient and family response 24. Initiate interprofessional care conferences and/or consultations 25. Facilitate integrated care for the patient and family across the continuum 26. Document in accordance with regulatory requirements

II. Consultation

27. Serve as content expert for patient and family advocacy groups

28. Serve as content expert for nursing orientation, nurse residency or internship programs 29. Serve as content expert for professional practice

30. Serve as content expert for legal and/or health policy issues

31. Serve as content expert in the development of population specific documentation systems 32. Provide consultation to develop population-specific educational programs

33. Provide consultation to develop methods to evaluate outcomes of educational interventions 34. Provide consultation in the development of population specific interprofessional guidelines for care 35. Provide consultation in performance improvement/quality initiatives

36. Provide consultation in the analysis of patient acuity levels and safe staffing 37. Disseminate consultation findings to stakeholders

III. Systems

A. Leadership

38. Evaluate impact of CNS and nursing practice on systems of care

39. Identify opportunities for practice changes and improvements based on benchmarks 40. Conduct audits to identify gaps in the system that affect patient care delivery

41. Design population specific programs/innovative models of practice across the continuum of care 42. Implement population specific programs/innovative models of practice across the continuum of care 43. Evaluate population specific programs/innovative models of practice across the continuum of care

Appendix A– Work Activities Statements A-2

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Task List for Final Survey

44. Promote compliance with regulatory (i.e. local, state, federal), accreditation (e.g. Magnet, The Joint Commission) and professional standards

45. Promote a supportive and healthy work environment (e.g. team development, conflict resolution, respect, accountability, civility, Just Culture)

46. Analyze fiscal and budgetary implications of practice and system modifications

47. Analyze programs, processes and technologies based on business and economic principles

48. Analyze the impact of physical environment (e.g., equipment access, room/unit design) and system factors on patient care delivery

49. Facilitate integration of organizational mission, goals, and systems in patient care practices

50. Perform system level assessments to identify variables that influence nursing practice and outcomes 51. Promote innovative systems thinking among the health care team

52. Analyze the impact of social, political, regulatory and economic forces on the delivery of care 53. Provide input into the design of information systems

54. Provide support for the use of information systems related to the delivery of care across the continuum 55. Evaluate the impact of information systems on the delivery of patient care

56. Use information technologies to enhance patient care

57. Evaluate impact of introduction or withdrawal of products, services, or technologies

58. Assist in the mobilization of organizational resources for local, state, and national emergencies 59. Assist in accreditation and credentialing initiatives

60. Assist in staff recognition initiatives

61. Serve on committees, councils, or administrative teams 62. Promote system-wide policies and protocols

63. Develops and maintains age- and population-specific clinical standards, algorithms, policies, procedures, protocols, and guidelines

B. Quality and Safety

64. Collect data for submission to appropriate national data bases

65. Facilitate review (e.g., root cause analysis, sentinel event analysis, FMEA) of patient safety issues to identify the need for a quality improvement initiative

66. Facilitate an interprofessional approach to quality improvement

67. Formulate evidence-based recommendations to improve quality care and practice based on an analysis of quality data. 68. Implement initiatives to address unit, department, system, program, or population quality improvement priorities 69. Disseminate data relative to quality improvement initiatives (e.g., dash board, report card)

C. Outcomes

70. Facilitate the development of outcome measures

71. Identify outcomes with consideration of the associated risks, benefits, and costs for the patient and family 72. Differentiate between outcomes that require care process modification at the individual patient level and those that

require modification at the system level –

73. Integrate organizational science and informatics to make changes in the care environment to improve health outcomes 74. Manage change initiatives to improve outcomes

75. Disseminate outcomes of system-level change internally and externally

IV. Coaching/Education

76. Coach patient and family to navigate the healthcare system 77. Coach colleagues in team building

78. Coach others in creating presentations and generating publications 79. Precept graduate nursing students

80. Precept new clinical nurse specialists to the role

81. Mentor professional colleagues (e.g., nurses, administrators, physicians, therapist)

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Task List for Final Survey

82. Serve as a role model to colleagues, patients, families, community 83. Provide feedback and evaluation of others

84. Design health information and population–specific education 85. Provide community based education

86. Provide direct education to nurses or other health care professionals

87. Facilitate continuing education and professional development of nurses and other health care professionals 88. Perform a learning needs assessment

89. Mentor professional colleagues through the process of quality improvement

90. Mentor professional colleagues through research utilization and evidence-based practice.

V. Collaboration

91. Establish collaborative relationships within and across roles/providers, departments, organization, networks, and/or agencies.

92. Establish collaborative relationships with academic partners (e.g., faculty, schools of nursing). 93. Partner with leadership to establish patient care provider competencies and evaluation of practice. 94. Facilitate interprofessional, intra-agency and inter-agency collaborations for transitioning care 95. Evaluate the effectiveness of interprofessional, intra-agency, and inter-agency collaboration

96. Engage in formal self-evaluation seeking feedback regarding own practice, from patients, peers, professional colleagues and others

VI. Evidence-based Practice and Research

97. Promote scholarly inquiry (e.g., journal club, research grand rounds, and research article review) 98. Identify clinical problems amenable to scholarly inquiry

99. Identify barriers and facilitators in the adoption of evidence-based practices.

100. Incorporate evidence into clinical practice (e.g., clinical decision-making, policies and procedures/protocols, standards, guidelines, products and technologies)

101. Analyze all sources of evidence for application to nursing practice

102. Conduct a study/investigation to evaluate new products, technologies, and techniques 103. Apply for grants or local/organizational research funding

104. Interact with an institutional review board

105. Serve as a team member on a research or evidenced based practice project (e.g., obtaining consent, collecting data, literature review, developing proposal, analyzing data)

106. Establish collaborative relationships with nurse scientists 107. Protect the rights of all participants involved in research.

108. Communicate evidence based practice guidelines to the interprofessional team

109. Disseminate evidence-based practice and/or research findings locally, nationally, or internationally

VII. Ethical Decision-making, Moral Agency and Advocacy

110. Advocate for the patient and/or family when there is concern about abuse, neglect or other forms of violence 111. Advocate for patient care issues at the organizational, state or national level

112. Advocate for the moral and legal rights of patients, families, groups and communities 113. Advocate for nurses to practice to the full extent of their education and scope of practice 114. Advocate for the nursing profession to internal and external policy makers and stakeholders 115. Advocate for a process of ongoing ethical inquiry into patient care practices

116. Promote a practice climate conducive to providing ethical care 117. Promote professional accountability in self and others

118. Promote the role and scope of practice of the CNS to legislators, regulators, other health care providers and the public 119. Facilitate patient, family, and healthcare team understanding of the ethical concerns, risks, benefits, and outcomes of

proposed healthcare regimen to promote informed decision making

120. Identify ethical implications of complex care situations, e.g. use of technology and end of life care 121. Identify system-specific ethical and/or moral dilemmas

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Task List for Final Survey

122. Address patient-specific ethical and/or moral dilemmas

123. Address health care provider-specific ethical and/or moral dilemmas

124. Evaluate the impact of scientific advances, cost, clinical effectiveness, patient/family values and preferences, and other external influences on patient care delivery

(21)

Appendix B

Demographic Data Summary

(22)

1. Primary Place of Work

Adult Health CNS Gerontological CNS Recruitment Counts (Percents) Respondents Counts (Percents) Recruitment Counts (Percents) Respondents Counts (Percents) Northeast 71 (12.70) 18 (12.77) 125 (22.36) 32 (21.48) South 201 (35.96) 40 (28.37) 155 (27.73) 38 (25.50) Midwest 227 (40.61) 61 (43.26) 206 (36.85) 62 (41.61) West 58 (10.38) 21 (14.89) 73 (13.06) 17 (11.41) Other 2 (0.36) 1 (0.71) 0 (0.00) 0 (0.00) Total 559 (100.00) 141 (100.00) 559 (100.00) 149 (100.00)

2. What is your gender?

Count Percent Female 280 96.89 Male 9 3.11 Total 289 100.00 Missing 1

3. What is your age?

Count Percent

Under 25 years old 0 0.00

25 - 34 years old 15 5.19 35 - 44 years old 41 14.19 45 - 54 years old 91 31.49 55 - 64 years old 115 39.79 65 and older 27 9.34 Total 289 100.00 Missing 1

Appendix B– Demographic Data Summary B-2

2012 Role Delineation Study: Adult-Gerontology Clinical Nurse Specialist –

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4. What is your race/ethnic background and Race? Count Percent Hispanic 2 0.71 Non-Hispanic 280 99.29 Total 282 100.00 Missing 8 Count Percent White 268 93.38 Black/African American 12 4.18

American Indian/Alaska Native 1 0.35

Asian or Pacific Islander 5 1.74

Two or More 1 0.35

Other 0 0.00

Total 287 100.00

Missing 3

5. Indicate the highest educational level you have completed:

Masters in Nursing 261 90.00

Masters in field other than Nursing 21 7.24

Post-Masters Certificate 8 2.76

Doctorate in Nursing Research (e.g., Ph.D., DNS, DSN) 16 5.52

Doctorate in Nursing Practice (DNP) 1 0.34

Doctorate in field other than Nursing 7 2.41

Other 12 4.14

Missing 1

*The percentage is computed using "Total = 290 "; however, the total counts are larger as this question asks the respondents to choose all that apply

(24)

6a. How many years of experience do you have as a registered nurse?

Number of Years Count Percent

0 to 9 19 6.57 10 to 19 40 13.84 20 to 29 66 22.84 30 to 39 114 39.45 40 to 49 47 16.26 50 to 59 3 1.04 Total 289 100.00 Missing 1 Mean 29.23

6b. How many years of experience do you have practicing as a Clinical Nurse Specialist?

Number of Years Count Percent

0 to 9 109 37.72 10 to 19 92 31.83 20 to 29 75 25.95 30 to 39 12 4.15 40 to 49 1 0.35 50 to 59 0 0.00 Total 289 100.00 Missing 1 Mean 13.49

(25)

7. Which one best characterizes your current clinical practice location(s)?

Rural (population less than 2,500) 4 1.39 Town (population between 2,500 - 49,999) 46 15.97 City (population between 50,000 - 249,999) 118 40.97 Metropolitan (population between 250,000 - 999,999) 66 22.92 Greater Metropolitan (population greater than 999,999) 52 18.06

National 2 0.69

Total 288 100.00

Missing 2

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A p p e n d ix B – D emo g rap h ic D at a S u mm ar y B -6 20 1 2 R o le D e lin e a tio n S tu d y : A d u lt -G er o n to lo g y C lin ical N u rse S p eci al ist – N at io n al S u rvey R e su lt s

8. Estimate the percentage of time (during an average week) that you provide health care for patients/clients in each of the age groups listed below.

Infant Preschool School age Adolescent Adult

(birth to 1 years) (2 to 4 years) (5 to 12 years) (13 to 17 years) (18 to 64 years)

Percent of Time Count Percent Count Percent Count Percent Count Percent Count Percent

Below 1% 276 95.17 272 93.79 268 92.41 249 85.86 49 16.90 1% to 19% 13 4.48 17 5.86 21 7.24 39 13.45 60 20.69 20% to 39% 1 0.34 1 0.34 1 0.34 2 0.69 98 33.79 40% to 59% 0 0.00 0 0.00 0 0.00 0 0.00 53 18.28 60% to 79% 0 0.00 0 0.00 0 0.00 0 0.00 17 5.86 80% to 100% 0 0.00 0 0.00 0 0.00 0 0.00 13 4.48 Total 290 100.00 290 100.00 290 100.00 290 100.00 290 100.00

Infant Preschool School age Adolescent Adult

(birth to 1 years) (2 to 4 years) (5 to 12 years) (13 to 17 years) (18 to 64 years)

Mean percent of time spent

with each age group 0.25 0.30 0.46 0.79 26.72

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A p p e n d ix B – D emo g rap h ic D at a S u mm ar y B -7 20 1 2 R o le D e lin e a tio n S tu d y : A d u lt -G er o n to lo g y C lin ical N u rse S p eci al ist – N at io n al S u rvey R e su lt s

8. Estimate the percentage of time (during an average week) that you provide health care for patients/clients in each of the age groups listed below.

Young-Old Middle-Old Oldest-Old

(65 to 74 years) (75 to 84 years) (85 years and older)

Percent of Time Count Percent Count Percent Count Percent

0% 15 5.17 3.79 3.79 24 8.28 1% to 19% 39 13.45 22.07 22.07 140 48.28 20% to 39% 177 61.03 55.86 55.86 90 31.03 40% to 59% 52 17.93 15.52 15.52 24 8.28 60% to 79% 7 2.41 2.41 2.41 8 2.76 80% to 100% 0 0.00 0.34 0.34 4 1.38 Total 290 100.00 290 100.00 290 100.00

Young-Old Middle-Old Oldest-Old

(65 to 74 years) (75 to 84 years) (85 years and older)

Mean percent of time spent

(28)

9. What is your primary patient/client base? (Select all that apply)

Well Patients 36 12.41

Maternity Patients 2 0.69 Patients with Acute Conditions 180 62.07 Patients with Chronic Conditions 231 79.66 Terminally Ill Patients 106 36.55 Patients with Behavioral/Emotional/Psychiatric Disorders 86 29.66 Patients with Geriatric Syndromes 153 52.76

Others 34 11.72

10. Which best describes your current primary employment setting?

Armed Forces 8 2.76

Community/Public Health (city/county/state/federal agency) 10 3.45

Home Health Care 13 4.48

Hospice/Palliative Care 23 7.93

Hospital, Inpatient 145 50.00

Managed Care (HMO, PPO, IPA) 8 2.76

Medical School 7 2.41

Not-for-Profit Clinic 5 1.72

Occupational Health 2 0.69

Outpatient 51 17.59

Owned Practice (group) 45 15.52

Owned Practice (solo) 3 1.03

Private Medical Practice 15 5.17

Rural Health Clinic 6 2.07

Skilled Nurse/Subacute/Long-Term Care 8 2.76

School or College Health 7 2.41

University School or College of Nursing 48 16.55

VA 21 7.24

Other 23 7.93

*The percentage is computed using "Total = 290 "; however, the total counts are larger as this question asks the respondents to choose all that apply

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11. Do you have prescriptive authority for:

a) medications in your current practice 118 40.69

b) controlled substance 94 32.41

c) non-pharmacologic interventions (e.g., wound care,

durable medical equipment) 122 42.07

12. Consider the care you provided within the past year. Estimate the percent of patient cases for which you prescribed/managed medications within each of these drug agent categories.

Number/Percent of Respondents Who Prescribed or Managed Medications within the Drug

Agent Category during one or more percent of patient

visits Count Percent Antiinfective agents 125 43.10 Antineoplastic agents 28 9.66 Cardiovascular agents 104 35.86 Endocrine agents 83 28.62

Eye, ear, and skin agents 96 33.10

Gastrointestinal agents 102 35.17 Genitourologic agents 78 26.90 Immunologic agents 46 15.86 Musculoskeletal agents 96 33.10 Neurologic agents 88 30.34 Psychiatric agents 93 32.07 Respiratory agents 86 29.66

13. Are you required to have:

a) a physician collaborator/supervisor for your practice 158 54.48

b) a physician collaborator/supervisor for your prescriptive

practice only 59 20.34

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A p p e n d ix B – D emo g rap h ic D at a S u mm ar y B -10 20 12 R o le D e lin e a tio n S tu d y : A d u lt -G er o n to lo g y C lin ical N u rse S p eci al ist – N a tio n a l S u rvey R e su lt s

14. Approximately what percentage of your average week is spent in each of the following activities?

Quality Improvement and

Direct Research/Evidence-based Consultation/ Education/ Risk Assessment Administrative or

patient care Practice Collaboration Coaching (Systems Leadership) Supervisory

Percent of

Time Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent

0% 43 14.83 74 25.52 24 8.28 27 9.31 85 29.31 148 51.03 1% to 19% 91 31.38 177 61.03 155 53.45 135 46.55 146 50.34 100 34.48 20% to 39% 44 15.17 33 11.38 88 30.34 85 29.31 49 16.90 22 7.59 40% to 59% 33 11.38 2 0.69 12 4.14 23 7.93 6 2.07 11 3.79 60% to 79% 41 14.14 3 1.03 2 0.69 17 5.86 2 0.69 7 2.41 80% to 100% 38 13.10 1 0.34 9 3.10 3 1.03 2 0.69 2 0.69 Total 290 100.00 290 100.00 290 100.00 290 100.00 290 100.00 290 100.00 Quality Improvement and

Direct Research/Evidence-based Consultation/ Education/ Risk Assessment Administrative or

patient care Practice Collaboration Coaching (Systems Leadership) Supervisory

Mean percent of time spent with each

(31)

14. Approximately what percentage of your average week is spent in each of the following activities? (Continued)

Other

Percent of Time Count Percent

0% 251 86.55 1% to 19% 31 10.69 20% to 39% 4 1.38 40% to 59% 4 1.38 60% to 79% 0 0.00 80% to 100% 0 0.00 Total 290 100.00 Other Mean percent of time spent with each

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A p p e n d ix B – D emo g rap h ic D at a S u mm ar y B -12 2012 R o le D e lin e a tio n S tu d y : A d u lt -G er o n to lo g y C lin ical N u rse S p eci al ist – N a tio n a l S u rvey R e su lt s © C opy right 2013 A m er ic an N ur s e s C redent ial ing C ent er , A ll R ight s R es er v ed

15. On average, what percentage of your patient visits are pertaining to conditions related to each of the body systems listed below.

Head, Eyes, Ears Respiratory Cardiovascular Gastrointestinal Genitourinary and Musculoskeletal

Nose and Throat System System System Reproductive Systems System

Percent of Time Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent

Below 1% 185 63.79 102 35.17 83 28.62 118 40.69 166 57.24 121 41.72 1% to 19% 95 32.76 107 36.90 72 24.83 130 44.83 107 36.90 115 39.66 20% to 39% 7 2.41 72 24.83 91 31.38 28 9.66 12 4.14 34 11.72 40% to 59% 0 0.00 7 2.41 14 4.83 6 2.07 1 0.34 9 3.10 60% to 79% 0 0.00 0 0.00 7 2.41 1 0.34 2 0.69 2 0.69 80% to 100% 2 0.69 2 0.69 23 7.93 7 2.41 2 0.69 9 3.10 Total 290 100.00 290 100.00 290 100.00 290 100.00 290 100.00 290 100.00

Head, Eyes, Ears Respiratory Cardiovascular Gastrointestinal Genitourinary and Musculoskeletal

Nose and Throat System System System Reporductive Systems System

Mean percent of time spent treating conditions within each body system 5.15 12.87 19.10 9.01 6.10 13.50

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13. On average, what percentage of your patient visits are pertaining to conditions related to each of the body systems listed below. (Continued) Endocrine System

Neurological (including metabolic Hematopoietic Immune Integumentary

System disorders) System System System

Percent of Time Count Percent Count Percent Count Percent Count Percent Count Percent

0% 107 36.90 139 47.93 202 69.66 197 67.93 143 49.31 1% to 19% 115 39.66 117 40.34 83 28.62 88 30.34 104 35.86 20% to 39% 28 9.66 23 7.93 5 1.72 2 0.69 19 6.55 40% to 59% 13 4.48 6 2.07 0 0.00 2 0.69 8 2.76 60% to 79% 3 1.03 2 0.69 0 0.00 0 0.00 4 1.38 80% to 100% 24 8.28 3 1.03 0 0.00 1 0.34 12 4.14 Total 290 100.00 290 100.00 290 100.00 290 100.00 290 100.00 Endocrine System

Neurological (including metabolic Hematopoietic Immune Integumentary

System disorders) System System System

Mean percent of time spent treating conditions within each

(34)

16. Are your services billed for reimbursement?

Yes, they are billed directly 67 23.59

Yes, they are billed under another provider 43 15.14

No, my services are not billed for reimbursement 174 61.27

Total 284 100.00

Missing 6

17. Do you have staff privileges to admit/discharge patients/clients from a facility?

Count Percent Yes 39 13.59 No 248 86.41 Total 287 100.00 Missing 3

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Appendix C

Work Activities Descriptive Statistics

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A p p e n d ix C – W o rk A ct ivi ties D escr ip tiv e Sta ti s ti c s C 2012 R o le D e lin e a tio n S tu d y : A d u lt -G er o n to lo g y C lin ical N u rse S p eci al ist – N at io n al S u rvey R e su lt s

Adult-Gerontology Clinical Nurse Specialist Survey Order

Performance

Expectation Consequence Frequency Overall Rank

N Mean Dev Std Med-ian Mean Dev Std Med- ian Mean Dev Std Med- ian Mean Dev Std

1 Perform a comprehensive, holistic, age-appropriate assessment

using advanced assessment techniques 290 1.87 0.37 2 1.81 0.86 2 3.17 0.81 3 31.79 8.77 2 Perform a problem-focused assessment and examination (e.g.,

functional assessment, physical assessment) 290 1.93 0.25 2 1.94 0.84 2 3.30 0.70 3 33.61 7.09 3 Assess the effects of interactions among the patient, family,

community, social systems, and physical environment on health and illness

290 1.83 0.38 2 1.46 0.81 2 3.22 0.73 3 29.15 9.08 4 Interprets values/results of laboratory and diagnostic tests with

consideration of age, ethnicity, and health status 290 1.87 0.36 2 2.19 0.84 2 3.27 0.78 3 33.66 8.75 5 Formulate differential diagnoses 290 1.65 0.61 2 1.89 0.92 2 2.83 1.10 3 27.97 12.26 6 Prioritize health problems/needs in collaboration with patient and

family, nurse and interdisciplinary team 290 1.90 0.31 2 1.67 0.79 2 3.36 0.64 3 31.62 7.82 7 Evaluate the impact of health care delivery options on the plan of

care and treatment choices 290 1.73 0.45 2 1.52 0.81 2 3.04 0.81 3 27.28 10.36 8 Collaborate with the patient, family and interprofessional team to

develop plan of care to achieve desired outcomes 290 1.92 0.28 2 1.61 0.79 2 3.46 0.68 4 31.83 7.00 9 Design strategies and therapies to meet the multifaceted needs of

the complex patient or a population 290 1.52 0.52 2 1.76 0.81 2 3.01 0.79 3 24.34 11.33 10 Prescribe pharmacologic therapies 290 1.02 0.89 1 2.09 1.24 3 1.80 1.53 2 19.36 16.69 11 Prescribe non-pharmacologic therapies (e.g., wound care,

behavioral therapies, physical therapies) 290 1.61 0.68 2 1.68 0.89 2 2.57 1.18 3 26.65 12.42 12 Prescribe durable medical equipment (DME) 290 1.19 0.89 2 1.19 0.97 1 1.76 1.40 2 18.32 14.48 13 Prescribe diagnostic and laboratory tests 290 1.18 0.89 2 1.65 1.12 2 2.03 1.50 3 20.50 15.76 14 Assist patient and family with making decisions regarding palliative

care and/or end-of-life care 290 1.64 0.55 2 1.62 0.91 2 2.47 0.93 2 25.90 11.29 15 Provide case management and/or coordination of care 290 1.69 0.55 2 1.43 0.85 2 2.77 1.00 3 26.54 11.05

Adult - Gerontology Clinical Nurse Specialist Role Delineation Study

2012