An essential component of a certification program ACTIVITIES PERFORMED BY ACUTE AND CRITICAL CARE ADVANCED PRACTICE NURSES: AMERICAN ASSOCIATION

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BACKGROUND Accreditation standards for certification programs require use of a testing mechanism

that is job-related and based on the knowledge and skills needed to function in the discipline.

OBJECTIVES To describe critical care advanced practice by revising descriptors to encompass the work

of both acute care nurse practitioners and clinical nurse specialists and to explore differences in the practice of clinical nurse specialists and acute care nurse practitioners.

METHODS A national task force of subject matter experts was appointed to create a comprehensive

delineation of the work of critical care nurses. A survey was designed to collect validation data on 65 advanced practice activities, organized by the 8 nurse competencies of the American Association of Crit-ical-Care Nurses Synergy Model for Patient Care, and an experience inventory. Activities were rated on how critical they were to optimizing patients’ outcomes, how often they were performed, and toward which sphere of influence they were directed. How much time nurses devoted to specific care problems was analyzed. Frequency ratings were compared between clinical nurse specialists and acute care nurse practitioners.

RESULTS Both groups of nurses encountered all items on the experience inventory. Clinical nurse

spe-cialists were more experienced than acute care nurse practitioners. The largest difference was that clini-cal nurse specialists rated as more criticlini-cal activities involving cliniclini-cal judgment and cliniclini-cal inquiry whereas acute care nurse practitioners focused primarily on clinical judgment.

CONCLUSIONS Certification initiatives should reflect differences between clinical nurse specialists and

acute care nurse practitioners. (American Journal of Critical Care. 2006;15:130-148)

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By Deborah Becker, MSN, CRNP, BC,Roberta Kaplow, RN, PhD,Patricia M. Muenzen, MA,and Carol Hartigan,

RN, MA.From University of Pennsylvania School of Nursing, Philadelphia, Pa (DB),DeKalb Medical Center, Decatur, Ga (RK),Professional Examination Service, New York, NY (PMM),and AACN Certification Corpora-tion, Aliso Viejo, Calif (CH).

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n essential component of a certification pro-gram is the ability to use a testing mechanism that is job related and based on the current knowledge and skills needed to function in the disci-pline. Between 2001 and 2003, Professional Exami-nation Service undertook a comprehensive study of the practice of acute and critical care nursing on behalf of the AACN Certification Corporation, the

credentialing arm of the American Association of Critical-Care Nurses (AACN). The study was under-taken in support of all of the corporation’s current and future nursing certification initiatives in acute and critical care nursing.

This article presents the study’s findings about advanced practice nurses working with acute and crit-ically ill patients. In this report, we describe and dis-cuss the activities performed by advanced practice nurses, the spheres of influence upon which they direct their practice, and the percentage of time they devote to specific problems related to patients’ care.

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Items on an experience inventory were validated and rated relative to their uniqueness to acute and critical care.

Background

The specialty certification programs in neonatal, pediatric, and adult critical care nursing were last revised by using data collected in a 1992 role delin-eation study of critical care nursing practice.1 In that

study, subject matter experts delineated and validated the domains and tasks in critical care nursing practice and the associated knowledge and skills. Eight sys-tems—cardiovascular, pulmonary, endocrine, hema-tology/immunology, neurology, gastrointestinal, renal, and multisystem—provided the context for the delin-eation of more than 75 problems related to patients’ care. Test specifications were published in terms of percentages of questions related to systems, problems with patients’ care, and associated knowledge and skills.

In a 1997 study, subject matter experts developed 5-point rating scales to behaviorally anchor the mid-point and endmid-points of a continuum describing each characteristic of patients and nurses as outlined in the AACN Synergy Model for Patient Care (described in the next section). The 5-point rating scales for the characteristics of patients were developed to include descriptors for the most compromised patients (level 1) and the least compromised patients (level 5), as well as for midpoint patients (level 3). Similarly, each rating scale for characteristics of nurses included descriptors reflecting novice (level 1), competent (level 3), and expert (level 5) performance by a criti-cal care nurse providing direct care to a patient—con-sistent with the pattern of skill acquisition described by Benner.2

In 1998, Professional Examination Service under-took a study to delineate the practice of acute and criti-cal care CNSs in terms of the 8 competencies of nurses of the Synergy Model. Expansion of the Synergy Model to reflect CNS practice involved the identifica-tion of activities performed by CNSs. These activities were labeled level 7 competencies.3,4No study, to date,

had been done to delineate the roles and responsibili-ties of the nurse practitioner within the context of the Synergy Model.

The AACN Synergy Model for Patient Care

During the 1990s, the AACN Certification Corpo-ration convened a think tank that developed a conceptual framework for certified practice. The framework was based on the premise that certified practice is more than tasks and should be grounded in nurses meeting the

needs of patients and optimizing patients’ outcomes. The model has 3 major components: patient characteris-tics, nurse competencies, and outcomes.5

The central concept of the AACN Synergy Model for Patient Care is that the needs or characteristics of patients and patients’ families influence and drive the characteristics or competencies of nurses.6 Synergy

results when the needs and characteristics of a patient, clinical unit, or system are matched with a nurse’s competencies. Further, when patient characteristics match nurse characteristics, patients’ outcomes are optimized.7

Each patient brings a unique set of characteristics to the healthcare situation. Among the many characteris-tics, 8 are consistently associated with patients who are experiencing critical events: resiliency, vulnerability, sta-bility, complexity, resource availasta-bility, participation in care, participation in decision making, and predictability (Table 1). These characteristics underlie the needs of the patients.5,8 Each characteristic exists on a continuum

from low (level 1) to high (level 5) (Table 2).

Depending on the needs of each patient, certain competencies of nurses are required for providing care to acute and critically ill patients and their families. Table 1 Characteristics of patients from the American Asso-ciation of Critical-Care Nurses Synergy Model for Patient Care Characteristic Resiliency Vulnerability Stability Complexity Resource availability Participation in care Participation in decision making Predictability Definition Patient’s capacity to return to a

restorative level of functioning by using compensatory and coping mechanisms

Susceptibility to actual or potential stressors that may adversely affect patients’ outcomes

Ability to maintain a steady-state equilibrium

The intricate entanglement of two or more systems (eg, body, family, therapies)

Extent of resources (personal financial, social, psychological, technical, etc) that the patient, the patient’s family, and the community bring to the current situation Extent to which the patient and

the patient’s family engage in care Extent to which the patient and the

patient’s family engage in decision making with respect to care A summative characteristic that

allows one to expect a certain course of illness

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As with the patient characteristics, each competency exists on a continuum from low (level 1) to high (level 5). The 8 competencies reflect an integration of knowl-edge, skills, and experience of the nurse. The nurse characteristics of the Synergy Model are clinical judg-ment, advocacy and moral agency, caring practices, col-laboration, systems thinking, response to diversity, clinical inquiry, and facilitator of learning5,8(Table 3).

Synergy occurs and optimal outcomes may result when the competencies of the nurse complement the needs of the patient. Implicit in the interactions between patients and nurses is the notion that the patients with the greatest level of need require the nurses with the highest degree of competency.

The Synergy Model was initially based on 5 assumptions9:

1. Each patient is a biological, social, and spir-itual entity who is at a particular developmen-tal stage. The whole patient (body, mind, and spirit) must be considered.

2. Each patient, the patient’s family, and the community contribute to providing a context for the nurse-patient relationship.

3. Patients can be described by a number of characteristics. All characteristics are con-nected and contribute to each other. Charac-teristics cannot be looked at in isolation. 4. Nurses can be described in a number of Table 2 Clinical continuum of characteristics of patients from the American Association for Critical-Care Nurses Synergy Model for Patient Care

Characteristic Resiliency Vulnerability Stability Complexity Resource availability Participation in care Participation in decision making Predictability Explanation of continuum

Level 1: Minimally resilient—unable to mount a response, failure of compensatory/coping mechanisms, minimal reserves, brittle

Level 3: Moderately resilient—able to mount a moderate response, able to initiate some degree of compensation, moderate reserves

Level 5: Highly resilient—able to mount and maintain a response, intact compensatory/coping mechanisms, strong reserves, endurance

Level 1: Highly vulnerable—susceptible, unprotected, fragile

Level 3: Moderately vulnerable—somewhat susceptible, somewhat protected Level 5: Minimally vulnerable—safe, out of the woods, protected, not fragile

Level 1: Minimally stable—labile, unstable, unresponsive to therapies, high risk of death

Level 3: Moderately stable—able to maintain steady state for limited period of time, some responsiveness to therapies

Level 5: Highly stable—constant, responsive to therapies, low risk of death

Level 1: Highly complex—intricate, complex patient-family dynamics, ambiguous or vague, atypical presentation

Level 3: Moderately complex—moderately involved patient-family dynamics

Level 5: Minimally complex—straightforward, routine patient-family dynamics, simple or clear-cut, typical presentation

Level 1: Few resources—necessary knowledge and skills not available, necessary financial support not available, minimal personal/psychological supportive resources, few social systems resources Level 3: Moderate resources—limited knowledge and skills available, limited financial support available,

limited personal/psychological supportive resources, limited social systems resources Level 5: Many resources—extensive knowledge and skills available and accessible, financial resources readily

available, strong personal/psychological supportive resources, strong social systems resources Level 1: No participation—patient and patient’s family unable or unwilling to participate in care Level 3: Moderate level of participation—patient and patient’s family need assistance in care Level 5: Full participation—patient and patient’s family fully able to participate in care

Level 1: No participation—patient and patient’s family have no capacity for decision making, requires surrogacy

Level 3: Moderate level of participation—patient and patient’s family have limited capacity, seeks input or advice from others in decision making

Level 5: Full participation—patient and patient’s family have capacity and make decisions for selves Level 1: Not predictable—uncertain, uncommon population of patients or uncommon illness, unusual

or unexpected course, does not follow critical pathway or no critical pathway developed Level 3: Moderately predictable—wavering, occasionally noted population of patients or occasionally

occurring illness

Level 5: Highly predictable—certain, common population of patients or common illness, usual and expected course, follows critical pathway

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dimensions. The interrelated dimensions paint a profile of the nurses.

5. A goal of nursing is to restore each patient to an optimal level of wellness as defined by the patient.

These basic assumptions provided the guide for iden-tification of characteristics of patients and competen-cies of nurses in the model.5,8

In February 2002, a practice analysis task force was created by the AACN Certification Corporation. The group consisted of advanced practice nurses from across the United States who worked in a variety of practice settings. The task force expanded the tions of the Synergy Model to include 4 more assump-tions5,10:

1. Nurses create the environment for the care of patients. The context or environment of care also affects what a nurse can do. 2. Impact areas are interrelated, and the nature of

the interrelatedness may change as a function of experience, situation, or setting changes. 3. Nurses may work to optimize outcomes for

patients, patients’ families, healthcare pro-viders, and the healthcare system/organization. 4. Nurses bring their background to each situ-ation, including various levels of education/ knowledge and skills/experience.

Outcomes are considered patients’ conditions measured along a continuum.6Six major quality

indi-cators were identified: (1) satisfaction of patients and their families, (2) rate of adverse incidents, (3) com-plication rate, (4) adherence to the discharge plan, (5) mortality rate, and (6) each patient’s length of stay.

The Synergy Model was congruent with outcomes derived from 3 sources: patients, nurses, and the healthcare system (see Figure). Outcomes derived from the patient include functional changes, behavioral changes, trust, satisfaction, comfort, and quality of life. Outcomes derived from nursing competencies include physiological changes, the presence or absence of com-plications, and the extent to which treatment goals were reached. Outcome data derived from the healthcare sys-tem include readmission rates, length of stay, and cost utilization per case.5,6,8

Advanced Practice Nursing

Advanced practice nursing is the “application of an expanded range of practical, theoretical, and research-based therapeutics to phenomena experienced by patients within a specialized clinical area of the larger discipline of nursing.”11 The CNS is one advanced

practice role.

More than 2 decades ago, the initial delineation of CNS practice was based on job specifications or roles. Table 3 Characteristics of nurses from the American Association of Critical-Care Nurses Synergy Model for Patient Care

Characteristic Clinical judgment Advocacy and moral agency Caring practices Collaboration Systems thinking Response to diversity Clinical inquiry Facilitator of learning Definition

Clinical reasoning that includes clinical decision making, critical thinking, and a global grasp of the situation, as well as nursing skills acquired through a process of integrating formal and experiential knowledge.

Working on another’s behalf and representing the concerns of patients, patients’ families, and/or nursing staff and serving as a moral agent in identifying and resolving ethical and clinical concerns within or outside the clinical setting.

A constellation of nursing activities that creates a compassionate, supportive, and therapeutic environment with patients and staff. The aim is to promote comfort, heal, and prevent unnecessary suffering. Working with others, including physicians, patients’ families, and other healthcare providers, in a way

that promotes and encourages each person’s contributions toward achieving optimal, realistic goals for the patient. Collaboration involves intradisciplinary and interdisciplinary work with colleagues. A body of knowledge and tools that allow nurses to manage whatever environmental and system

resources exist for the patient, the patient’s family, and staff within or across healthcare and nonhealthcare systems.

The sensitivity to recognize, appreciate, and incorporate differences into the provision of care. Differences may include, but are not limited to, individuality, cultural differences, spiritual beliefs, sex, race, ethnicity, disability, family configuration, lifestyle, socioeconomic status, age, values, and alternative medicine involving patients’ families and members of the healthcare team. The ongoing process of questioning and evaluating practice and providing informed practice and

creating practice changes through research utilization and experiential knowledge.

The ability to help patients, nursing staff, physicians, and other healthcare providers learn both formally and informally.

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These roles included direct care and independent prac-tice, research, and consultation.12A few years later, the

published subroles and competencies of the CNS were modified to include clinical practice and direct care of patients, consultation, education, research, collabora-tion, and clinical leadership.7,13

Consistent with the National Association of Clini-cal Nurse Specialists Statement on CliniClini-cal Nurse Specialist Practice and Education,14the roles of a CNS

are currently described on the basis of 3 spheres of influence: (1) patients and patients’ families, (2) nurse-to-nurse, and (3) system.4,14,15

The multifaceted role of a CNS who cares for acute and critically ill patients and their families, working within an organization and with nursing staff, can also be described according to the Synergy Model. The model aligns not only the 8 characteristics of patients and the 8 competencies of nurses but also the role of the CNS in relation to the 3 spheres of influence.16

CNSs manage, support, and coordinate the care of acutely and critically ill patients with episodic illness or acute exacerbation of chronic illness7while addressing

both system and staff interaction. In Standards of Practice and Professional Performance for the Acute and Critical Care Clinical Nurse Specialist,17 AACN

delineates several activities of CNSs in relation to each of the competencies inherent in the Synergy Model and the 3 spheres of influence.

ACNP is a second advanced practice role that has existed for approximately 12 years. In the early 1990s, the nursing profession recognized that the needs of patients were not being adequately met.18 It became

evident that nurse practitioners had a scope of practice that could be maximized to meet both the medical and nursing needs of these vulnerable acutely ill patients.19,20

The American Nurses Association and the AACN formed a task force of experts to delineate the scope of practice for adult ACNPs. According to the

docu-The American Association of Critical-Care Nurses Synergy Model for Patient Care.

Nurse competencies Patient characteristics Functional change, behavioral change, trust, ratings, satisfaction, comfort, quality of life

Patient System Recidivism, costs/resource utilization Physiological changes, presence or absence of complications, extent to which care or treatment objectives were attained Nurse

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ment defining the scope,21“the purpose of the ACNP

is to provide advanced nursing care across the contin-uum of acute care services to patients who are acutely and critically ill.” ACNPs focus on the stabilization of acute medical problems, prevention and management of complications, comprehensive management of injury and/or illness, and restoration to maximal levels of health within an interdisciplinary and collaborative healthcare team.21

Since development of the ACNP scope and stan-dards and the subsequent offering of a national certifica-tion examinacertifica-tion by the American Nurses Credentialing Center (ANCC) starting in 1996, Kleinpell has surveyed those ACNPs who sought certification to determine practice habits, practice environments, and emerging roles.22-26Since 1997, Kleinpell’s reporting of

longitudi-nal survey results has served as a means of keeping practitioners, educators, administrators, and colleagues informed of changes in the role. At the inception of the role, it was thought that ACNPs would work primarily in intensive care units (ICUs). Results of Kleinpell’s most recent survey26 indicate that most ACNPs do

work in ICUs; however, nearly 50% of the respondents reported a practice environment other than the traditional ICU or urgent/acute care practice setting. Although the practice setting may vary among ACNPs, the main focus of their practice remains direct management of patients’ care, with 85% to 88% of time reportedly spent on this responsibility.26

Recognizing the need for consensus on the core competencies of ACNPs, the National Organization of Nurse Practitioner Faculties convened a national panel of ACNPs to identify ACNP competencies. The panel described entry-level competencies for graduates of master’s and post-master’s ACNP programs.27 The

panel’s report describes for educators, practitioners, and the public the unique philosophy of ACNPs and the needs of the populations served. Further, the descrip-tions of the competencies include the role components of ACNPs within the 7 core domains outlined in the section on domains and core competencies of nurse practitioner practice of the same document.27

Research Design and Method

The practice analysis task force of the AACN Certification Corporation was conducting the study reported in this article at the same time as the compe-tencies were being developed by the National Organiza-tion of Nurse PractiOrganiza-tioner Faculties. Advanced practice nursing in acute and critical care has existed for more than 20 years. However, no study had been conducted on a national level to define the activities of both CNSs and ACNPs for the purposes of certification. The goals

of the study we report here were to define the unique activities performed by ACNPs and to confirm that CNS activities have not changed.

Specific aims of the study were to obtain criticality and frequency ratings for each of 65 advanced practice activities, as determined by the practice analysis task force; compare the spheres of influence of the individ-ual activities when performed by either the CNS or ACNP; compare the percentage of time that CNSs and ACNPs devote to specific problems related to patients’ care; and obtain frequency ratings for the items on the experience inventory that are unique to critical care.

Development of a Comprehensive

Description of Critical Care Nursing Practice

Subject Matter Expert Committee

The standard approach to job analysis used by licensure and certification agencies involves 2 phases: (1) obtaining and describing job information and (2) validating the job description. The second phase of the job analysis is usually accomplished by surveying per-sons doing the job. In the following section, we describe this process as it was undertaken by AACN.28

A task force of subject matter experts was appointed to create a comprehensive delineation of the work of crit-ical care nurses. Examination of advanced practice nurs-ing was part of a larger study of the continuum of critical care practice (new-to-critical care competencies, updated levels 1, 3, and 5 of the Synergy Model as described ear-lier); only the results related to advance practice nurses are reported in this article. The task force comprised 15 experts representing practitioners and educators, and it included CCRNs, CCNSs, and ACNPs who served neonatal, pediatric, and adult patients. Committee mem-bers were drawn from rural, suburban, and urban practice settings across the United States.

The task force met 4 times during the course of the project. The focus was on developing a comprehensive delineation of practice in acute and critical care. At each meeting, time was spent both in full-group discussions and in small-group work. Two nurse staff members from the AACN Certification Corporation attended all meetings of the task force. Staff from Professional Examination Service, the corporation’s testing com-pany at the time, facilitated all of the meetings.

Sampling Plan

A sampling plan was designed to permit compari-son of the populations of patients and the techniques and tools of advanced practice nurses and to allow validation of the competencies required for advanced level practice in acute and critical care nursing. The CNS sample con-sisted of all holders of the CCNS credential (N = 332)

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plus 168 holders of the CCRN credential who indicated that they were working as CNSs. The ACNP sample consisted of 500 ACNPs selected randomly from the population of currently certified ACNPs. A total of 75% of this combined CNS/ACNP pool received the Survey of Advanced Practice in Acute and Critical Care Nurs-ing, and 25% of the pool received the Survey of Patient Care Problems in Acute and Critical Care.

Measures

The Survey of Advanced Practice in Acute and Critical Care Nursing was designed to collect data that would validate advanced practice activities, the 8 competencies of nurses, and the experience inventory. For each of the 65 advanced practice activities (Table 4), organized according to the 8 competencies of nurses of the Synergy Model, 3 rating scales were used:

Criticality: How critical is the activity to optimiz-ing outcomes for acutely and critically ill patients?

1 = Not critical 2 = Minimally critical 3 = Moderately critical 4 = Highly critical

Frequency: How frequently did you perform the activity during the past year in your role as an advanced practitioner?

1 = Never

2 = Less than once a month

3 = At least once a month, but less than every week

4 = At least once a week, but less than 3 times a week

5 = At least 3 times a week

Sphere(s) of influence: Toward which sphere(s) of influence did you direct the activity during the past year? (Respondents were able to select all that apply.)

1 = Individual patients 2 = Populations of patients 3 = Nursing staff

4 = Other disciplines, organizations, or systems

Complementary Data Collection Initiatives

Three additional data collection initiatives were conducted to complement and extend the work of the practice analysis task force: focus panels, critical inci-dent telephone interviews, and indepeninci-dent reviews.

Focus Panels.A focus panel of CNSs (n = 12) and another of ACNPs (n = 18) were conducted in May and June 2002. Each focus panel lasted 2 hours and was facilitated by a moderator from Professional Examina-tion Service. All panels consisted of a mix of guided discussion and document reviews. In addition to responding to and discussing open-ended questions,

each group was asked to review materials developed by the task force. The primary task of the CNS and ACNP groups was to define the competencies required of advanced practice nurses in acute and critical care.

Critical Incident Telephone Interviews.Each mem-ber of the task force was asked to nominate ACNPs and CNSs who would be willing to participate in a telephone interview. Nomination parameters included emphasis on creating a diverse pool of interviewees with experience working with different populations of patients (neonatal, pediatric, and adult) and nurses working in diverse geo-graphical areas. Interviewees were contacted by e-mail and telephone to establish a time for the interview and were sent materials to review. All interviewees received the list of problems related to patients’ care that was used in the CCNS examination program and were asked to review the list appropriate to the age of the patients with whom they worked. CNSs and ACNPs received the advanced practice competencies.

A total of 21 interviews were conducted in June 2002. Each interviews was conducted by telephone and lasted from 25 to 50 minutes. A protocol was cre-ated to guide the interviews.

Independent Reviews.Subject matter experts inde-pendently reviewed the various aspects of the practice delineation. In September 2002, materials for inde-pendent review were mailed. The advanced practice competency list was disseminated to 9 CNSs and 8 ACNPs. The advanced practice competencies were returned by 3 CNSs and 4 ACNPs.

Results

Survey of Advanced Practice in Acute and Critical Care Nursing

The Survey of Advanced Practice in Acute and Critical Care Nursing was distributed to 750 advanced practice nurses (375 CNSs and 375 ACNPs) and was completed and returned by 261 respondents, for a 35% response rate. The group of respondents comprised 158 CNSs (42% response rate), 77 ACNPs (21% response rate), and 26 individuals who worked in either a blended CNS/ACNP role or in an “other” role. Because the pri-mary goal of data analyses was to compare and contrast the practice of CNSs and ACNPs, the 26 respondents who could not be assigned unambiguously to either group were eliminated from subsequent quantitative analysis. Thus, the results reported in the remainder of this section are for the 158 CNSs and 77 ACNPs who responded to the survey.

Characteristics of the Sample

Nearly all ACNP respondents (95%) indicated that they worked in the role of a nurse practitioner;

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Table 4 Activities of advanced practice nurses organized by the 8 characteristics of nurses of the American Association of Critical-Care Nurses Synergy Model for Patient Critical-Care

Characteristic Clinical judgment

Advocacy and moral agency

Caring practices

Activities of advanced practice nurses

Synthesizes, interprets, makes decisions and recommendations, and evaluates responses on the basis of complex, sometimes conflicting, sources of data

Identifies and prioritizes clinical problems on the basis of education, research, and experiential knowledge Develops, implements, evaluates, and modifies plans of care for individual patients, patients’ families,

and cohorts

Prescribes medications, therapeutics, and monitoring modalities in collaboration with physicians and other members of the healthcare team as necessary

Develops, implements, and evaluates research-based algorithms, clinical guidelines, protocols, and path-ways for various populations of patients.

Develops proactive interventions; implements/directs others to act on actual or potential clinical problems Facilitates development of clinical judgment in healthcare team members (eg, nursing staff, medical staff,

other healthcare providers) through serving as a role model, teaching, coaching, and/or mentoring Formally and informally evaluates the clinical practice of other members of the healthcare team (eg,

nursing staff, medical staff, other healthcare providers)

Evaluates one’s own clinical practice through self-reflection and feedback from others

Facilitates patients and patients’ families, healthcare professionals, and payors to understand a broad perspective (ie, the “big picture”)

Elicits comprehensive history and performs physical examinations on the basis of each patient’s initial signs and symptoms

Develops a list of differential diagnoses on the basis of findings obtained from each patient’s medical history and findings on physical examination

Orders appropriate diagnostic studies and interprets findings to manage patients’ care in collaboration with physicians and other members of the healthcare team as necessary

Initiates appropriate referrals and performs consultations

Performs invasive procedures (eg, placement of pulmonary artery catheters, central venous catheters, arterial catheters; thoracentesis; lumbar punctures)

Uses internal resources (eg, ethics committee, risk management, legal department) and external resources (eg, professional organizations, government officials, community agencies) to facilitate reso-lution of issues of advocacy or moral agency

Participates in problem solving to anticipate and prevent recurrences of dissatisfaction or concern among patients or patients’ families

Facilitates resolution of ethical and clinical conflicts between patients or patients’ families and other health-care professionals

Promotes an environment for ethical decision making and advocacy for patients

Recognizes and promotes programs to ensure that the rights of patients and patients’ families are incor-porated into the plan of care

Facilitates development of nurses’ advocacy and moral agency through serving as a role model, teaching, coaching, and/or mentoring

Empowers patients and patients’ families to act as their own advocates

Integrates concerns and value systems of each patient and the patient’s family, nursing staff, and other healthcare team members, administrators, and payors into the patient’s plan of care

Promotes a caring and supportive environment

Supports the implementation of complementary therapies

Facilitates healthcare team’s development of caring practices through serving as a role model, teaching, coaching, and/or mentoring

Cares for the caregivers (eg, conflict resolution, debriefing, crisis intervention)

Provides patients and their families with the skills to navigate transitions along the healthcare contin-uum (ie, facilitates safe passage)

Interprets and communicates needs of complex patients and their families and administrative needs to other caregivers

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Table 4 continued Characteristic Collaboration Systems thinking Response to diversity Clinical inquiry

Activities of advanced practice nurses

Leads and facilitates coordination of intradisciplinary and interdisciplinary teams to develop or revise programs focused on group or systems issues

Leads and facilitates coordination of intradisciplinary and interdisciplinary teams to develop or revise plans of care focused on issues related to patients and/or patients’ families

Initiates and facilitates active involvement with external agencies (eg, industry, payors, community groups, political agencies)

Serves as a role model, teaches, coaches, and mentors healthcare team to understand and use resources and expertise of others

Serves as a role model, teacher, coach, and mentor for both professional leadership and accountability for nursing’s role within the healthcare team and community

Facilitates the creation of a common vision for care within the healthcare team or system

Facilitates development, implementation, and evaluation of professional practice models for nursing Creates, coordinates, implements, and evaluates formal and informal intradisciplinary and

interdisciplinary education to improve patients’ outcomes and quality of care

Interprets and facilitates integration of organizational mission, goals, and systems into practices related to patients’ care

Assesses and facilitates understanding of the impact of social, political, regulatory, and economic (eg, payors, products) forces on the delivery of care

Using knowledge of the system, works with internal clients (eg, nursing staff, medical staff, other healthcare providers, administrators) and external clients (eg, institutions, sales representatives) to optimize delivery of care

Identifies and communicates resources, both internal and external (eg, consultants, referrals, community programs, and other healthcare systems) to optimize outcomes for patients and patients’ families Develops, implements, and evaluates strategies to optimize outcomes for patients , patients’ families, and payors

Develops strategies to facilitate transitional movement of patients through the healthcare system Continually evaluates the care delivery model and recommends modifications based on outcomes data Facilitates processes of change within the healthcare system to provide evidence-based, cost-effective care Models and mentors innovative systems thinking and resource use among the healthcare team Identifies diversity issues and facilitates awareness of these issues

Recognizes and assists the healthcare team to integrate individual differences in tailoring the delivery of care to meet the diverse needs and strengths of patients

Serves as a role model, teacher, coach, and/or mentor for acceptance of and responsiveness to diversity Promotes and incorporates research and experiential knowledge into plans of care related to diverse

populations

Identifies clinical problems amenable to research

Serves as a role model, teacher, coach, and/or mentor of staff on the use, implementation, and evaluation of research findings

Evaluates current and innovative practices in patients’ care on the basis of evidence-based practice, research, and experiential knowledge

Develops processes to evaluate outcomes data

Incorporates evidence-based practice guidelines, research, and experiential knowledge to formulate, evaluate, and/or revise policies, procedures, and protocols

Critiques research findings and determines applicability to practice

Communicates research results and develops a means to incorporate research findings into practice Reviews, evaluates, and facilitates incorporation of new products and technologies into practice

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85% of these respondents reported that their primary position was as an ACNP. The CNS respondents held more varied positions. Although 72% of the CNS respondents worked as a CNS, another 9% worked as nurse educators, and 3% to 4% each worked as first-line managers, middle managers, and nurse researchers. Of the CNS respondents, 68% said that the CNS role was their primary position; another 11% reported that their primary role was as a staff nurse.

The most typical employment setting for both CNS respondents and ACNP respondents was community nonprofit hospitals; 50% of CNS respondents and 26% of ACNP respondents worked in that setting. About one fourth of both groups worked at a university medical center. Ten percent of the ACNP respondents worked in private industry, whereas no CNS respondents worked in that setting. Finally, ACNP respondents were more likely than CNS respondents to work in a for-profit community hospital and in “other” settings.

The type of unit(s) worked in as the primary employment setting of CNS respondents and ACNP respondents was obtained. CNS respondents were more than twice as likely as ACNP respondents to work in a medical ICU, neuro/neurosurgical ICU, progressive care unit, surgical ICU, or trauma unit. ACNP dents were more than twice as likely as CNS respon-dents to work in catheterization laboratories, burn units, medical cardiology unit, outpatient clinics, pri-vate practice, subacute care and “other” units (Table 5). In addition, ACNPs primarily cared for patients who were adults (60%) and geriatric (22%). For CNS respon-dents, 72% of the patients cared for were adults and 15% were geriatric.

The demographic characteristics of the advanced practice survey respondents were compiled. A total of 98% of the CNS respondents and 92% of the ACNP

respondents were women. The CNS respondents were more experienced than the ACNP respondents. CNS respondents had a mean of 22 years of experience, 19 years working in acute/critical care, and 9 years as a CNS. ACNPs had a mean of 16 years of experience, 13 years in acute/critical care, and 5 years as an ACNP. A total of 86% of the CNS respondents and 76% of the ACNP respondents indicated that they were 35 to 54 years old. However, the ACNP respondents were 4 times as likely to indicate they were 25 to 34 years old (24% of ACNPs and 6% of CNSs). No respondents from either cohort were less than 25 years old or more than 65 years old. The CNS sample was slightly older than the ACNP sample, consistent with the data on years of experience.

For the highest degree earned by respondents, 74% of the CNS respondents indicated they had earned a master’s degree as a CNS; 8%, an unspecified master’s degree; and 7%, a doctorate. No more than 3% indi-cated any other advanced degree earned. Of the ACNP respondents, 65% indicated that they had earned a mas-ter’s as an ACNP; 14% earned 2 masmas-ter’s 1 as a CNS and 1 as an ACNP, and 14% were educated as ACNPs in a post-master’s certificate program. No more than 3% of the respondents indicated earning any other advanced degree.

Table 6 indicates the states or territories where CNS and ACNP respondents practice. The CNS respondents worked in 33 different jurisdictions. California con-tributed the largest percentage of CNS respondents (12%). Another 5 states (Illinois, Minnesota, Missouri, New Jersey, and Texas), contributed 6% each, and Ohio contributed 5%. The ACNP respondents worked in 27 different jurisdictions. A total of 8% each worked in Illi-nois and Texas, 6% worked in Maryland, and 5% each worked in Arkansas, New York, Pennsylvania, South Table 4 continued

Characteristic Facilitator of

learning

Activities of advanced practice nurses Conducts needs assessment before developing educational plans and programs Develops, implements, and evaluates programs on the basis of the needs of learners

Adapts teaching strategies to the unique needs and strengths of patients and their families to facilitate the teaching and learning process

Contributes to and advances the knowledge base of the healthcare community through research, presentations, publications, and involvement in professional organizations

Facilitates and/or mentors professional advancement of nursing staff

Deliver formal and informal intradisciplinary and interdisciplinary education to improve patients’ outcomes and quality of care

Promotes value of lifelong learning and evidence-based practice while continually acquiring knowledge and skills needed to address questions arising in practice to improve patients’ care

(11)

Table 5 Type of unit(s) reported as primary employment set-ting by clinical nurse specialists (CNSs) and acute care nurse practitioners (ACNPs)* Unit Acute hemodialysis Burn Cardiac rehabilitation Cardiac surgery/operating room Cardiovascular/surgical ICU Catheterization laboratory CCU

Combined adult/pediatric ICU Combined ICU/CCU

Corporate industry Critical care transport/flight Emergency department General medical/surgical Home care ICU

Interventional cardiology Long-term care Medical cardiology Medical ICU Neonatal ICU Neurological/neurosurgical ICU Oncology unit Operating room Outpatient clinic Pediatric ICU Private practice Progressive care Recovery room/PACU Respiratory ICU Step-down unit Subacute care Surgical ICU Telemetry unit Trauma Other CNS (n = 158) ACNP (n = 77) % 1 4 3 8 27 19 26 1 14 0 0 19 12 0 12 5 26 16 0 8 5 3 17 1 14 6 5 0 26 10 16 27 4 30 1 3 2 6 21 15 20 1 11 0 0 15 9 0 9 4 20 12 0 6 4 2 13 1 11 5 4 0 20 8 12 21 3 23 % 2 1 5 6 27 8 23 4 24 0 1 14 13 0 9 1 11 27 6 12 2 0 3 6 1 15 8 5 21 1 30 31 13 15 3 2 8 9 42 12 36 7 38 0 2 22 21 0 15 1 17 42 9 19 3 0 4 10 1 23 12 8 33 2 48 49 21 24

*Responses do not total 100% because multiple responses were permitted.

Abbreviations: CCU, coronary care unit; ICU, intensive care unit; PACU, postanesthesia care unit.

Table 6 State or territory of primary employment setting for clinical nurse specialists (CNSs) and acute care nurse practi-tioners (ACNPs) responding to advanced practice survey

State/territory Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming CNS (n = 158) ACNP (n = 77) % 3 0 0 5 1 1 3 0 0 4 3 0 0 8 0 0 0 0 4 0 6 3 4 1 3 3 0 0 0 0 4 0 5 4 0 4 1 0 5 0 0 5 0 5 8 0 1 5 0 0 1 0 2 0 0 4 1 1 2 0 0 3 2 0 0 6 0 0 0 0 3 0 5 2 3 1 2 2 0 0 0 0 3 0 4 3 0 3 1 0 4 0 0 4 0 4 6 0 1 4 0 0 1 0 % 2 0 1 0 12 3 1 1 0 4 4 0 0 6 1 0 1 1 1 0 3 4 3 6 1 6 0 0 0 0 6 1 4 3 0 5 1 2 4 0 0 0 0 2 6 0 0 1 3 0 3 1 3 0 1 0 19 5 1 1 0 6 7 0 0 9 1 0 1 1 2 0 5 6 5 9 1 9 0 0 0 0 9 2 6 5 0 8 1 3 6 0 0 0 0 3 10 0 0 2 5 0 5 1 No. No. No. No.

(12)

Carolina, Tennessee, and Virginia. Sixteen jurisdictions were not represented by either cohort.

Criticality and Frequency

The list of 65 advanced practice nursing activities performed in the care of acutely and critically ill patients is organized within the 8 characteristics of nurses of the Synergy Model as shown in Table 4. Respondents were asked to rate the criticality and frequency of each activity. Criticality describes how critical the activity is to optimizing the outcomes for acute and critically ill patients. The mean criticality rating for each nurse characteristic for CNS and ACNP respondents was obtained. The criticality ratings for the CNS respon-dents indicated that the 8 characteristics of nurses are

generally moderately to highly critical to optimizing outcomes for acute and critically ill patients. With only a single exception, the criticality ratings of the ACNP respondents were slightly lower than those of the CNS respondents. For collaboration, both the CNS and the ACNP respondents rated the characteristic as moderately to highly critical.

The advanced practice activities that the CNS respondents rated highest on the criticality scale were associated with the characteristics of clinical judg-ment and clinical inquiry. The advanced practice activities that ACNP respondents rated highest on the criticality rating scale were associated with clinical judgment and reflected the primary role of ACNPs in directly providing care to patients (Tables 7 and 8). Table 7 Activities rated most critical by clinical nurse specialists (mean score on the criticality scale = 3.5)

Activity

Clinical judgment

Synthesizes, interprets, makes decisions and recommendations, and evaluates responses on the basis of complex, sometimes conflicting, sources of data

Identifies and prioritizes clinical problems on the basis of education, research, and experiential knowledge

Facilitates development of clinical judgment in healthcare team members (eg, nursing staff, medical staff, other healthcare providers) through serving as a role model, teaching, coaching, and/or mentoring

Caring practices

Promotes a caring and supportive environment Facilitator of learning

Promotes value of lifelong learning and evidence-based practice while continually acquiring knowledge and skills needed to address questions arising in practice to improve patients’ care

Clinical inquiry

Evaluates current and innovative practices in patients’ care on the basis of evidence-based practice, research, and experiential knowledge

Incorporates evidence-based practice guidelines, research and experiential knowledge to formulate, evaluate, and/or revise policies, procedures, and protocols

Table 8 Activities rated most critical by acute care nurse practitioners (mean score on the criticality scale = 3.5) Activity

Clinical judgment

Orders appropriate diagnostic studies and interprets findings to manage patients’ care in collaboration with physicians and other members of the healthcare team as necessary

Prescribes medications, therapeutics, and monitoring modalities in collaboration with physicians and other members of the healthcare team as necessary

Elicits comprehensive history and performs physical examinations on the basis of each patient’s initial signs and symptoms Develops a list of differential diagnoses on the basis of findings obtained from each patient’s medical history and findings on

physical examination

Synthesizes, interprets, makes decisions and recommendations, and evaluates responses on the basis of complex, sometimes conflicting, sources of data

Initiates appropriate referrals and performs consultations Advocacy and moral agency

(13)

Frequency ratings of the CNS and ACNP respon-dents were generally similar for the advanced practice activities. However, for 8 of the activities, the fre-quency ratings of CNS and ACNP respondents dif-fered by 1 level or more (Table 9). Of the 8 activities, 7 are in the area of clinical judgment.

Of the 65 activities, both the CNS and ACNP respondents performed all but 1 activity at least once a month. The remaining activity, Performs invasive pro-cedures (eg, placement of pulmonary artery catheters, central venous catheters, arterial catheters; thoracente-sis; lumbar punctures), was performed less than once a month by the CNS respondents. However, 2% of the CNSs who responded reported performing invasive procedures, although much less often then the ACNP respondents (Table 9).

Spheres of Influence

The Survey of Patient Care Problems in Acute and Critical Care Nursing Practice was conducted to col-lect data that would validate the 65 advanced clinical activities identified by the practice analysis task force. Each respondent was asked to assign a sphere of influ-ence (individual patient, populations of patients, nursing staff, or others) to each of the activities as it related to the respondents’ practice.

The mean percentage of practice time that respon-dents directed toward the spheres of influence was deter-mined (Table 10). For both CNSs and ACNPs, many of

the activities were directed toward more than a single sphere of influence. The largest difference in responses from the CNS and ACNP respondents was the differ-ence in the time each spent with individual patients. Consistent with the diversity of roles of CNSs, these respondents were more likely to direct their time to nursing personnel (36%), populations of patients (21%), and other disciplines, organizations, or systems (17%). As expected, and reflecting the direct care role of ACNPs, these respondents direct 74% of their practice toward individual patients, whereas the CNS respon-dents directed only 26% of their practice time to individ-ual patients. ACNP respondents directed relatively eqindivid-ual amounts of time to the other spheres of influence.

Ratings of Problems Related to Patients’ Care by CNSs and ACNPs

The Survey of Patient Care Problems in Acute and Critical Care Nursing Practice was disseminated to 125 CNSs and 125 ACNPs. Of the 250 surveys sent, 143 were completed and returned, resulting in a 62% return rate for CNSs and a 43% return rate for ACNPs. A total of 54% of CNS respondents reported working primar-ily in a community hospital (nonprofit) setting, and 20% reporting working in a university medical center. In contrast, ACNP respondents were most likely to work in a university medical center (29%), and then either a nonprofit (19%) or a for-profit (16%) commu-nity hospital.

Table 9 Eight activities performed more frequently by acute care nurse practitioners (ACNPs) than by clinical nurse specialists (CNSs) responding to the survey on advanced practice

Activity

Clinical judgment

Develops, implements, evaluates, and modifies plans of care for individual patients and patients’ families and cohorts

Prescribes medications, therapeutics, and monitoring modalities in collaboration with physicians and other members of the healthcare team as necessary

Elicits comprehensive history and performs physical examinations on the basis of each patient’s initial signs and symptoms

Develops a list of differential diagnoses on the basis of findings obtained from each patient’s medical history and findings on physical examination

Orders appropriate diagnostic studies and interprets findings to manage patients’ care in collaboration with physician and other members of the healthcare team as necessary

Initiates appropriate referrals and performs consultations

Performs invasive procedures (eg, placement of pulmonary artery catheters, central venous catheters, arterial catheters; thoracentesis; lumbar punctures)

Advocacy and moral agency

Empowers patients and patients’ families to act as their own advocates

CNS 3.9 2.7 2.8 2.5 2.4 3.1 1.2 3.3 ACNP 4.9 4.9 4.7 4.8 4.9 4.7 2.2 4.3 Mean frequency score

(14)

At least 20% of the CNS cohort indicated each of 6 primary employment settings: combined ICU/coronary care unit (29%), medical ICU (28%), telemetry unit (23%), cardiovascular/surgical ICU (23%), step-down unit (20%), and surgical ICU (20%). Three employ-ment settings were indicated by more than 20% of ACNP respondents: step-down unit (27%), medical cardiology unit (22%), and telemetry unit (22%).

CNS respondents reported that the acuity levels of the majority of their patients were critical; however, about one fourth of their patients require acute care, and about 6% require subacute care. Conversely, for the ACNP respondents, the acuity levels of their patients were almost equally distributed among the 3 acuity levels.

Table 11 lists the problems related to patients’ care organized by systems. The percentages of time that CNS and ACNP respondents devoted to such problems in each system was calculated. Table 12 lists those problems for which the percentages of time allocated to the problem differed by 5% or more between ACNPs and CNSs. CNSs most often provided care for patients with life-threatening coagulopathies, acute renal fail-ure, diabetic ketoacidosis, chronic renal failfail-ure, and septic shock. ACNP respondents reported caring most often for patients with acute hypoglycemia, life-threat-ening coagulopathies, stroke, chronic lung disease, gas-troesophageal reflux, acute renal failure, chronic renal failure, and septic shock. Four problems required large amounts of time for both CNSs and ACNPs: acute and chronic renal failure, life-threatening coagulopathies, and septic shock.

Experience Inventory

For comparison purposes, respondents were asked to provide a frequency rating for each item on the experience inventory (Table 13). Respondents were asked this question: During the past year, how frequently did you provide direct bedside care to patients receiv-ing this intervention, test, procedure, medication,

and/or monitoring device? The following scale was used:

0 = Never

1 = Less than once a month

2 = At least once a month, but less than every week

3 = At least once a week, but less than 3 times a week

4 = At least 3 times a week.

Mean frequency ratings for the CNS and ACNP survey participants were calculated and compared. Gen-erally, the frequency ratings of CNS and ACNP respon-dents were similar for the advanced practice activities. The percentage of respondents who rated each item as unique to critical care was also included. Six items were rated by more than 90% of the participants as unique to critical care: hemodynamic monitoring and/or pul-monary artery monitoring (92%); cardiac assist devices (92%); pulmonary artery monitoring (96%); invasive determination of cardiac output and cardiac input (93%); direct monitoring of the right atrium, left atrium, or pulmonary artery (94%); and monitoring of intracra-nial pressure (93%). Respondents confirmed that all of the items on the inventory were experienced by both the ACNPs and CNSs caring for patients with critical and acute illness.

Discussion

In order for the AACN Certification Corporation to support its current and future certification initiatives, a study of practice of acute and critical care nursing was conducted between 2001 and 2003. Only that part of the study relative to advanced practice nurses is pre-sented here.

A practice analysis task force set out to define the activities performed by ACNPs and to confirm that the activities performed by CNSs remained as previously defined. In addition, frequency ratings for the activities of advanced practice nurses, an experience inventory, and problems related to patients’ care were obtained from the study respondents.

As the term ACNP denotes, care provided by these practitioners occurs in areas where acute or critical care is provided. Indeed, respondents reported that the care provided by these practitioners occurred in areas outside of traditional critical care units, such as cardiac catheterization laboratories, burn units, private practice, outpatient clinics, and medical cardiology areas. In Kleinpell’s most recent study,26 similar practice areas

were identified; however, the findings are in contrast to the care provided by CNSs in our study, which was provided primarily in ICUs and reflected the study sample.

Table 10 Mean percentage of practice directed toward each sphere of influence by clinical nurse specialists (CNSs) and acute care nurse practitioners (ACNPs) responding to the advanced practice survey

Sphere of influence Individual patients Populations of patients Nursing personnel Other disciplines, organizations, or systems Mean SD CNS 25.8 21.4 36.2 16.7 20.8 13.5 21.2 14.6 Mean SD ACNP 73.9 9.4 9.6 7.3 20.5 12.4 7.9 10.5 Percentage

(15)

A debate about combining the CNS and ACNP role has ensued since 1986. Analysis of master’s degree pro-grams to prepare advanced practice nurses has shown the same basic core curriculum for ACNPs and CNSs,

with the exception that ACNP curricula emphasize his-tory taking, physical assessment, and pharmacology.29

Moloney-Harmon4 described the practice of the

CNS by using the 8 competencies of nurses of the Table 11 Problems related to patients’ care, organized by system

Cardiovascular

Myocardial conduction system defects

Acute congestive heart failure/pulmonary edema Cardiogenic shock

Congenital heart defect/disease Hypovolemic shock

Dysrhythmias

Acute myocardial infarction/ischemia Acute inflammatory disease

Cardiomyopathies Cardiac trauma

Acute coronary syndromes Conduction defects Heart failure Pulmonary edema Hypertensive crisis Shock states

Structural heart defects

Ruptured or dissecting aneurysm Acute peripheral vascular insufficiency Cardiac tamponade

Cardiac surgery

Pulmonary hypertension Pulmonary

Acute respiratory infections Respiratory distress syndrome Transient tachypnea of the newborn Pulmonary hypertension

Pulmonary trauma Pulmonary aspirations Air-leak syndromes Chronic lung disease Apnea of prematurity Congenital anomalies Acute respiratory failure Thoracic trauma

Acute respiratory distress syndrome Respiratory distress

Status asthmaticus, exacerbation of chronic obstructive pulmonary disease, emphysema, bronchitis

Acute pulmonary embolus Thoracic surgery

Aspirations

Bronchopulmonary dysplasia Endocrine

Inborn errors of metabolism Infant of diabetic mother Acute hypoglycemia

Syndrome of inappropriate secretion of antidiuretic hormone

Diabetes insipidus Diabetic ketoacidosis Adrenal disorders

Syndrome of inappropriate diuresis

Hyperglycemic hyperosmolar nonketotic coma

Hematology Life-threatening coagulopathies Immunosuppression Hyperbilirubinemia Anemia of prematurity Organ transplantation Sickle cell crisis HELLP syndrome Neurology

Hydrocephalus

Neurological infectious diseases Seizure disorders

Encephalopathy Spinal fusion

Acute spinal cord injury

Congenital neurological abnormalities Neuromuscular disorders

Aneurysm

Space-occupying lesions

Stroke (embolic events, hemorrhagic)

Intracranial hemorrhage/intraventricular hemorrhage Neurosurgery Neuromuscular disorders Gastrointestinal Gastrointestinal abnormalities Bowel infarction/obstruction/perforation Gastroesophageal reflux Hepatic failure/coma Acute abdominal trauma Acute hemorrhage Pancreatitis

Gastrointestinal surgeries Renal

Acute renal failure

Congenital renal-genitourinary abnormalities Renal trauma

Acute and chronic renal failure Life-threatening electrolyte imbalances Near-drowning

Multisystem

Septic shock/infectious diseases Exposure to toxic agents Asphyxia

Low birth weight/prematurity

Life-threatening maternal-fetal complications Ingestions and inhalations of toxic agents Burns

Hemolytic uremic syndrome Multisystem trauma

Systemic inflammatory response syndrome, sepsis, multiorgan dysfunction syndrome

(16)

Synergy Model. Interventions were delineated on the basis of the 3 spheres of influence: patients and patients’ families, nurse-nurse, and system. As noted, CNS prac-tice had historically been delineated on the basis of roles, including clinician, educator, researcher, and consultant.12Nurse practitioner practice has also been

defined by using the same roles.30 However, in the

study we report here, the majority of ACNP time was spent in the role of clinician, directing practice toward the individual patient sphere of influence. This finding is consistent with Kleinpell’s finding that 85% to 88% of ACNPs’ time is spent directly providing care to patients.26 CNS respondents reported directing their

practice fairly evenly across all 4 spheres of influence asked about in the survey.

In 2003, the ANCC conducted a role delineation study31of nurse practitioners in 7 different specialties:

acute care, adult, family, gerontology, pediatric, adult psychiatric, and mental health. In that study,31data were

collected on the roles and responsibilities of nurse prac-titioners working in each of these specialties. Response rates ranged among specialties from 17% to 51.4%.

Similar to the findings in our study, the majority of the respondents in the ANCC study were women (93%). A total of 43% of the respondents were between the ages 41 and 50 years, a finding that parallels the ACNP respondents in our study, 76% of whom indi-cated that they were 35 to 54 years old.

The ANCC assessed frequency (how often an activ-ity was performed, ranging from never to daily or approximately every other day), performance expecta-tion (when the ACNP was expected to perform this activity on the job, ranging from never to within the first 6 months as an ACNP), and consequence (what Table 12 Problems related to care of adult patients for which the percentage of time allocated by clinical nurse specialists (CNSs) and acute care nurse specialists (ACNPs) differed by 5% or more

Problem Cardiovascular

Acute congestive heart failure/pulmonary edema Pulmonary

Acute respiratory distress syndrome Chronic lung disease

Pulmonary hypertension (eg, persistent pulmonary hypertension of the newborn) Respiratory distress (eg, emphysema, bronchitis)

Endocrine

Acute hypoglycemia

Adrenal disorders (eg, adrenal insufficiency) Diabetic ketoacidosis

Syndrome of inappropriate diuresis Hematology/immunology

Immunosuppression (eg, Rh incompatibilities, blood group incompatibilities, hydrops fetalis, congenital, acquired [HIV infection, AIDS, neoplasms])

Life-threatening coagulopathies (eg, idiopathic thrombocytopenia purpura, disseminated intravascular coagulation, hemophilia, heparin-induced thrombocytopenia, ReoPro-induced)

Organ transplantation (eg, liver, bone marrow, kidney, heart, pancreas, lung) Neurology

Head trauma (blunt, penetrating)

Neurosurgery (eg, evacuation of hematoma, tumor resection) Stroke (embolic events, hemorrhagic)

Gastrointestinal

Gastroesophageal reflux

Gastrointestinal surgeries (eg, Whipple procedure, esophagogastrectomy, gastric bypass) Renal

Acute renal failure (eg, acute tubular necrosis, hypoxia, dialysis) Chronic renal failure

Multisystem

Septic shock/infectious diseases (eg, congenital viral, bacterial, catheter sepsis, nosocomial infections, immunosuppression)

Systemic inflammatory response syndrome, sepsis, multiorgan dysfunction syndrome Ingestions and inhalations of toxic agents (eg, drug/alcohol overdose, poisoning)

CNS 11.9 12.7 9.3 1.0 5.4 14.4 6.3 46.3 2.8 23.8 54.3 8.8 13.7 10.1 19.9 5.9 15.7 43.3 31.0 31.0 23.2 10.5 4.5 4.1 18.9 6.6 10.7 36.2 12.2 9.2 7.9 9.5 63.1 16.8 5.1 3.7 40.9 32.9 9.1 31.7 42.2 53.6 12.9 3.9 ACNP Percentage of time

(17)

degree of harm would come to a patient if the activity were performed incorrectly, ranging from little to severe harm). Criticality data were calculated on the basis of these 3 variables, a different method than was used in our study.

The respondents in our study were asked to rate the 65 advanced practice activities on how critical each activity is to optimizing the outcomes of acute and critically ill patients. The CNSs rated 8 activities in the nurse characteristics of clinical judgment and clinical inquiry as most critical, and the ACNPs rated 8 activities in the nurse characteristic of clinical judg-ment as most critical. Again, this focus on clinical judgment corresponds to the main focus of patients’ care. The 8 activities rated highest in frequency by the ACNPs (Table 8) were also reported to be performed by the ACNPs in the Kleinpell study.26

Only a single activity was performed less than once a month by both ACNPs and CNSs: performing

invasive procedures (eg, placement of pulmonary artery catheters, central venous catheters, arterial catheters; thoracentesis; lumbar punctures). Although CNSs are generally not thought of as performing invasive proce-dures, 2% of the CNS respondents reported performing an invasive activity less than once a month. ACNPs are often thought of as spending a majority of their time performing invasive procedures; however, we found this idea to be untrue. Kleinpell26 also found that

ACNPs do not spend most of their time performing invasive procedures.

Nurse practitioner respondents in the ANCC study who worked as ACNPs or adult nurse practitioners reported spending 73% and 76%, respectively, of the time with direct care of patients. This finding is consis-tent with the findings of our study, in which ACNPs reported spending most of their time with activities associated with clinical judgment. ACNPs and adult nurse practitioners in the ANCC study spent 12% and Table 13 Experience inventory items

Cardiovascular

Electrocardiographic monitoring 12-Lead electrocardiogram

Hemodynamic and/or pulmonary monitoring Percutaneous transluminal coronary angioplasty Transcutaneous (external) pacemakers

External pacemakers (eg, transesophageal) Temporary pacemakers

Programmable pacemakers Internal pacemakers

Automatic implantable cardioverter defibrillators Phosphodiesterase inhibitors (eg, amrinone, milrinone) Cardiac assist devices (eg, intra-aortic balloon pump, right

ventricular assistive device, biventricular assistive device, left ventricular assistive device)

Pericardiocentesis Neonatal resuscitation Arterial pressure monitoring Central venous pressure monitoring Pulmonary artery pressure monitoring Invasive cardiac output/index determination

Direct right atrial, left atrial, pulmonary artery pressure monitoring

Umbilical arterial and venous pressure monitoring Hematology/immunology

Blood product administration Blood screening and typing Immunizations

Exchange transfusions

Modes of phototherapy (eg, fiber-optic blanket, halogen lights)

Plasmapheresis Renal

Ultrafiltration

Renal replacement therapies

Pulmonary Pulse oximeter Pulmonary monitor

Continuous respiratory monitors End-tidal carbon dioxide monitor

Nasal/facial continuous positive airway pressure, bilevel positive airway pressure

Conventional mechanical ventilation Heliox

Pressure control/support ventilation Nonconventional mechanical ventilation

(eg, high frequency, jet/oscillating) Survanta

Surfactant replacement therapy

Rapid ventilation systems, pediatric high frequency Oscillating ventilators, pediatric jet oscillating High-frequency ventilation

Synchronized ventilation

Train-of-four (peripheral nerve stimulator) Nitric oxide

Extracorporeal membrane oxygenation

Airway management (eg, new tracheostomy, endotracheal tube)

Chest tubes Neurology

Intracranial pressure monitoring devices Ventriculostomy Extraventricular drain Brain resuscitation Ventricular reservoirs/shunt Gastrointestinal Sclerosing therapies Trophic feedings

Parenteral and enteral feeding systems Multisystem

Figure

Table 1 Characteristics of patients from the American Asso- Asso-ciation of Critical-Care Nurses Synergy Model for Patient Care Characteristic Resiliency Vulnerability Stability Complexity Resource availability Participation in care Participation in  decis

Table 1

Characteristics of patients from the American Asso- Asso-ciation of Critical-Care Nurses Synergy Model for Patient Care Characteristic Resiliency Vulnerability Stability Complexity Resource availability Participation in care Participation in decis p.2
Table 3 Characteristics of nurses from the American Association of Critical-Care Nurses Synergy Model for Patient Care

Table 3

Characteristics of nurses from the American Association of Critical-Care Nurses Synergy Model for Patient Care p.4
Table 4 Activities of advanced practice nurses organized by the 8 characteristics of nurses of the American Association of Critical- Critical-Care Nurses Synergy Model for Patient Critical-Care

Table 4

Activities of advanced practice nurses organized by the 8 characteristics of nurses of the American Association of Critical- Critical-Care Nurses Synergy Model for Patient Critical-Care p.8
Table 4 continued Characteristic Collaboration Systems thinking Response to  diversity Clinical inquiry

Table 4

continued Characteristic Collaboration Systems thinking Response to diversity Clinical inquiry p.9
Table 6 indicates the states or territories where CNS and ACNP respondents practice. The CNS respondents worked in 33 different jurisdictions

Table 6

indicates the states or territories where CNS and ACNP respondents practice. The CNS respondents worked in 33 different jurisdictions p.10
Table 6 State or territory of primary employment setting for clinical nurse specialists (CNSs) and acute care nurse  practi-tioners (ACNPs) responding to advanced practice survey

Table 6

State or territory of primary employment setting for clinical nurse specialists (CNSs) and acute care nurse practi-tioners (ACNPs) responding to advanced practice survey p.11
Table 5 Type of unit(s) reported as primary employment set- set-ting by clinical nurse specialists (CNSs) and acute care nurse practitioners (ACNPs)* Unit Acute hemodialysis Burn Cardiac rehabilitation Cardiac surgery/operating  room Cardiovascular/surgica

Table 5

Type of unit(s) reported as primary employment set- set-ting by clinical nurse specialists (CNSs) and acute care nurse practitioners (ACNPs)* Unit Acute hemodialysis Burn Cardiac rehabilitation Cardiac surgery/operating room Cardiovascular/surgica p.11
Table 9 Eight activities performed more frequently by acute care nurse practitioners (ACNPs) than by clinical nurse specialists (CNSs) responding to the survey on advanced practice

Table 9

Eight activities performed more frequently by acute care nurse practitioners (ACNPs) than by clinical nurse specialists (CNSs) responding to the survey on advanced practice p.13
Table 11 lists the problems related to patients’ care organized by systems. The percentages of time that CNS and ACNP respondents devoted to such problems in each system was calculated

Table 11

lists the problems related to patients’ care organized by systems. The percentages of time that CNS and ACNP respondents devoted to such problems in each system was calculated p.14

References

Updating...

Related subjects : essential component