MISSION VISION VALUES ETHICS

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MISSION

AACN Certification Corporation contributes to consumer health and safety through

comprehensive credentialing of nurses to ensure their practice is consistent with established

standards of excellence in caring for acutely and critically ill patients and their families.

VISION

As the undisputed leader in credentialing nurses, the AACN Certification Corporation has

demonstrated that certification contributes to achieving optimal outcomes that are consistent

with the goals and values of acutely and critically ill patients and their families.

VALUES

As the Corporation works to advance its mission and vision and fulfill its purpose and inherent

obligation to ensure the health and well being of patients experiencing acute and critical illness,

the Corporation is guided by a set of deeply rooted values.



Providing leadership to bring all stakeholders together to create and foster cultures of

excellence and innovation.



Acting with integrity and upholding ethical values and principles in all relationships

and in the provision of sound, fair and defensible credentialing programs.



Committing to excellence in credentialing programs by striving to exceed industry

standards and expectations.



Promoting leading edge, research-based credentialing programs that reach diverse

certificants.



Demonstrating stewardship through fair and responsible management of resources

and cost-effective business processes.

ETHICS

AACN and AACN Certification Corporation consider the American Nurses Association

(ANA) Code of Ethics for Nurses foundational for nursing practice, providing a framework for

making ethical decisions and fulfilling responsibilities to the public, colleagues and the

profession. AACN Certification Corporation’s mission of public protection supports a standard

of excellence that certified nurses have a responsibility to read, understand and act in a manner

congruent with the ANA Code of Ethics for Nurses.

The following AACN Certification Corporation programs have been accredited by the National Commission for Certifying Agencies (NCCA), the accreditation arm of the Institute for Credentialing Excellence (ICE):

∙ Adult CCRN®

and CCRN-ETM

∙ Pediatric and Neonatal CCRN®

∙ Adult, Pediatric and Neonatal CCNS®

∙ Adult ACNPC®

∙Adult CMC®

∙Adult CSC®

Our advanced practice certification programs, CCNS and ACNPC, have also been recognized by the National Council of State Boards of Nursing (NCSBN).

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Study of Practice Summary

for the

Pediatric

Clinical Nurse Specialist

and

New

ACCNS-P Test Plan

June 2011

Prepared for AACN Certification Corporation by:

Lawrence J. Fabrey, PhD

Senior Vice President, Psychometrics

Jennifer L. Benavente, BA/BEd

Research Assistant

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List of Tables

Table 1. Overview of Adult/Gerontology Clinical Nurse Specialist Certification Test Plan ...16

Table 2. Overview of Pediatric Clinical Nurse Specialist Certification Test Plan ...17

Table 3. Overview of Neonatal Clinical Nurse Specialist Certification Item Allocation ...18

List of Figures

Figure 1. Region ... 7

Figure 2. Years of Experience as RN ... 8

Figure 3. Years of Experience as Advanced Practice Nurse ... 9

Figure 4. Years of Experience in Acute/Critical Care Setting ... 9

Table of Appendices

Appendix A: Significance Ratings in Survey Order ...21

Appendix B: Significance Ratings in Descending Mean Order ...41

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Introduction

AACN Certification Corporation frequently conducts national studies examining the practice of nurses who work with acutely ill patients. In order to distinguish the roles of acute care nurses caring for patients with similar illnesses and diseases, these nurses are surveyed so similarities and differences in patient populations, nursing roles and practices among AACN Certification Corporation credentials (CCRN, PCCN, CCRN-E, CMC, CSC, CCNS, ACNPC) can be identified.

The purpose of conducting this job analysis, also known as a Study of Practice (SOP) or a practice analysis, was to describe the job activities of AACN Certification Corporation Certified Clinical Nurse Specialists in sufficient detail to provide a basis for the Certified Adult/Gerontology Clinical Nurse Specialist, Certified Pediatric Clinical Nurse Specialist and Certified Neonatal Clinical Nurse Specialist examinations covering the spectrum of wellness through acute care. AACN Certification Corporation requested the services of Applied Measurement Professionals, Inc. (AMP) to design and conduct a study that would provide the support necessary to develop specifications upon which certification examinations with substantial evidence of content validity could be developed.

As with all AACN Certification Corporation job analyses, several steps were undertaken to develop a comprehensive inventory of patient care problems encountered by and skills, procedures, and synergy competencies performed by the Adult/Gerontology, Pediatric and Neonatal Clinical Nurse Specialist. First, a Practice Analysis Task Force (PATF) comprised of a diverse group of experienced practitioners was selected. The PATF membership represented diversity that was reflective of the intended candidate population in terms of relevant

demographic characteristics and took into account expertise related to the current role and knowledge needed for the anticipated evolution of the Clinical Nurse Specialist‟s scope of practice, including those with expertise in gerontology.

While developing the survey, the Practice Analysis Task Force (PATF) consulted a number of references regarding the role and competencies of the CNS and CCNS including: the American Association of Critical-Care Nurse's Standards of Practice and Professional Performance for the Acute and Critical Care Clinical Nurse Specialist (2010); the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (2008); the 2004 Hartford Nurse Practitioner and Clinical Nurse Specialist Competencies for Older Adult Care; Changes in Healthcare Professions’ Scope of Practice: Legislative Considerations (2007); AACN

Certification Corporation’s CCNS Synergy Competencies (2006); the national Clinical Nurse Specialist Core Competencies 2010; and the Adult-Gerontology Clinical Nurse Specialist Competencies (2010).

An inventory of patient care problems – both population-specific and those seen across the lifespan – skills and procedures, and synergy competencies was developed by considering the current Clinical Nurse Specialist Test Plans, as well as the recently revised CCRN Test Plan (2009), the PCCN Test Plan (2008), the Cardiac Medical Subspecialty Certification Test Plan (2010) and the Cardiac Surgery Subspecialty Test Plan (2010), as well as the Center for Disease Control's (CDC) National Health Statistics Reports/National Hospital Discharge Data Set, the CDC's Health, United States, 2010, and the CDC's Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2009.

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This inventory was sent to the members of the PATF who were asked for their review and comment. The PATF then revised and finalized the inventory and survey instrument, distributed the instrument to at least 3,534 individuals, reviewed the results, and established the test specifications for the examinations.

The job analysis survey was distributed to persons throughout the United States according to the sampling plan developed by the PATF. The data returned were evaluated to determine the degree of consensus among these experts on the significant aspects of the Adult/Gerontology Clinical Nurse Specialist‟s, Pediatric Clinical Nurse Specialist‟s and Neonatal Clinical Nurse Specialist‟s job. Specifically, the data were analyzed to answer the following questions:

Is there a common knowledge base and a set of core activities that is significant to the effective performance of the Certified Adult/Gerontology Clinical Nurse Specialist, Certified Pediatric Clinical Nurse Specialist and Certified Neonatal Clinical Nurse Specialist?

What percentage of Certified Adult/Gerontology Clinical Nurse Specialists, Certified Pediatric Clinical Nurse Specialists, and Certified Neonatal Clinical Nurse Specialists encounter each patient care problem and perform each skill, procedure and synergy competency?

The purpose of these questions was to identify the more significant topics to be considered for inclusion in the assessment procedure.

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Methodology

Formation of the Practice Analysis Task Force

The Practice Analysis Task Force (PATF) was established to ensure that expert judgment was available to AMP staff at every stage of the project. Members of the PATF were experienced practitioners selected by AACN Certification Corporation, and included members who were familiar with the duties and activities of the Clinical Nurse Specialist‟s job. Additionally, AACN Certification Corporation consulted with the Pediatric Nursing Certification Board (PNCB) for recommendations of pediatric experts who could provide advice regarding the incorporation of wellness aspects of the pediatric population in the survey. As a result three PNCB experts became members of the PATF.

The PATF membership represented diversity that was reflective of the intended candidate population in terms of relevant demographic characteristics and took into account expertise related to the current role and knowledge needed for the anticipated evolution of the scope of practice of Clinical Nurse Specialist on the continuum of wellness through acute care. This study could not have been successful without the significant time involvement of the PATF. AMP is grateful to each of these individuals for their guidance and expertise, as well as their devotion to this project. Listed below are the responsibilities of the PATF.

Responsibilities of the Task Force

1. Developing a definition of the Certified Clinical Nurse Specialist 2. Developing a sampling plan for the survey

3. Identifying patient care problems, skills, procedures, and synergy competencies for the survey instrument

4. Determining rating scales

5. Determining the relevant demographic variables of interest 6. Integrating the definitions, problems, tasks, competencies, rating

scale, and demographics into a survey instrument

Development of the Job Analysis Inventory

Defining the Clinical Nurse Specialist. The first step in survey development was to

operationally define the Clinical Nurse Specialist. For the purposes of the survey, the PATF defined the Clinical Nurse Specialist as follows:

An entry level acute or critical care nurse is eligible for CCNS certification through completion of graduate advanced practice education program offered by an accredited college or university that offers a Master’s degree or higher in nursing with a concentration as an acute and/or critical care clinical nurse specialist.

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Development of the Patient Care Problem, Skills and Procedures (Actions), and Synergy Competency List.

The PATF, with the assistance of AMP project staff, prepared a comprehensive inventory of patient care problems, actions, and competencies using all of these materials. The survey was designed to assess the job-related competencies needed for entry-level practices as a clinical nurse specialist. A pilot test of the survey instrument included several components, as discussed further in this report. The complete inventory consisted of 101 patient care problems from across the lifespan, 43 adult-specific, 45 pediatric-specific and 14 neonatal-specific patient care problems, 104 skills and procedures organized into eleven body systems, and 144 synergy competencies as listed below. Respondents were also encouraged to suggest additional patient care problems, skills and procedures, and synergy competencies that were not included in the survey.

Clinical Nurse Specialist Content Areas

I. Clinical Judgment A. Cardiovascular B. Pulmonary C. Endocrine D. Musculoskeletal E. Hematology/Immunology F. Neurology G. Gastrointestinal H. Renal/Genitourinary I. Integumentary J. Multisystem K. Psychosocial/Behavioral/Cognitive II. Advocacy

III. Caring Practices IV. Collaboration

V. Systems Thinking VI. Diversity

VII. Clinical Inquiry

VIII. Facilitation of Learning

Selection of the Rating Scale. The PATF also assisted in the development of the rating scale

to be used with the inventory. The significance scale was used by respondents and was included as part of the inventory. This scale was recommended by AMP project staff and based on similar scales used in previous national job analysis studies. The scale helps to ensure that the PATF can conclude with confidence that the problems, actions, and competencies that remain viable for the examination specifications are clearly a part of practice, as well as significant enough to practice from a variety of perspectives to warrant inclusion on a national examination.

Significance. This scale is designed to identify those patient care problems,

skills and procedures, and synergy competencies that are more significant to the achievement of the objectives of the Clinical Nurse Specialist‟s job. Thus, the following question was used:

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How significant is this problem/task/action to entry level CNS practice in your setting? Not Necessary Minimally Significant Moderately Significant Significant Quite Significant Of Maximum Significance

Selection of Background Information Questions. This section of the inventory was designed

to gather information concerning the respondents‟ background characteristics. The PATF reviewed and adapted background information that had been used in previous job analysis studies, and selected the following areas to include:

 state of employment setting,  size of community,

 primary employment setting,  number of beds in facility,

 highest level of formal education,  primary position,

 units/areas worked,

 percentage of patients from various age groups,  percentage of patients from various levels of care,  percentage of time directed to various areas,

 years of experience as RN, advanced practice nurse and in an acute care setting,  prescriptive authority,

 hours worked per week,  patients seen each day,  highest degree in nursing,

 Clinical Nurse Specialist (CNS) certification,  other specialty certifications,

 and gender, race and age.

Several of these demographic variables were used to create subgroups, which the PATF would be able to analyze to ensure that the resulting specifications were applicable to the intended candidate population. For example, the state of employment setting was used to identify regional subgroups for separate analysis of the significance ratings for the Adult-Gerontology Clinical Nurse Specialist, to ensure that remaining problems, actions, and competencies were appropriate for a national examination.

Integration of Definition, Patient Care Problems, Skills and Procedures, Synergy Competencies, Rating Scale, and Demographics into a Survey Instrument. Following the

first meeting with the PATF, all components of the survey were combined and designed into a draft survey instrument. Prior to distributing the survey to the full sample of professionals, the draft survey was distributed to the PATF for review and comment. The purpose of this review was to determine if any significant activities were missing from the survey, if the directions were clear, and if the rating scale was easy to use and understand. Comments from the PATF were reviewed with the PATF representatives, and minor changes were made prior to sending the survey invitations. Following the PATF‟s review, the survey was sent to Clinical Nurse Specialists credentialed by the Medical-Surgical Nursing Certification Board. These participants

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were asked to review the survey specifically looking for inclusion of topics from the wellness spectrum of care. In addition, other subject matter experts were consulted to ensure that the competencies appropriately reflected practice with Gerontological patients. Both aspects of the additional reviews were summarized and discussed with representatives of the PATF. This supplement to the pilot test confirmed that the survey was well-structured and no additional changes were needed.

Sample Selection

In an effort to obtain information from representative groups of respondents, 3,534 Adult, Pediatric, and Neonatal Clinical Nurse Specialists throughout the United States as well as those AACN members who held the American Nurses Credentialing Center (ANCC) CNS-BC certification for Adult, Gerontological and/or Pediatric populations were identified by AACN Certification Corporation and emailed a survey invitation. In addition, other Adult ACNPs were contacted via e-news blasts, AACN Certification Corporation‟s website and social media website. Respondents were offered an incentive to complete and return the survey by the published deadline.

Results

Return Rate

Of the 3,534 survey invitations distributed, 432 invitations were returned as undeliverable, leaving 3,102 individuals who did receive the survey invitation. In addition, responses from 118 individuals who responded to less than 10% of patient care problems were removed prior to analysis. Eight hundred ten (810) individuals provided usable responses in time for data analysis. This resulted in an approximate 27.1% usable response rate (810/2,984), and this response rate is considered to be quite acceptable for similar studies

Reliability of Ratings

To determine the extent to which the respondents were consistent in rating inventory tasks, a statistic known as the intraclass correlation (Guilford, 1978) was used. Separate reliability estimates were calculated for each content area, and each of scales can be consider reliable, with most coefficients exceeding 0.90; and the few that did not exceed that value were based on a small number of problems, actions, or competencies, therefore, lower values can be expected. In addition, coefficient alpha was calculated for each content area, and the resulting values were all quite acceptable, providing an indication that the items within the area represented a homogeneous set of content. Based on these data, it is likely that a different sample from the same population would have produced similar ratings.

After completing the ratings, respondents were asked to indicate how well they thought the survey covered the job of a clinical nurse specialist. Three choices were provided for response: "completely," "adequately," and "inadequately." Among the 669 individuals who responded, 50.1% (N=335) indicated the survey completely covered the problems and tasks associated with the practice of a clinical nurse specialist and 48.7% (N=326) said it adequately covered the problems and tasks. Eight respondents (1.2%) indicated that coverage was inadequate. Thus, 98.8% of the job experts who responded said the problems, skills, procedures, and synergy competencies in the survey completely or adequately described the job of the clinical nurse specialist.

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Description of the Rating Sample

The Background Information section of the survey provides descriptive information about the rating sample. The data show that the most typical respondent is a 49-year-old, white female, practicing in the Midwest. Her highest degree in nursing is a Master‟s degree. She does not hold the any of the CCNS certifications nor does she hold prescriptive authority but she does hold the CCRN credential. She has over 24 years of experience as an RN, nearly 12 years as an advanced practice nurse, and 23 years in an acute/critical care setting. She works full-time as a Unit-based CNS at a community hospital in an urban setting with more than 500 beds. On average, she sees approximately ten primarily adult, critical patients per day. The majority of her work day is devoted to teaching and she spends most of her teaching time educating nursing personnel. More detailed about selected demographic responses follows.

Figure 1. Region

East – CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VA, VT, WV; South – AL,AR, FL, GA, LA,

MS, NC, OK, TN, TX, SC; Midwest – IA, IL, IN, KY, MI, MN, MO, OH, WI;

West – AK, AZ, CA, CO, HI, ID, KS, MT, ND, NE, NM, NV, OR, SD, UT, WA, WY

Figure 1 shows the geographical region of practice for respondents. Eleven (11) respondents did not answer the question. These data show that all regions were well represented, and the largest group of respondents resides in the Midwestern states. Over half of respondents (53.9%) practice in urban settings, 36.9% practice in suburban settings and 9.3% practice in small towns or rural settings. Although the largest group of respondents works in a Community Hospital (45.7%), a substantial number work in a University Medical Center (27.8%). Remaining respondents practice in a variety of settings including Children‟s Hospital, College/University, and Military/Government Hospital. As noted, many respondents (34.6%) work in large facilities with more than 500 beds, but a substantial number work in smaller facilities, with 29.0% in facilities with 301-500 beds, 20.2% in 201-300, and 16.2% in smaller facilities. As expected, a majority (64.1%) holds a position as a CNS, either unit- or population-based, but other positions with more than three percent of the respondents included manager/director, nurse practitioner, nurse educator, staff nurse, or other.

Some respondents occasionally spent time with neonatal and pediatric patients, but as expected most respondents work primarily with Adult patients (mean = 45.7%, median = 49.0%), followed by Geriatric patients (mean = 41.9%, median = 50.0%). Respondents devote

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the majority of their time (mean = 27.2%, median = 25.0%) teaching although this nursing task was followed very closely by providing consultation (mean = 22.9%, median = 20.0%) and providing direct patient care (mean = 22.1%, median = 10.0%) with administration (mean = 17.5%, median = 10.0%) and research (mean = 10.2%, median = 10.0%) comprising the smallest portion of respondents‟ work time. Most of the respondents‟ teaching time (mean = 58.6%) is spent with nursing personnel, with a mean of 22.2% of their time teaching nursing personnel, and approximately 10% each with patient populations and other disciplines/organizations/systems.

Three figures that follow depict the experience of the respondent group. Figure 2 shows respondents‟ years of experience as a Registered Nurse (mean = 24.6, median = 26 years). Figure 3 shows respondents‟ years of experience as an Advanced Practice Nurse (mean = 11.87, median = 11 years). Figure 4 shows respondents‟ years of experience in an Acute/Critical Care setting (mean = 22.7, median = 24 years).

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Figure 3. Years of Experience as Advanced Practice Nurse

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Most respondents do not hold prescriptive authority and of the 29.4% of respondents who do hold it, approximately fourteen percent do not use it. Most respondents hold more than one certification, including 62.5% holding the CCRN certification, with much smaller numbers holding a variety of others.

The PATF reviewed the demographic data and concluded that none of the results could be considered atypical. Therefore, they judged that the results were representative of Clinical Nurse Specialists.

Mean Ratings

Descriptive data for each of the 101 patient care problems from across the lifespan, 43 adult-specific, 45 pediatric-adult-specific, and 14 neonatal-specific patient care problems, 104 skills and procedures, and 144 synergy competencies are presented in Appendix A. Included are the descriptive label for that task, number of respondents, mean significance rating, standard error, standard deviation, and the percentage of respondents not performing the task. For example, Patient Problem #1, from the Cardiovascular body system “Acute coronary syndromes” is listed as "AllProb01" Seven hundred, thirty-four (734) respondents rated the task with a mean rating of 3.48, a standard error of the mean of 0.049, and a standard deviation of 1.33. The percentage of respondents who rated it as “not performed” was 8.82%. The standard error indicates the "accuracy" of the mean. In this case, the “real mean” is likely to lie between 3.38 and 3.58, 95% of the time (mean +/- 2 standard errors).

The Clinical Nurse Specialist PATF reviewed the results separately for each patient care problem, skills, procedures, and synergy competency. They concluded that, in general, the ratings obtained in the practice analysis study were in agreement with their own judgments based on their experience in the field. Consequently, it was concluded that the job analysis survey data was adequate for defining the jobs of the Adult/Gerontology, Pediatric and Neonatal Clinical Nurse Specialist on a national basis. Moreover, the data were judged to be sufficient for the purpose of delineating the structure and content of a voluntary national credentialing examination for AACN Certification Corporation.

The PATF also evaluated the responses from various subgroups, based on responses to pertinent demographic questions. For each subgroup analysis, the valid number of respondents in each subgroup was displayed, along with the mean rating, standard error, and an indication of the number of subgroups with a mean rating below a specified threshold for each item on the survey.

Examination Specifications

In developing the test plan (i.e., examination specifications or detailed content outline) for the examinations, the judgment of the PATF was used to interpret the data gathered from the practice analysis survey. Of particular significance to a certification examination program is that the test specifications appropriately reflect the responsibilities of all groups who will participate in that program. Therefore, it is important to ensure that the test plan and the resulting examination forms sample patient care problems, skills and procedures, and synergy competencies that are considered to be significant responsibilities of the individuals for whom the examination is intended.

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Several decision rules were proposed for consideration by the PATF in determining which topics should be considered ineligible for assessment, and therefore, excluded from the test content outline. The general areas for consideration are shown below:

1. Overall mean significance ratings for the total sample 2. Overall percent of "not performed" ratings

3. Comparison of mean significance ratings by region 4. Comparison of mean significance ratings by community 5. Comparison of mean significance ratings by position

6.

Comparison of mean significance ratings by setting

7.

Comparison of mean significance ratings by beds

8.

Comparison of mean significance ratings by years of experience as an Advance Practice Nurse

9.

Comparison of mean significance ratings by hours worked

10.

Comparison of mean significance ratings by Adult CCNS Certification

11.

Comparison of mean significance ratings by Pediatric CCNS Certification

12.

Comparison of mean significance ratings by Neonatal CCNS

Certification

The specific decision rules adopted by the PATF and their impact on inclusion of topics are discussed in detail in the following section. The first two decision rules are general and involve an analysis of all respondents. The decision rules 3 through 12 involve comparing mean ratings by subgroups. Applying these rules ensures that the resulting examination reflects the responsibilities of the Adult/Gerontology, Pediatric and Neonatal Clinical Nurse Specialiston a national basis and is representative of the typical Adult/Gerontology, Pediatric and Neonatal Clinical Nurse Specialist‟sactivities.

The PATF decided items from the Clinical Judgment area would be written to assess patient care problems. In addition, items should be written to reflect approved skills and procedures and synergy competencies. Synergy competencies, skills, and procedures deemed critical to practice are eligible for assessing knowledge of content underlying an item.

Application of Decision Rules and Criteria

Rule 1. Is the patient care problem seen by and skill, procedure, and synergy competency performed by a majority of entry level Clinical Nurse Specialists?

By consensus, the PATF decided that a patient care problem must be seen by at least 80% of the respondents in order to be included in the final test specifications, nursing actions must be seen by at least 40% and synergy competency must be performed by at least 90% of the respondents to remain eligible for in-depth assessment. Eighteen patient care problems (Allprob45, 79, Adultprob15, 22, 24, 28, 29, 30, 31, 32, 35, 38, 39, Pedsprob02, 04, 17, 26, and 29) were eliminated from the test specifications. Seventy-eight skills and procedures (Cardiotask07, 09, 11, 14, 16, 17, 19, 21, 22, 23, 25, 26, 27, 29, 31, 32, 33, Endotask01, Gastrotask01, 02, 03, 04, 05, 06, Hemtask01, 02, 03, 04, 05, 06, 07, 08, Integ01, 03, 04, 05, 06, Multitask01, 03, 05, Musculotask01, 02, 03, 04, 05, 06, 07, Neurotask01, 02, 03, 04, 05, 06, 07, 08, 09, 10, 11, 12, 13, 14, 15, 16, 17, 18, Psychtask01, Pulmtask05, 06, 07, 08, 10, 11, Renaltask01, 02, 03, 04, 05, 06) and 6 competencies (ClinJudgComp18, 19, 20, 21, 22, 23)

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were considered to be less important to entry level clinical nurse specialist practice and were excluded. The PATF reviewed each excluded patient care problem, skill, and procedure and determined that three patient problems (AdultProb30, 32, and PedProb29), two skills and procedures (Gastrotask06, Renaltask01) were critical to practice and were retained by unanimous agreement. Additionally, the wording of one procedure (Multitask 05) and six competencies (ClinJudgComp18, 19, 20, 21, 22, and 23) was edited and they were also retained. Details of the edited content can be found below.

Rule 2. Is the patient care problem seen by and skill, procedure, and synergy competency considered significant to the practice of an entry level Clinical Nurse Specialists?

By consensus, the PATF decided that a mean significance rating of 2.50 would be used to examine patient care problems, skills and procedures, and synergy competencies. Forty-six additional patient care problems (Allprob20, 27, 33, 34, 40, 41, 42, 44, 64, 73, 78, 80, 81, 95, Adultprob12, 13, 14, 16, 17, 18, 19, 20, 25, 26, 27, 41, Pedsprob01, 05, 08, 15, 19, 20, 24, 25, 27, 28, 30, 34, 35, 36, 38, 39, 40, 41, 42, 43) fell below the established threshold. One additional skill and procedure (Cardiotask12) was also considered to be less significant to entry level clinical nurse specialist practice and was excluded. No synergy competencies were affected. Again, the PATF reviewed each excluded patient care problem, skill, and procedure and determined that four of the patient care problems (Pedsprob19, 35, 36, 42) were critical to practice and were retained by unanimous agreement. Additionally it was determined that content from two patient care problems (Allprob40, 42) was critical to pediatric practice and was retained for the Pediatric Clinical Nurse Specialist examination specifications. Similarly Allprob41 was deemed critical to neonatal practice and was retained for the Neonatal Clinical Nurse Specialist examination specifications.

Rule 3. Is the patient care problem considered significant regardless of geographic region?

To determine if patient care problems seen by the Clinical Nurse Specialist were viewed differently by geographic region, a comparison of the mean significance ratings between regions was made. The PATF decided to review patient care problems that had mean ratings of less than 2.40 in any of the four geographic subgroups. Application of this criterion helps to ensure that the examination reflects uniform practice across regions. Ten additional patient care problems (Allprob100, Adultprob10, Pedsprob03, 09, 12, 18, 22, 23, 37, 44) were removed as a result of this rule. Again, the PATF reviewed each excluded patient care problem and determined that one patient care problem (Pedsprob18) was critical to practice and was retained by unanimous agreement.

Rule 4. Is the patient care problem considered significant regardless of community size?

To determine if patient care problems seen by the Clinical Nurse Specialist were viewed differently by community size, a comparison of the mean significance ratings between rural, suburban, and urban communities was made. The PATF decided to review patient care problems that had mean ratings of less than 2.40 in any of the three community subgroups. Application of this criterion helps to ensure that the examination reflects uniform practice across communities. Seven additional patient care problems (Allprob43, 48, 77, Pedsprob13, 16, 21, 45) were removed as a result of this rule. Again, the PATF reviewed each excluded patient care problem, and determined that four patient care problems (Pedsprob13, 16, 21, 45) were critical

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to practice and were retained by unanimous agreement. Additionally, content from Allprob48 was deemed critical to pediatric and neonatal practice and was retained for the Pediatric and Neonatal Clinical Nurse Specialist examination specifications.

Rule 5. Is the patient care problem considered significant regardless of position?

To determine if patient care problems seen by the Clinical Nurse Specialist were viewed differently by position, a comparison of the mean significance ratings between position subgroups was made. The PATF decided to review patient care problems that had mean ratings of less than 2.40 in any of the CNS position subgroups (Population based CNS, Unit-based CNS, CNS Free Responses). Application of this criterion helps to ensure that the examination reflects uniform practice across different positions. No additional patient care problems were removed as a result of this rule.

Rule 6. Is the patient care problem considered significant regardless of setting?

To determine if patient care problems seen by the Clinical Nurse Specialist were viewed differently by setting, a comparison of the mean significance ratings between settings was made. The PATF decided to review patient care problems that had mean ratings of less than 2.40 in any of the setting subgroups. Application of this criterion helps to ensure that the examination reflects uniform practice across different settings. No additional patient care problems were removed as a result of this rule.

Rule 7. Is the patient care problem considered significant regardless of facility size? To determine if patient care problems seen by the Clinical Nurse Specialist were viewed differently by facility size, a comparison of the mean significance ratings between various sized facilities was made. The PATF decided to review problems that had mean ratings of less than 2.40 in any of the four facility size subgroups. Application of this criterion helps to ensure that the examination reflects uniform practice across different sized facilities. No additional patient care problems were removed as a result of this rule.

Rule 8. Is the patient care problem considered significant regardless of years of experience as an advanced practice nurse?

To determine if patient care problems seen by the Clinical Nurse Specialist were viewed differently by those with various levels of experience, a comparison of the mean significance ratings was made. The PATF decided to review patient care problems that had mean ratings of less than 2.40 in 0-2 years of experience subgroups to ensure problems were critical to entry level Clinical Nurse Specialists. Application of this criterion helps to ensure that the examination reflects uniform practice across years of experience. One additional patient care problem (Adultprob01) was removed as a result of this rule however; the PATF considered this topic to be of critical importance and it was retained by unanimous agreement.

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Rule 9. Is the patient care problem considered significant regardless of hours worked per week?

To determine if patient care problems seen by the Clinical Nurse Specialist were viewed differently by those who worked different hours per week, a comparison of the mean significance ratings between those who worked full- and part-time was made. The PATF decided to review patient care problems that had mean ratings of less than 2.40 in either of the position subgroups. Application of this criterion helps to ensure that the examination reflects uniform practice across time worked per week. One additional patient care problem (AllProb38) was removed as a result of this rule.

Rule 10. Is the patient care problem considered significant regardless of Adult CCNS certification?

To determine if patient care problems seen by the Clinical Nurse Specialist were viewed differently by those who did and did not hold the Adult CCNS certification, a comparison of the mean significance ratings was made. The PATF decided to review the patient care problem ratings of those who held the Adult CCNS certification. Application of this criterion helps to ensure that the examination reflects population-specific practice as determined by those who are most familiar with the population. No additional changes were made as a result of this rule.

Rule 11. Is the patient care problem considered significant regardless of Pediatric CCNS certification?

To determine if patient care problems seen by the Clinical Nurse Specialist were viewed differently by those who did and did not hold the Pediatric CCNS certification, a comparison of the mean significance ratings was made. The PATF decided to review the patient care problem ratings of those who held the Pediatric CCNS certification. Application of this criterion helps to ensure that the examination reflects population-specific practice as determined by those who are most familiar with the population. Three additional patient care problems (Allprob01, 12, 61) were removed from the Pediatric Clinical Nurse Specialist examination specifications as a result of this rule.

Rule 12. Is the patient care problem considered significant regardless of Neonatal CCNS certification?

To determine if patient care problems seen by the Clinical Nurse Specialist were viewed differently by those who did and did not hold the Neonatal CCNS certification, a comparison of the mean significance ratings was made. The PATF decided to review the patient care problem ratings of those who held the Neonatal CCNS certification. Application of this criterion helps to ensure that the examination reflects population-specific practice as determined by those who are most familiar with the population. Eleven additional patient care problems (Allprob01, 07, 11, 12, 24, 25, 58, 61, 68, 84, 99) were removed from the Neonatal Clinical Nurse Specialist exam specifications as a result of this rule.

Final Approval of Problems, Activities, and Competencies. In addition to reviewing the

statistics for the survey, the PATF examined the respondents' comments regarding the patient problems, activities, and competencies included in the survey. The PATF considered suggestions for additional content, and for changes to existing content. Based on this review, the PATF did not add any patient problems, activities, or competencies.

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Two patient care problems were edited by the PATF following survey distribution. Allprob25 – “Pulmonary Problem – Thoracic and pulmonary trauma and injuries” was edited to remove “and injuries”. Allprob47 – “Neurology Problem – Head and brain trauma and injury” was similarly edited. Three additional patient care problems were edited for the Neonatal Clinical Nurse Specialist examination specifications. Allprob18 – “Pulmonary Problem - Asthma and reactive airway disease” was edited to remove “Asthma” because the condition is not seen in neonates. Similarly, Allprob67 – “Gastrointestinal Problem – Hepatic failure and coma” was edited to remove „and coma‟. Allprob76 – “Renal Problem – Infections (e.g., UTI, PID, STDs)” was edited to remove the list of examples. Multitask05 – “Multisystem Task – Prescribe pharmaceutical interventions” appears on all Clinical Nurse Specialist examination specifications and was edited to read “Manage (i.e., recommend/prescribe) to account for states in which Clinical Nurse Specialists do not have prescriptive authority. Similarly, synergy competencies ClinJudComp18 through 23, which all began with the verb “Prescribe”, were edited to read “Prescribe, according to legal restrictions in the state”.

Following consideration of all sources of input from the survey, 101 patient care problems remained for the Adult/Gerontology Clinical Nurse Specialist, 98 for the Pediatric Clinical Nurse Specialist, and 85 for the Neonatal Clinical Nurse Specialist. Of the 103 skills and procedures, twenty-eight are eligible for assessment. All synergy competencies remain available for assessment as well. Appendix C presents the Detailed Content Outline (DCO) content outline for the multiple choice examination developed after the application of the decision rules and review of respondent comments.

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Development of Test Plans

The PATF reviewed the patient care problems, skills, procedures, and synergy competencies that remained after application of the above decision rules. They considered the mean significance ratings for each of the content categories, as well as the number of remaining patient care problems and synergy competencies in each category. Table 1 presents the results from the content allocation question on the survey. The PATF used this information, along with current test specifications to guide their final decisions regarding the number of items for each of the areas of practice.

Table 1. Overview of Adult/Gerontology Clinical Nurse Specialist Certification Test Plan

Section Title Items # of

I. Clinical Judgment 92 A. Cardiovascular 19 B. Pulmonary 17 C. Endocrine 5 D. Musculoskeletal 3 E. Hematology/Immunology/Oncology 5 F. Neurology 10 G. Gastrointestinal 8 H. Renal/Genitourinary 7 I. Integumentary 3 J. Multisystem 10 K. Psychosocial/Behavioral/Cog. Health 5

II. Advocacy/Moral Agency 7

III. Caring Practices 10

IV. Collaboration 8

V. Systems Thinking 10

VI. Response to Diversity 4

VII. Clinical Inquiry 10

VIII. Facilitation of Learning 9

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Table 2. Overview of Pediatric Clinical Nurse Specialist Certification Test Plan

Section Title Items # of

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Table 3. Overview of Neonatal Clinical Nurse Specialist Certification Item Allocation

Section Title _Items# of

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Cognitive Complexity

After the number of items was determined, the next step involved defining the cognitive complexity of the content. As described in Table 4, it was decided that items will normally require that the candidate apply knowledge underlying the patient care problem (or other topic) to be able to select the correct response. Some items will also require analysis on the part of the candidate. Rarely will items be written to require only recall, and recall items will normally only be approved when a higher cognitive process is not applicable to practice and/or for knowledge that is highly essential for practice.

Table 4. Cognitive Complexity Scale

Recall

Requires only the identification, recall, or recognition of isolated information, such as specific facts, generalizations, concepts, principles, or procedures. The information generally does not vary relative to the situation.

Application

Requires comprehension, interpretation, or manipulation of limited concepts or data, in which the response or outcome is situationally dependent, but not overly complex (e.g., application of knowledge which varies based on patient characteristics and environment). Tasks that require candidates to recognize elements and relationships among data and to classify, explain, or differentiate are usually application level.

Analysis/Evaluation

Requires the integration or synthesis of a variety of concepts or elements to solve a specific problem situation (e.g., evaluating and rendering judgments on complex problems with many situational variables).

The test plan included in Appendix C will be used by item writers and Examination Committee to develop the Pediatric Clinical Nurse Specialist Certification examination. Using the results obtained from this study, the PATF, with direction from AMP project staff, developed the test specifications. The PATF based the test specifications on the empirical results of this study as well as the members' many years of experience. The detailed content outline specifies what areas are to be assessed, and their representation (weighting) on the examination. The detailed content outline provides the rationale for test development and can be used in the demonstration of the content validity of the examination.

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Summary

The practice analysis described in this report was undertaken to serve as the basis for documenting the content validity of the Clinical Nurse Specialist certification examinations for AACN Certification Corporation. The purpose of this study was twofold: (1) to determine and comprehensively describe the job of the Clinical Nurse Specialist, and (2) to evaluate these descriptions through the ratings of job experts to define areas that should be assessed on a certification examination.

A Practice Analysis Task Force was formed to prepare a comprehensive list of patient care problems, skills and procedures and synergy competencies describing the role of the Clinical Nurse Specialist caring for patients along the continuum of wellness through acute care. This inventory was completed by a representative sample of job experts throughout the United States, and the rating results were reviewed by the Clinical Nurse SpecialistPATF.

These results were used to develop test plans (examination specifications) directly related to the significant activities performed by the Clinical Nurse Specialist. These specifications, empirically derived from a national practice analysis study, represent the plan for development of criterion-referenced examinations. Each form of each examination will contain the specified number of items, with a representative sampling of patient care problems, skills and procedures, and synergy competencies within each domain. Therefore, each test form developed to match these job-related test specifications will demonstrate substantial content-related evidence in support of the validity of examination results.

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Appendix A

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Patient Problems, Skills and Procedures, and Competencies

Presented in Survey Order N Mean SEM SD Performing % Not

AllProb001 Cardio- Acute coronary syndromes 734 3.48 .049 1.33 8.82

AllProb002 Cardio- Acute inflammatory disease 762 2.73 .045 1.23 5.34

AllProb003 Cardio- Cardiac surgery 677 3.07 .054 1.42 16.00

AllProb004 Cardio- Cardiac tamponade 737 2.97 .050 1.37 8.22

AllProb005 Cardio- Cardiogenic shock 756 3.31 .048 1.33 5.97

AllProb006 Cardio- Cardiomyopathies 764 3.07 .047 1.30 5.09

AllProb007 Cardio- Decompensated heart failure 763 3.56 .047 1.30 5.22

AllProb008 Cardio- Dysrhythmias 797 3.76 .044 1.25 1.48

AllProb009 Cardio- Heart failure 779 3.74 .045 1.26 3.35

AllProb010 Cardio- Hypertension 784 3.68 .043 1.19 2.37

AllProb011 Cardio- Hypertensive crisis 761 3.31 .046 1.26 5.11

AllProb012 Cardio- Peripheral vascular insufficiency 732 3.15 .045 1.21 9.07

AllProb013 Cardio- Pulmonary edema 782 3.56 .043 1.19 2.25

AllProb014 Cardio- Structural heart defects & diseases 735 2.57 .047 1.28 7.89

AllProb015 Pulm- Acute respiratory failure 790 4.16 .037 1.05 1.25

AllProb016 Pulm- Air-leak syndromes 771 3.38 .044 1.23 2.53

AllProb017 Pulm- Aspirations 789 3.67 .041 1.16 1.25

AllProb018 Pulm- Asthma & reactive airway disease 779 3.24 .044 1.22 2.26

AllProb019 Pulm- Chronic lung disease 791 3.43 .042 1.17 1.25

AllProb020 Pulm- Congenital & acquired anomalies 729 2.38 .048 1.30 8.65 AllProb021 Pulm- Exacerbation of chronic lung disease 779 3.46 .043 1.21 2.50

AllProb022 Pulm- Pulmonary hypertension 777 3.15 .043 1.19 2.88

AllProb023 Pulm- Pulmonary infections 786 3.79 .039 1.09 0.88

AllProb024 Pulm- Thoracic surgery 747 3.16 .048 1.31 6.74

AllProb025 Pulm- Thoracic & pulmonary trauma & injuries 720 2.94 .052 1.39 10.22

AllProb026 Pulm- Upper airway obstruction 770 3.29 .047 1.31 3.27

AllProb027 Endo- Adrenal disorders 756 2.31 .042 1.17 4.91

AllProb028 Endo- Diabetes insipidus 751 2.83 .049 1.35 5.06

AllProb029 Endo- Hypoglycemia 769 3.49 .045 1.25 1.28

AllProb030 Endo- SIADH 762 2.68 .047 1.29 3.91

AllProb031 Musculo- Functional issues 775 3.52 .046 1.28 3.00

AllProb032 Musculo- Infections 778 3.88 .042 1.17 1.64

AllProb033 Musculo- Osteoporosis & bone disease 715 2.33 .046 1.24 10.06

AllProb034 Musculo- Stress fractures 667 2.09 .046 1.19 16.31

AllProb035 Musculo- Traumatic fractures 700 2.69 .053 1.41 11.84

AllProb036 Hem-Immuno- Anemia 780 3.20 .043 1.19 1.39

AllProb037 Hem&Immuno- Autoimmune diseases 751 2.60 .043 1.18 4.33

AllProb038 Hem&Immuno- Blood group incompatibilities 735 2.60 .050 1.36 6.49

AllProb039 Hem&Immuno- Coagulopathies 773 3.40 .042 1.18 2.03

AllProb040 Hem&Immuno- Congenital & acquired

immunosuppression 724 2.41 .046 1.24 8.35

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AllProb042 Hem&Immuno- Leukemia & tumors 692 2.30 .048 1.25 12.18 AllProb043 Hem&Immuno- Organ & tissue transplantation 639 2.58 .057 1.44 19.11

AllProb044 Hem&Immuno- Polycythemia 696 2.02 .044 1.15 11.68

AllProb045 Neuro- Congenital neurological abnormalities 632 2.14 .051 1.28 20.10

AllProb046 Neuro- Encephalopathy 723 2.91 .050 1.34 8.02

AllProb047 Neuro- Head and brain trauma & injury 700 3.20 .057 1.50 10.60

AllProb048 Neuro- Hydrocephalus 636 2.52 .056 1.40 19.49

AllProb049 Neuro- Increased intracranial pressure 721 3.43 .054 1.45 8.50 AllProb050 Neuro- Intracranial & intraventricular

hemorrhage 735 3.51 .052 1.42 7.20

AllProb051 Neuro- Neurologic infectious diseases 704 2.72 .051 1.34 10.43

AllProb052 Neuro- Neuromuscular disorders 724 2.65 .046 1.24 8.01

AllProb053 Neuro- Seizure disorders 755 3.06 .047 1.30 4.31

AllProb054 Neuro- Space-occupying lesions 682 2.63 .052 1.36 13.12

AllProb055 Neuro- Spinal cord injury 672 2.91 .057 1.49 14.83

AllProb056 Neuro- Stroke 761 3.88 .045 1.23 3.55

AllProb057 Neuro- Vascular malformation 698 2.61 .049 1.30 10.97

AllProb058 Gastro- Abdominal trauma 665 2.85 .056 1.44 14.41

AllProb059 Gastro- Acute GI hemorrhage 741 3.48 .046 1.25 3.89

AllProb060 Gastro- Bowel infarction, obstruction,

perforation 749 3.35 .045 1.22 3.10

AllProb061 Gastro- Gallbladder disease 695 2.54 .047 1.23 10.55

AllProb062 Gastro- Gastro-esophageal reflux 737 2.80 .047 1.26 5.03

AllProb063 Gastro- Gastrointestinal infectious diseases 716 2.61 .049 1.30 6.77

AllProb064 Gastro- GI abnormalities 688 2.25 .048 1.25 11.23

AllProb065 Gastro- GI motility disorders 734 2.56 .046 1.25 5.41

AllProb066 Gastro- GI surgeries 716 2.85 .048 1.28 7.25

AllProb067 Gastro- Hepatic failure & coma 718 3.02 .048 1.30 7.47

AllProb068 Gastro- Hepatitis 720 2.68 .047 1.27 6.86

AllProb069 Gastro- Malnutrition 736 3.15 .048 1.30 4.54

AllProb070 Gastro- Nausea & vomiting 744 3.24 .047 1.28 3.13

AllProb071 Renal- Acute renal failure 770 3.99 .038 1.05 1.16

AllProb072 Renal- Chronic renal failure 753 3.59 .042 1.14 2.21

AllProb073 Renal- Congenital & acquired renal &

genitourinary abnormalities 677 2.29 .047 1.23 12.42

AllProb074 Renal- Electrolyte imbalances 773 4.20 .034 .94 0.77

AllProb075 Renal- Fluid volume imbalances 769 4.22 .034 .94 0.77

AllProb076 Renal- Infections 745 3.31 .048 1.30 3.62

AllProb077 Renal- Renal and genitourinary surgeries 686 2.52 .048 1.25 11.48

AllProb078 Renal- Renal calculi 654 2.17 .047 1.21 14.73

AllProb079 Integ- Congenital & acquired abnormalities 604 1.93 .049 1.20 21.96

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AllProb081 Integ- Infectious skin disorders 681 2.27 .048 1.26 10.86

AllProb082 Integ- Pressure ulcers 752 3.90 .045 1.24 2.72

AllProb083 Integ- Wounds 755 3.83 .042 1.16 1.95

AllProb084 Multi- Compartment syndrome 719 3.05 .050 1.35 6.62

AllProb085 Multi- Distributive shock 734 3.54 .049 1.33 4.30

AllProb086 Multi- End of life issues 766 4.21 .037 1.04 0.91

AllProb087 Multi- Hypovolemic shock 751 3.92 .044 1.20 2.21

AllProb088 Multi- Hypoxic ischemic encephalopathy 726 3.28 .050 1.34 5.71

AllProb089 Multi- Infectious diseases 756 3.89 .042 1.15 2.20

AllProb090 Multi- Pain 767 4.43 .031 .85 0.52

AllProb091 Multi- Palliative care issues 760 4.00 .040 1.12 1.55

AllProb092 Multi- Patient safety issues 768 4.38 .034 .95 0.26

AllProb093 Multi- Sensory impairment 740 2.74 .048 1.31 3.90

AllProb094 Multi- SIRS, sepsis, septic shock, MODS 752 4.01 .044 1.20 2.72

AllProb095 Multi- Toxic exposure 667 2.49 .051 1.31 12.47

AllProb096 Psych- Age-related developmental issues 709 2.99 .052 1.38 7.92

AllProb097 Psych- Failure to thrive 655 2.62 .053 1.35 14.15

AllProb098 Psych- Maltreatment 713 2.74 .051 1.36 6.43

AllProb099 Psych- Medical nonadherence 738 3.19 .047 1.28 4.16

AllProb100 Psych- Sleep disorders 699 2.51 .046 1.21 8.63

AllProb101 Psych- Substance abuse 746 3.16 .046 1.25 2.86

AdultProb01 Cardio- Cardiac trauma 576 2.71 .060 1.44 14.92

AdultProb02 Cardio- Dyslipidemia 636 3.18 .053 1.35 5.92

AdultProb03 Cardio- Ruptured & dissecting aneurysm 621 3.29 .052 1.29 7.73

AdultProb04 Pulm- Acute pulmonary embolus 659 3.88 .041 1.06 1.93

AdultProb05 Pulm- ALI (ARDS) 645 3.82 .048 1.21 3.44

AdultProb06 Pulm- Obstructive sleep apnea 646 3.16 .049 1.25 3.73

AdultProb07 Endo- Diabetes mellitus 668 4.18 .037 .95 0.74

AdultProb08 Endo- Diabetes ketoacidosis & HHNK 655 3.46 .048 1.23 2.67

AdultProb09 Endo- Hyperglycemia 662 3.95 .039 1.01 1.19

AdultProb10 Endo- Hormone imbalances & issues 642 2.61 .047 1.20 4.75

AdultProb11 Endo- Thyroid disorders 654 2.66 .047 1.19 2.97

AdultProb12 Musculo- Acute gout 552 1.97 .049 1.14 17.37

AdultProb13 Musculo- Osteoarthritis 590 2.16 .049 1.20 11.68

AdultProb14 Musculo- Spinal disease 573 2.05 .049 1.18 13.96

AdultProb15 Musculo- Sports injuries 467 1.99 .056 1.21 30.19

AdultProb16 Hem&Immuno- AIDS & HIV 622 2.43 .050 1.25 7.16

AdultProb17 Hem&Immuno- HELLP syndrome 545 2.26 .056 1.31 18.05

AdultProb18 Hem&Immuno- Sickle cell disease 575 2.17 .052 1.24 13.92

AdultProb19 Neuro- Migraine headaches 538 2.01 .052 1.21 18.73

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AdultProb21 Gastro- Pancreatitis 621 3.14 .049 1.21 3.72

AdultProb22 Renal- Gynecological problems 514 1.85 .049 1.11 23.63

AdultProb23 Renal- Incontinence 595 2.50 .055 1.33 11.46

AdultProb24 Renal- Obstetrical issues 450 1.94 .054 1.15 32.94

AdultProb25 Renal- Prostate problems 548 2.00 .048 1.12 18.09

AdultProb26 Renal- Renal trauma 541 2.33 .056 1.29 19.13

AdultProb27 Integ- Pruritus 529 1.90 .049 1.13 19.11

AdultProb28 Multi- Burns 417 2.19 .068 1.38 37.57

AdultProb29 Multi- Life-threatening maternal-fetal complications

370 2.28 .074 1.42

44.69

AdultProb30 Multi- Multisystem trauma 509 3.12 .069 1.56 23.57

AdultProb31 Multi- Near-drowning 439 2.36 .066 1.38 34.48

AdultProb32 Multi- Toxic ingestions & inhalations 524 2.56 .059 1.36 21.32

AdultProb33 Psych- Aggression 625 2.82 .053 1.31 7.54

AdultProb34 Psych- Anxiety disorders 630 2.88 .053 1.32 6.25

AdultProb35 Psych- ADHD 497 1.99 .054 1.20 26.70

AdultProb36 Psych- Delirium 649 3.85 .047 1.19 3.85

AdultProb37 Psych- Dementia 652 3.46 .047 1.20 3.55

AdultProb38 Psych- Eating disorders 494 1.84 .050 1.12 27.03

AdultProb39 Psych- Learning disabilities & disorders 523 1.93 .050 1.15 22.63

AdultProb40 Psych- Mood disorders 614 2.80 .053 1.31 8.90

AdultProb41 Psych- Personality disorders 598 2.47 .053 1.30 10.61

AdultProb42 Psych- Risk-taking behaviors 589 2.75 .056 1.37 12.48

AdultProb43 Psych- Suicidal behavior 618 2.84 .055 1.36 7.62

NeoProb01 Cardio- PDA 19 4.37 .175 .76 0.00

NeoProb02 Pulm- Apnea of prematurity 19 4.42 .159 .69 0.00

NeoProb03 Pulm- PPHN 19 4.26 .227 .99 0.00

NeoProb04 Pulm- Respiratory distress syndrome 19 4.47 .160 .70 0.00

NeoProb05 Pulm- Transient tachypnea of newborn 19 3.68 .297 1.29 0.00

NeoProb06 Endo- Inborn errors of metabolism 18 3.39 .304 1.29 0.00

NeoProb07 Endo- Infant of diabetic mother 19 4.42 .159 .69 0.00

NeoProb08 Musculo- Congenital anomalies 19 4.00 .216 .94 0.00

NeoProb09 Neuro- Periventricular leukomalacia 19 3.42 .279 1.22 0.00

NeoProb10 Multi- Child of addicted mother 19 4.00 .254 1.11 0.00

NeoProb11 Multi- Life-threatening maternal-fetal complications

19 4.11 .228 .99

0.00 NeoProb12 Multi- Low birth weight & prematurity 19 4.53 .160 .70 0.00

NeoProb13 Multi- Transition to extrauterine life 19 4.21 .196 .85 0.00

NeoProb14 Psych- Behavioral state 19 4.58 .159 .69 0.00

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PedsProb02 Cardio- Dyslipidemia 50 1.56 .143 1.01 23.08

PedsProb03 Cardio- PDA 59 2.80 .196 1.51 10.61

PedsProb04 Cardio- Ruptured & dissecting aneurysm 43 1.81 .164 1.07 35.82

PedsProb05 Pulm- Acute pulmonary embolus 63 2.35 .154 1.22 4.55

PedsProb06 Pulm- Acute life-threatening events 66 3.95 .158 1.28 0.00

PedsProb07 Pulm- ALI & ARDS 63 3.81 .157 1.24 4.55

PedsProb08 Pulm- Obstructive sleep apnea 62 2.35 .163 1.28 6.06

PedsProb09 Pulm- Pulmonary hemorrhage 62 2.53 .145 1.14 6.06

PedsProb10 Endo- Diabetes mellitus 64 3.72 .167 1.34 4.48

PedsProb11 Endo- Diabetic ketoacidosis & HHNK 65 3.74 .170 1.37 2.99

PedsProb12 Endo- Hormone imbalances & issues 64 2.52 .146 1.17 4.48

PedsProb13 Endo- Hyperglycemia 66 3.42 .166 1.35 1.49

PedsProb14 Endo- Inborn errors of metabolism 64 2.89 .161 1.29 4.48

PedsProb15 Endo- Thyroid disorders 64 2.22 .155 1.24 4.48

PedsProb16 Musculo- Congenital abnormalities 65 2.97 .167 1.35 1.52

PedsProb17 Musculo- Osteoarthritis 40 1.75 .142 .90 38.46

PedsProb18 Musculo- Spinal disease 59 2.69 .176 1.36 11.94

PedsProb19 Musculo- Sports injuries 60 2.48 .162 1.26 10.45

PedsProb20 Hem&Immuno- AIDS & HIV 56 2.34 .188 1.40 8.20

PedsProb21 Hem&Immuno- Sickle cell disease 62 3.16 .174 1.37 7.46

PedsProb22 Gastro- Inflammatory bowel disease 55 2.64 .156 1.16 8.33

PedsProb23 Gastro- Pancreatitis 65 2.60 .150 1.21 2.99

PedsProb24 Renal- Gynecological problems 57 1.56 .125 .95 14.93

PedsProb25 Renal- Incontinence 56 2.05 .162 1.21 16.42

PedsProb26 Renal- Obstetrical issues 37 1.24 .112 .68 43.94

PedsProb27 Renal- Renal trauma 54 2.39 .168 1.23 19.40

PedsProb28 Integ- Pruritus 57 1.91 .140 1.06 12.31

PedsProb29 Multi- Burns 53 2.40 .191 1.39 20.90

PedsProb30 Multi- Child of addicted mother 58 2.22 .191 1.45 13.43

PedsProb31 Multi- Multisystem trauma 56 3.96 .155 1.16 16.42

PedsProb32 Multi- Near-drowning 58 3.66 .157 1.19 13.43

PedsProb33 Multi- Toxic ingestions & inhalations 61 3.49 .158 1.23 8.96

PedsProb34 Psych- Aggression 59 2.31 .166 1.28 10.61

PedsProb35 Psych- Anxiety disorders 61 2.25 .163 1.27 8.96

PedsProb36 Psych- ADHD 62 2.47 .159 1.25 7.46

PedsProb37 Psych- Autism & autism spectrum disorders 62 2.58 .160 1.26 7.46

PedsProb38 Psych- Delirium 57 1.98 .145 1.09 14.93

PedsProb39 Psych- Disorders of elimination 56 1.96 .167 1.25 16.42

PedsProb40 Psych- Eating disorders 58 2.10 .151 1.15 13.43

PedsProb41 Psych- Learning disabilities & disorders 61 2.21 .144 1.13 8.96

PedsProb42 Psych- Mood disorders 62 2.26 .151 1.19 6.06

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PedsProb44 Psych- Risk-taking behaviors 61 2.52 .156 1.22 8.96

PedsProb45 Psych- Suicidal behavior 63 2.94 .158 1.26 5.97

CardioTask01 Interpret ECG rhythms 724 4.26 .041 1.10 2.95

CardioTask02 Interpret 12-lead ECGs 682 3.57 .051 1.32 8.33

CardioTask03 Determine lead selection for ECGs 696 3.68 .049 1.30 6.83

CardioTask04 Interpret hemodynamic values 715 4.08 .044 1.17 4.28

CardioTask05 Interpret non-invasive hemodynamic values 718 4.11 .042 1.13 3.49 CardioTask06 Manage transcutaneous (external) pacemakers 621 3.50 .055 1.37 16.53 CardioTask07 Insert temporary transvenous pacemakers 293 2.56 .084 1.43 60.46 CardioTask08 Manage temporary transvenous pacemakers 559 3.33 .061 1.45 24.36 CardioTask09 Insert permanent transvenous pacemakers 239 2.46 .093 1.44 67.83 CardioTask10 Manage permanent transvenous pacemakers 531 3.12 .062 1.42 28.53

CardioTask11 Insert transesophageal pacemakers 198 2.10 .092 1.30 73.32

CardioTask12 Manage transesophageal pacemakers 326 2.40 .080 1.44 55.83

CardioTask13 Manage epicardial pacemakers 464 3.21 .070 1.52 37.04

CardioTask14 Insert implantable cardioverter defibrillators (ICDs)

193 2.33 .105 1.46

73.95 CardioTask15 Manage implantable cardioverter defibrillators

(ICDs)

508 2.94 .064 1.44

30.88 CardioTask16 Insert intra-aortic balloon catheter 195 2.58 .111 1.55 73.68 CardioTask17 Remove intra-aortic balloon catheter 285 2.86 .085 1.44 61.49 CardioTask18 Manager cardiac assist devices (e.g., RVAD,

BVAD. LVAD, ECMO)

364 3.04 .078 1.49

50.94

CardioTask19 Perform pericardiocentesis 223 2.26 .090 1.34 69.86

CardioTask20 Direct cardiopulmonary resuscitation 666 3.92 .050 1.29 10.12

CardioTask21 Insert arterial pressure catheters 274 2.98 .088 1.46 62.97

CardioTask22 Insert central venous pressure catheters 260 2.93 .091 1.47 64.86 CardioTask23 Insert pulmonary artery pressure catheters 229 2.64 .096 1.45 69.05 CardioTask24 Adjust pulmonary artery pressure catheters 371 3.00 .075 1.45 49.93

CardioTask25 Perform stress testing 222 2.41 .095 1.41 70.04

CardioTask26 Interpret echocardiograms 275 2.40 .083 1.37 62.79

CardioTask27 Direct extracorporeal compression pressure (EECP) therapy

171 2.02 .097 1.27

76.89

CardioTask28 Perform elective cardioversion 389 2.94 .073 1.44 47.57

CardioTask29 Perform tilt-table testing 200 2.24 .096 1.35 72.97

CardioTask30 Disconnect pacer wire 349 3.23 .077 1.43 52.90

CardioTask31 Harvest saphenous vein graft 129 2.05 .121 1.37 82.40

CardioTask32 Perform interventional radiology 142 2.08 .113 1.35 80.84

CardioTask33 Interpret stress tests 215 2.38 .097 1.42 70.79

PulmTask01 Order nasal/facial CPAP/BiPAP 406 3.15 .069 1.40 45.21