Report of findings from the role delineation study of nurse practitioners and clinical nurse specialists

Tags: NCSBN, National Council of State Boards of Nursing, Inc., NPs, nursing practice, Statistically Significant, Nurse Practitioners, Clinical Nurse Specialists, health care, respondents, Nurse Practitioner, Role Delineation Study, Clinical Nurse Specialist, importance ratings, National Council of State Boards of Nursing, health care team, diagnostic reasoning, CNSs, response rate, electronic survey, survey statements, acute care facility, critical thinking, durable medical equipment, practical significance, state boards of nursing
Content: NCSBN research brief Volume 30 | May 2007 Role Delineation Study of Nurse Practitioners and Clinical Nurse Specialists
Report of Findings from the Role Delineation Study of Nurse Practitioners and Clinical Nurse Specialists Kevin Kenward, PhD National Council of State Boards of Nursing, Inc. (NCSBN®)
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Role Delineation Study of Nurse Practitioners and Clinical Nurse Specialists
Mission Statement The National Council of State Boards of Nursing, composed of member boards, provides leadership to advance regulatory excellence for public protection. Copyright © 2007 National Council of State Boards of Nursing, Inc. (NCSBN®) All rights reserved. The NCSBN logo, NCLEX®, NCLEX-RN® and NCLEX-PN® are registered trademarks of NCSBN and this document may not be used, reproduced or disseminated to any third party without written permission from NCSBN. Permission is granted to boards of nursing to use or reproduce all or parts of this document for licensure related purposes only. Nonprofit education programs have permission to use or reproduce all or parts of this document for educational purposes only. Use or reproduction of this document for commercial or for-profit use is strictly prohibited. Any authorized reproduction of this document shall display the notice: "Copyright by the National Council of State Boards of Nursing, Inc. All rights reserved." Or, if a portion of the document is reproduced or incorporated in other materials, such written materials shall include the following credit: "Portions copyrighted by the National Council of State Boards of Nursing, Inc. All rights reserved." Address inquiries in writing to NCSBN Permissions, 111 E. Wacker Drive, Suite 2900, Chicago, IL 60601-4277. Suggested Citation: National Council of State Boards of Nursing. (2007). Report of Findings from the Role Delineation Study of Nurse Practitioners and Clinical Nurse Specialists. (Research Brief Vol. 30). Chicago: Author. Printed in the United States of America ISBN# 0-9779066-7-1 National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Table of Contents iii Table of Contents List of Tables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 I. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 II. Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Advisory Panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Panel of Subject Matter Experts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Survey Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Lists Received for Survey Sample. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Pilot Test of Electronic Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Sampling for the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Postcards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Response Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 III. Study Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Demographics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Gender. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Initial Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Highest Degree. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Certifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Hours Worked . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Administrative Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Direct Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Time for Direct Patient Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Number of Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Patient Age. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Employment Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Immediate Supervisor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Exempt or Nonexempt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Frequency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Priority. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 No Significant Differences in Priority of Activities Between Nurse Practitioners and Clinical Nurse Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Criticality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Statistical Significance Versus Practical Significance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Knowledge Category Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 IV. Limitations of the Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
iv TABLE OF CONTENTS V. Summary of Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Appendix A: Advisory Panel Members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Appendix B: Subject Matter Expert (SME) Panels. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Appendix C: Tests of Significance Frequency and Importance of Activities. . . . . . . . . . . . . . . . . . . . 41 Appendix D: Tests of Significance for Importance of Knowledge Categories . . . . . . . . . . . . . . . . . . 51 Appendix E: Analysis Excluding Nurses in Psychiatric, mental health and Acute Care Settings. . . . 52 Appendix F: Knowledge Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
LIST OF TABLES
v
List of Tables Table 1. Regulatory Approaches to APRNs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Table 2. Minimum Educational Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Table 3. Prescriptive Authority. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Table 4. Level of Prescriptive Authority. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Table 5. Prescriptive Authority Relative to Controlled Substances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Table 6. Authority to Order Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Table 7. Respondents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Table 8. Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 9. Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 10. Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Table 11. Ethnicity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Table 12. Type of Initial Nurse Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Table 13. Highest Degree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Table 14. Certifications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Table 15. Hours Worked. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Table 16. Administrative Time in Hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Table 17. Direct Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Table 18. Percentage of Time (Hours) for Direct Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Table 19. Number of Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Table 20. Age of Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Table 21. Employment Setting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Table 22. Immediate Supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Table 23. Exempt Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Table 24. Years of Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Table 25. Activity Statements with Frequency Rated Significantly Higher by Nurse Practitioners than Clinical Nurse Specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Table 26. Activity Statements with Frequency Rated Significantly Higher by Clinical Nurse Specialists than Nurse Practitioners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Table 27. No Significant Differences in Frequency of Activities Between Nurse Practitioners and Clinical Nurse Specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Table 28. Activity Statements with Priority Rated Significantly Higher by Nurse Practitioners than Clinical Nurse Specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Table 29. Activity Statements with Priority Rated Significantly Higher by Clinical Nurse Specialists than Nurse Practitioners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Table 30. No Significant Differences in Priority of Activities Between Nurse Practitioners and Clinical Nurse Specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Table 31. Activity Statements with Criticality Rated Significantly Higher by Nurse Practitioners than Clinical Nurse Specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Table 32. Activity Statements with Criticality Rated Significantly Higher by Clinical Nurse Specialists than Nurse Practitioners. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Table 33. No Significant Differences in Criticality of Activities Between Nurse Practitioners and Clinical Nurse Specialists. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Table 34. Importance in Knowledge Categories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
ACKNOWLEDGMENTS vii Acknowledgments This study would not have been possible without support from the nurse practitioners and clinical nurse specialists from all parts of the U.S. The time and attention they gave to completing a lengthy, detailed survey demonstrated their commitment to the nursing profession. I would also like to thank Lynn Webb and Richard Smiley for their invaluable assistance. The author also gratefully acknowledges the NCSBN Advanced Practice Advisory Panel and Nancy Chornick for their review and support of this research endeavor. National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
EXECUTIVE SUMMARY 1
Executive Summary
The National Council of State Boards of Nursing (NCSBN) conducted a study on the roles of the nurse practitioner (NP) and the clinical nurse specialist (CNS). The goal of the role delineation study was to provide data to boards of nursing to assist them in determining the level of regulation appropriate for NPs and CNSs. A logical analysis of the literature was conducted to develop activity and knowledge statements. The lists of statements were further reviewed and refined by expert panels, and used as the basis of an electronic survey. The electronic survey resulted in a response rate of 11%, so NCSBN mailed a paper version of the survey to the sample of NPs and CNSs. The final response rate was 30% and the survey results are based on 1,526 NPs and 1,344 CNSs. The majority of respondents were Caucasian, female and between 40-59 years old. The most common certification obtained among NPs was family nurse practitioner and among CNSs was clinical specialist in adult psychiatric and mental health nursing. Generally, the findings indicate that CNSs focus on administration more than NPs as indicated by the percentage of time specified for administration. NPs focus on direct patient care, as evidenced by the percentage of time spent providing direct patient care. The most common employment setting for NPs was an office/private practice, while the most common site for CNSs was an acute care facility. The most common supervisor of NPs was a physician; for CNSs it was a nurse. There were many activity statements that the NPs rated as having performed more frequently than did the CNSs. Reading the list of activities rated higher in frequency by the NPs, one sees the focus of direct patient care in terms of physical examination, performing tests, differential diagnosis, prescribing and evaluating interventions, selecting treatment, prescribing medication, evaluating outcomes, revising diagnoses, patient follow-up, maintaining patient records, advocating for patients, ordering equipment, obtaining referrals and initiating consultations.
Reading the list of activities rated higher in priority by the NPs, one again sees the focus of direct patient care in terms of physical examination, performing tests, differential diagnosis, prescribing and evaluating interventions, selecting treatment, prescribing medication, evaluating outcomes, revising diagnoses, patient follow-up, maintaining patient records, advocating for patients, ordering equipment, obtaining referrals and initiating consultations. The frequency and priority scores were combined to create an indicator of criticality. While there were some statistically significant differences between the scores of NPs and CNSs, these differences are sometimes found in activities that both roles rated relatively highly or lowly. For example, CNSs and NPs tend to agree on what the 15 most critical activities are. CNSs and NPs place nine (60%) of the same items in the top 15 most critical activities. Three of the top four activities are common to the two roles including: Demonstrates critical thinking and diagnostic reasoning skills in clinical decision making. Maintains clinical records that reflect diagnostic and therapeutic reasoning. Determines appropriate pharmacological, behavioral and other nonpharmacological treatment modalities in developing a plan of care. In addition to the three activities listed above, the following 11 activities were highly critical to both nurse practitioners and clinical nurse specialists: Analyzes and interprets history, presenting symptoms, physical findings and diagnostic information to formulate differential diagnoses. Prescribes, orders, and/or implements pharma- cologic and nonpharmacologic interventions, treatments, and procedures for patients and family members as identified in the plan of care. Designs and implements a plan of care to attain, promote, maintain and/or restore health.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
2 EXECUTIVE SUMMARY
Employs appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy. Incorporates risk/benefit factors in developing a plan of care. Verifies diagnoses based on findings. Assesses, diagnoses, monitors, coordinates and manages the health/illness status of patients over time.
One way to identify differences between the two roles is to look at activities that were rated highly by one role but not the other. The highest criticality ratings from NPs that were not highest for CNSs described prescribing medications, using laboratory tests, adjusting medications and performing physical examinations. The highest criticality ratings from CNSs that were not highest for NPs described functioning in a variety of role dimensions, promoting patient advocacy, working in interdisciplinary teams and using evidence-based research.
Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated.
Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
Evaluates results of interventions using ac- cepted outcome criteria, revises the plan of care and consults/refers when appropriate.
Plans follow-up visits to monitor patients and evaluate health/illness care.
Both roles emphasize critical thinking and diagnostic reasoning skills in clinical decision making; maintaining clinical records that reflect diagnostic and therapeutic reasoning; and determining appropriate pharmacological, behavioral and other nonpharmacological treatment modalities in developing a plan of care. Both roles also analyze and interpret history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses, design and implement a plan of care to attain, promote, maintain, and/or restore health, and employ appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Report of Findings from the Role Delineation Study of Nurse Practitioners and Clinical Nurse Specialists National Council of State Boards of Nursing, Inc. (NCSBN®)
4 INTRODUCTION
Introduction
Nursing specialties have existed since the 1900s. Nurse midwives and nurse anesthetists laid the formative foundations early in the 20th century for what is now known as advanced practice nursing (Bankert, 1989 and Rooks, 1997). Even though advanced practice roles are not new, historically, they have lacked clarity (Redekopp, 1997 and Scott, 1999).There continues to be a lack of knowledge among health care colleagues and consumers about what these nurses do. This study contributes to the body of knowledge about advanced practice nursing by delineating the roles of nurse practitioners (NP) and clinical nurse specialists (CNS); this knowledge will assist boards of nursing in determining the level of regulation appropriate for NPs and CNSs. NPs and CNSs are two of the four general types of advanced practice nurses, which include clinical nurse specialists, nurse anesthetists, nurse midwives and nurse practitioners. Advanced practice registered nurses (APRNs), are registered nurses (RNs) with advanced education, knowledge, skills and scopes of practice. Most APRNs possess a master's or doctoral degree in nursing and may also have passed additional certification examinations. APRNs are regulated as a separate group by 52 boards of nursing (NCSBN, 2002). In at least 45 states, advanced practice nurses are allowed to prescribe medications, while 16 states have granted APRNs authority to practice independently without physician collaboration or supervision. Tennessee and West Virginia do not regulate or recognize APRNs as a separate group, but nurses requesting prescriptive authority are regulated or recognized within the jurisdiction. The types of advanced practice nurses that are regulated by boards of nursing include: Certified nurse midwives provide prenatal and gynecological care to normal healthy women; deliver babies in hospitals, private homes and birthing centers; and continue with follow-up postpartum care (48 boards). Certified registered nurse anesthetists administer more than 65% of all anesthetics given to patients each year and are the sole providers of anesthesia
in approximately one-third of U.S. hospitals (50 boards). Clinical nurse specialists provide care in a range of specialty areas including cardiac, oncology, neonatal, pediatric and obstetric/gynecological nursing. Clinical nurse specialist--no specialty designa- tion (31 boards) Clinical nurse specialist psych/mental health (35 boards) Clinical nurse specialist--other types (30 boards) Nurse practitioners deliver front-line primary and acute care in community clinics, schools, hospitals and other settings. They also perform services that include diagnosing and treating common acute illnesses and injuries; providing immunizations; conducting physical exams; and managing high blood pressure, diabetes and other chronic conditions. Acute Care Nurse Practitioner (33 boards) Adult Health Nurse Practitioner (34 boards) Child Health/Pediatric Nurse Practitioner (35 boards) College Health Nurse Practitioner (14 boards) Emergency Nursing Nurse Practitioner (19 boards) Family Nurse Practitioner (35 boards) family planning Nurse Practitioner (22 boards) Geriatric Nurse Practitioner (35 boards) Neonatal Nurse Practitioner (33 boards) Nurse Practitioner--no specialty designation (28 boards) Obstetrical and/or Gynecological and/or Women's Health Nurse Practitioner (34 boards) Psychiatric and/or Mental Health Nurse Practitioner--including all its subspecialties (31 boards) School Health Nurse Practitioner (31 boards)
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
INTRODUCTION 5
There are additional categories of APRNs but they are regulated or recognized by only a single board or a very small number of boards. It is understood that many activities and compe- tencies of NPs and CNSs will be applicable to the roles listed above. In some jurisdictions, the roles of NPs and CNS may be very similar. NCSBN's Profiles of Member Boards (2002) also delineates the regulatory approaches for the various APRNs. These data are summarized in Table 1. The regulatory oversight for CNSs and NPs is mostly done by the state boards of nursing (45 boards for CNSs and 44 boards for NPs). Other oversight bodies include advanced practice nursing board, department of health and board of advanced registered nurse practice. The minimal educational requirements for legal recognition as an advanced practitioner also vary between boards of nursing. These data are summarized in Table 2. It is not surprising to see that prescriptive authority also varies by boards of nursing. These data are summarized in Table 3. The level of prescriptive authority also varies by boards of nursing. It will be interesting to explore these differences across the roles of NP and CNS. The data, as presented by NCSBN in 2003, are summarized in Table 4.
Table 1.Regulatory Approaches to APRNs
Regulatory Approach
N Boards N Boards for CNSs for NPs
Board-issued advanced practice license
9
12
Board-issued certificate to practice
7
11
Board-issued letter of recognition or authorization to practice
18
20
Other
12
10
Table 2.Minimum Educational Requirements
Minimum Educational Requirements
N Boards for CNSs
Post-basic advanced practice program
5
leading to a certificate of completion
Graduate degree with a concentration in
8
an advanced nursing practice category
Graduate degree with a major in nursing
10
Other
23
N Boards for NPs 12 8 0 30
Table 3. Prescriptive Authority Prescriptive Authority Prescriptive authority is automatically granted to those who meet all requirements for legal recognition Prescriptive authority is NOT automatically granted to those who meet all requirements for legal recognition Other
N Boards for CNSs 13
N Boards for NPs 25
31
24
5
4
Table 4.Level of Prescriptive Authority Level of Prescriptive Authority Granted Independent but restricted to area of practice experience Independent without restrictions Restricted to formulary Restricted to protocol and practice agreement with physician Restricted to protocol Restricted to practice agreement with physician None Other
N Boards N Boards for CNSs for NPs
8
12
1
4
1
2
2
3
0
3
5
8
11
2
14
18
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
6 INTRODUCTION
There is even greater variation seen across boards of nursing when looking specifically at prescriptive authority relative to controlled substances. These data are summarized in Table 5. Finally, the boards of nursing differ in the authority automatically granted to order durable medical equipment to APRNs who meet all requirements for legal recognition. These data are summarized in Table 6. This study is based on work conducted by Lynn Webb and Associates on behalf of NCSBN in 2005-2006 to examine the roles of NPs and CNSs. The purpose of the study was to identify the similarities and differences between NPs and CNSs in terms of the activities they perform as well as their knowledge, skills and abilities. Results of the study may be used as a resource for boards of nursing in determining the level of regulation appropriate for NPs and CNSs, Educational Programs to plan curriculums and additional organizations involved in the assessment of competencies.
Table 5. Prescriptive Authority Relative to Controlled Substances
Prescriptive Authority Relative to Controlled Substances
N Boards for CNSs
N Boards for NPS
Schedules I-V
3
3
Schedules II-V
13
22
Schedules III-V
3
4
Schedule V
1
0
None
9
4
None, Legend Only
3
2
(Other)
10
16
Table 6.Authority to Order Durable Medical Equipment
Authority to Order Durable Medical Equipment
N Boards N Boards for CNSs for NPs
Authority to order durable medical equipment is automatically granted to APRNs who meet all requirements for legal recognition
21
32
Authority to order durable medical
10
7
equipment is NOT automatically granted
to APRNs who meet all requirements for
legal recognition
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
METHODOLOGY 7
Methodology
The methodology for the project is consistent with model-based practice analysis described by Kane in which the first phase involves model development (logical job analysis) and the second stage involves data collection and analysis (incumbent job analysis) (Kane, 1997). The premise of a two-phase approach is to structure collection of the data so that the results are readily translated into a description of practice. The study followed a five-step process: 1. Create a draft listing of important job activities and associated knowledge/skills/abilities from a review of the literature. Job activities are duties, functions or responsibilities involved in performing the job. 2. Have subject matter experts (SMEs) review the listing and contribute additional information. 3. Create a list of important job activities based on SMEs' input. 4. Create a role delineation questionnaire from the job activities list and distribute it to a representative sample of incumbents (i.e., nurses). The purposes of the questionnaire are to validate the work from the logical analysis and expert panels (verify the accuracy of the information) and to assess the relative importance of each job activity. 5. Have SMEs review and approve the results. Materials reviewed as part of the logical analysis included: Draft pharmacotherapeutics curriculum guide- lines (HHS, HRSA, 1998) Report of Findings from the 2002 RN Practice Analysis: Linking the NCLEX-RN® Examination to Practice Essentials of Master's Education for Advanced Practice Nursing (AACN, 1996) Domains and Competencies of Nurse Practitio- ner Practice (NONPF, 2000)
Criteria for Evaluation of Nurse Practitioner Programs: A Report of the National Task Force on Quality Nurse Practitioner Education (NONPF, AACN, 2002) Statement on Clinical Nurse Specialist Practice and Education (NACNS, 2004) Scope of Practice and Standards of Professional Performance for the Acute and Critical Care Clinical Nurse (ANA, AACCN, 1995) Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric and Women's Health (HHS, HRSA, 1998) Based on this review, 332 statements were prepared under the three content headings of: Management of Patient Care Activities Elicits a comprehensive health history Performs a comprehensive physical examination Orders diagnostic tests Analyzes patient data to determine health status Formulates a list of differential diagnoses Verifies diagnoses based on findings Determines appropriate pharmacological, behavioral and other nonpharmacologic treatment modalities in developing a plan of care Designs a plan of care to attain/promote, maintain and/or restore health Executes the plan of care Evaluates patient outcomes in relation to the plan of care Modifies the plan of care when indicated Uses principles of ethical decision making in selecting treatment modalities
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
8 METHODOLOGY
Promotes principles of patient advocacy in patient interactions and in the selection of treatment modalities Incorporates risk/benefit factors in develop- ing a plan of care Management of Health Care Delivery SySTEM activities Maintains clinical records that reflect diag- nostic and therapeutic reasoning Applies knowledge of the regulatory pro- cesses to deliver safe, effective patient care Develops a quality assurance/improvement plan to evaluate and modify practice Delivers cost-effective care that demonstrates knowledge of patient payment systems and provider reimbursement systems Management of Role and Professional Relationships Articulates the NP role and scope of practice Collaborates with health care professionals to meet patient health care needs Refers patients to other health care profes- sionals when indicated by patient health care needs To remain consistent, the term patient was used throughout the study, although it was noted that some APRNs prefer the term client. Advisory Panel An advisory panel of three NPs and three CNSs was selected to oversee this study (Appendix A). Panel members collectively represent geographically diverse boards of nursing. The advisory panel assisted the project team with: Selecting expert panel members Reviewing draft materials for expert panel meeting Selecting pilot test volunteers Addressing unanticipated events that affected the study (e.g., low response rate)
Panel of Subject Matter Experts SME panels of 10 NPs and nine CNSs were selected to assist with the analysis and critical review of competencies, activities and knowledge categories. The major tasks of the SME panel members were reviewing lists of activities and delineating the knowledge required to perform the activities. The panel members had expertise in their roles and provided a representation of geography, work setting and specialty area. The SME panel members were currently working and performing tasks typical of NPs or CNSs. Lists of the two expert panels are included as Appendix B. Practice specialties included women's health, legal, hospital, family, pediatrics, psychiatry/mental health, academia, medical-surgical, orthopedic, child and adolescent, Veterans Administration (VA) and home health. Each panel examined a list of 332 activities that a review of the literature indicated was fitting for the roles of NPs or CNSs. Activities were deleted if they were not important, important to every profession, not just advanced practice nursing or important to all RNs. After the activities were reviewed, each panel created a list of the knowledge required to perform the activities. The panels reviewed a handout of categories of knowledge from the Report of Findings from the 2002 RN Practice Analysis: Linking the NCLEX-RN® Examination to Practice, as an example of knowledge categories. Each SME panel delineated the general knowledge areas needed for safe and effective practice. The panels used general knowledge categories, not specific facts. The two lists of activities and knowledge statements were reviewed by the panels. Statements were retained if both SME panels said they were relevant and activities were deleted if both panels said they should be deleted. Activities that were on only one panel's list were included. Redundant activities were eliminated and some statements that were similar in content were combined. The activities were resequenced so the ones that were similar in content appeared in the same section. The final list of activities included 93 statements.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
METHODOLOGY 9
Survey Process Two online forms of the survey were created with 46 activities on one form and 47 of the 93 activities on the other form. Two forms of the survey were used to reduce the time burden on individual respondents. The two forms were alternated as people accessed the survey electronically. The knowledge statements were the same for both surveys, as were the demographic activity statements and descriptions of the work environment. Lists Received for Survey Sample Many state boards of nursing submitted lists of NPs, CNSs or APRNs following a request accompanying an explanation of the study. States not represented in the study were Delaware, New Hampshire and Wyoming. States that submitted lists of APRNs but did not separately identify NPs and CNSs were also not represented. These states were Alaska, Arizona, California, Illinois, Michigan, Pennsylvania, Vermont, Washington and Wisconsin. After the lists were finalized, a proportionate sample from each participating state was drawn. Pilot Test of Electronic Survey The Web site address was sent to 29 people who were invited to participate in the pilot survey, representing a combination of the Advisory Panel, people recommended by the Advisory Panel, and people who were nominated for previous phases of this study (Advisory Panel or SME Panels). There were 17 people who went to the survey site, and nine who completed at least the content for the actual survey. The pilot study was conducted to assess the time required to complete the survey, the ease in responding, and the clarity of directions and statements. Pilot participants were asked to make notes of any directions or statements that were unclear. Not all participants answered the additional pilot questions. There were five people who finished the survey with only one login; three people logged in two times. The responses to actual survey statements were varied and did not indicate any problems with the statements. Even with the small number of pilot respondents the survey instrument was judged satisfactory.
Sampling for the Survey A stratified random sample was selected from lists provided by boards of nursing to create a mailing list of 5,000 CNSs, 4,000 NPs and 1,000 unspecified APRNs. A separate sample was created for backup in the likely case of returned postcards. This sample contained 200 CNSs, 400 NPs and 400 unspecified APRNs. The final mailing list of 10,000 APRNs was sent the four postcard mailings for this study. Postcards The first postcard sent to the sample of 10,000 APRNs had the NCSBN logo on one side in color. The other side of the card was used for the address of the nurse sampled, the return address and text that provided a description of the study. It was hoped that this postcard would provide motivation to participate in the study. The second postcard provided the survey Web site address, but contained a typographical error in the address. To minimize the impact of this error, the third postcard, which was intended to serve as a reminder, was sent sooner than originally planned with the correct Web site address. Some nurses realized the Web site address problem and accessed the survey. Others called or sent e-mails to NCSBN about the error and were told the correct address. The fourth postcard was merely a reminder to motivate nonresponders. Response Rate The first postcard mailing was sent to 10,000 nurses. Of those, 1,112 were undeliverable, bringing the total sample to 8,888. When the initial response was lower than expected, a supplemental sample of 704 was mailed the first postcard, of which 639 were deliverable. Adding 8,888 and 639 gives a denominator of 9,527. There were 1,013 usable responses giving a response rate of approximately 11% (1,013/9,527) for the online survey. Follow-up phone calls were made to a portion of the sampled nurses to try to establish why the response rate was so low, and what might be done to improve it. Most nurses indicated they were too busy to participate. Other factors possibly contributing to the low response include the length of
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
10 METHODOLOGY
the questionnaire, which was estimated to take 30 minutes to complete, conducting the survey online which usually results in lower response rates than paper questionnaires and the issuance of a draft of NCSBN's APRN Vision Paper the same time the survey was launched. The Vision Paper suggested that CNSs should not be considered advanced practice nurses, which angered many nurses, some of whom commented they would not complete the survey because of recommendations in the position paper. In order to improve the response rate a paper-andpencil version of the two online survey forms was produced, and a shorter form was also created. Phone calls were made to encourage participation in the electronic survey, and incentives were offered for filling out the paper version of the survey. The paper surveys yielded 2,472 respondents. Of these, 615 returned surveys were excluded from the analysis since they did not specify whether they were NPs or CNSs. Overall, 1,013 NPs and CNSs filled out the online survey and 1,857 completed a paper survey bringing the total response rate to 2,870 of 9,527, or 30%. Table 7 shows that the paper survey yielded almost double the responses compared to the electronic survey.
Table 7.Respondents
Source of
Total NP
Data
Group
N
N
Paper Survey
1,857 1,061
Electronic Survey
1,013 465
Total
2,870 1,526
CNS N 796 548 1,344
Total Group % 65% 35% 100%
NP CNS
%
%
37% 28%
16% 19%
53% 47%
The responses to the paper survey by NPs and CNSs were analyzed to assess comparability to the electronic survey. The results indicate that respondents to the paper survey were equivalent to respondents to the electronic survey. In both survey methods: The majority of respondents were 40-59 years old. The majority of respondents were women. The majority of respondents were Caucasian. A bachelor's degree in nursing (BSN) was the most common type of initial nursing education. A master's degree in nursing (MSN) was the most common highest degree Among NPs, Family Nurse Practitioner was the most common certification Among CNSs, clinical specialist in adult psychi- atric and mental health nursing was the most common certification CNSs indicated a higher percentage of time on administrative functions than NPs did. The majority of respondents indicated that they provide direct care for patients. NPs indicated higher percentages of time pro- viding direct care for patients than CNSs did. The majority of respondents indicated caring for adults. The most common work setting for NPs was office/private practice. The most common work setting for CNSs was acute care facility. The most common supervisor for NPs was a physician. The most common supervisor for CNSs was a nurse. The majority of respondents indicated that they are salaried employees. The respondents represented a wide range of experience (in years).
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 11
Study Participants
Demographics, Experiences and Practice Environments of Participants Demographic information including age, gender, ethnicity, educational preparation and certification are presented followed by descriptions of respondents' work environments, including setting, time spent in various activities and client characteristics. Demographics Within the demographic section, respondents were asked to indicate whether they are currently working as an NP or CNS. Table 8 presents the results for this question. In the paper survey, some APRNs did not indicate NP or CNS, yet they completed the survey. It is also possible that some nurses work part-time in both roles and were unsure of how to respond. They are not shown in the tables because they did not contribute to the comparison of NPs and CNSs. Age Respondents were asked to enter their age. Table 9 presents the age results in 10-year increments, and shows that most of the respondents were 40-59 years old. Gender Respondents were asked to indicate their gender. Table 10 presents the results of the gender question and shows that most of the respondents were women.
Table 8. Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS)
NP or CNS
Total Group
Nurse Practitioner
1,526 (53%)
Clinical Nurse Specialist
1,344 (47%)
Total
2,870 (100%)
Table 9.Age
Age
Total NP CNS Total NP CNS
Group
N
N Group
%
%
N
%
20-29
19
16
3
1% 1% 0%
30-39
204 145
59
7% 5% 2%
40-49
671 373 298 23% 13% 10%
50-59
950 443 507 33% 15% 18%
60-69
219
81 138
8% 3% 5%
70-79
15
3
12
0% 0% 0%
80-89
3
2
1
0% 0% 0%
No Response
789 463 326 27% 16% 11%
Total
2,870 1,526 1,344 99%* 53% 47%
Table 10.Gender
Gender
Total Group N
Male
131
NP CNS Total
N
N Group
%
88
43
5%
NP CNS
%
%
3% 1%
Female
2,702 1,418 1,284 94% 49% 45%
No Response
37
20
17
1% 1% 1%
Total
2,870 1,526 1,344 100% 53% 47%
* Does not total to 100% due to rounding error National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
12 STUDY PARTICIPANTS
Ethnicity Respondents were asked to indicate their racial/ ethnic background. Table 11 indicates that most of the respondents were Caucasian. Initial Education Respondents were asked what initial educational degrees they held. Table 12 presents the results for this question, and shows that for both NPs and CNSs BSN was the most common degree. Highest Degree Respondents were asked to indicate the highest degree they hold. Table 13 presents the results for this question, and shows that MSN was the most common response.
Table 11.Ethnicity
Racial/Ethnic Background
Total Group N
Caucasian
2,713
African-
61
American
Asian
24
Pacific
2
Islander
Native
10
American
Other
34
No Response
26
Total
2,870
NP CN
N
N
1,423 1,290
38
23
19
5
2
0
3
7
24 17 1,526
10 9 1,344
Total % 94% 2% 1% 0% 0% 1% 1% 99%*
NP CNS %% 50% 45% 1% 1% 1% 0% 0% 0% 0% 0% 1% 0% 1% 0% 53% 47%
Table 12. Type of Initial Nurse Education
Type of Education
Total Group N
NP CNS Total
N
N Group
%
Diploma
536 275 261 19%
AD
568 347 221 20%
BSN
1,691 858 833 59%
No Response
75
46
29
3%
Total
2,870 1,526 1,344 99%*
NP CNS
%
%
10% 9% 12% 7% 30% 29% 2% 1% 53% 47%
Table 13.Highest Degree
Highest
Total
NP
Degree
Group
N
N
BSN
73
51
MSN
2,308 1,229
PhD, DNS, EdD
180
66
Other
240
139
No Response
69
41
Total
2,870 1,526
CNS Total N Group %
22
3%
1,079 80%
114
6%
101
8%
28
2%
1,344 99%*
NP CNS
%
%
2% 1% 43% 38% 2% 4%
5% 3% 1% 1% 53% 47%
* Does not total to 100% due to rounding error National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 13
Certifications Respondents were asked to indicate the certifications they hold. Table 14 presents the results for this question. Among NPs, family nurse practitioner was the most common certification. Among CNSs, clinical specialist in adult psychiatric and mental health nursing was the most common certification.
Table 14. Certifications Certification Acute Care Nurse Practitioner Adult Nurse Practitioner Family Nurse Practitioner Geronotological Nurse Practitioner Pediatric Nurse Practitioner Neonatal Nurse Practitioner Adult Psychiatric & Mental Health NP Family Psychiatric & Mental Health NP Advanced Diabetes Mgt. NP Clinical Specialist in Gerontological Nursing Clinical Specialist in Medical-Surgical Nursing Clinical Specialist in Pediatric Nursing Clinical Specialist in Adult Psychiatric and Mental Health Nursing Clinical Specialist in Child and Adolescent Psychiatric and MHN Clinical Specialist in Community/Public Health Nursing Advanced Diabetes Mgt. ­ Clinical Specialist Advanced Practice palliative care Nurse Midwife Women's Health Care/Obstetrics/Gynecology Certified Registered Nurse Anesthetist (CRNA) Advanced Nursing Administration Other Total*
Total Group N 94 286 654 78 188 54 145 19 11 50 305 47 505 109 39 20 17 19 136 14 8 550 3,348
NP N 88 265 647 75 174 50 76 16 7 4 52 9 85 21 12 3 6 17 116 13 4 190 1,930
CNS N
Total Group %
NP
CNS
%
%
6
3%
3%
0%
21
10%
9%
1%
7
23%
23%
0%
3
3%
3%
0%
14
7%
6%
0%
4
2%
2%
0%
69
5%
3%
2%
3
1%
1%
0%
4
0%
0%
0%
46
2%
0%
2%
253
11%
2%
9%
38
2%
0%
1%
420
18%
3%
15%
88
4%
1%
3%
27 17 11 2 20 1 4 360 1,418
1%
0%
1%
1%
0%
1%
1%
0%
0%
1%
1%
0%
5%
4%
1%
0%
0%
0%
0%
0%
0%
19%
7%
13%
* Respondents were allowed to choose more than one category. National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
14 STUDY PARTICIPANTS
Hours Worked Respondents to the electronic survey were asked how many hours they worked on their most recent day of work. Results for this question are shown in Table 15 (This question was not included in the paper survey). Some respondents may have misread the question because they indicated they worked more than 24 hours on their most recent day of work. Thirty-two percent of NPs indicated that they worked from seven to 10 hours on their most recent day of work while 40% of CNSs indicated they worked this many hours. Administrative Time Respondents were asked the percentage of time they spent on administrative functions and the results are shown in Table 16. CNSs indicated a higher percentage of time spent on administrative activities compared to NPs. Direct Care Respondents were asked if they provide direct care to patients. The majority of respondents provide direct care for patients.
Table 15.Hours Worked
Hours
Total
NP
Worked
Group
N
N
1-2
5
0
3-4
14
4
5-6
38
15
7-8
293 147
9-10
444 183
11-12
136
67
13-14
24
15
15-16
5
4
Other
54
30
Total
1,013** 465
CNS Total N Group %
NP CNS
%
%
5
0% 0% 0%
10
1% 0% 1%
23
4% 2% 2%
146 29% 14% 14%
261 44% 18% 26%
69 13% 7% 7%
9
2% 1% 1%
1
0% 0% 0%
24
5% 3% 2%
548 99%* 46% 54%
Table 16.Administrative Time in Hours
% of Time
Total
On
Group
Administration
N
NP CNS Total
N
N Group
%
NP CNS
%
%
1-20%
2,061 1,242 819 72% 43% 29%
21-40%
457 181 276 16% 6% 10%
41-60%
126
39
87
4% 1% 3%
61-80%
45
20
25
2% 1% 1%
81-100%
33
8
25
1% 0% 1%
No response
148
36 112
5% 1% 4%
Total
2,870 1,526 1,344 100% 53% 47%
Table 17. Direct Care
Direct Care for Patients
Total Group N
Yes
2,531
No
260
No response
79
Total
2,870
NP N 1,440 47 39 1,526
CNS N 1,091 213 40 1,344
Total Group % 88% 9% 3% 100%
NP CNS
%
%
50% 38% 2% 7% 1% 1% 53% 47%
* Does not total to 100% due to rounding error ** This question was not included in the paper survey. National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 15
Time for Direct Patient Care If respondents indicated that they provide direct care, they were asked to indicate what percentage of time was spent providing direct patient care on their last day at work. Results for this question are presented in Table 18 and show that NPs indicated higher percentages of time providing direct care for patients compared to CNSs. Number of Patients Respondents were asked the number of patients for whom they were responsible on their most recent day at work (This question was not included in the paper survey). They were asked to include the provision of direct or indirect care. Results for this question are presented in Table 19. Patient Age Respondents were asked to indicate the ages of patients for whom they typically provide care, by selecting the single best category of those listed. Results for this question are presented in Table 20 and show that the majority of respondents provided care for adults.
Table 18. Percentage of Time (Hours) for Direct Care
Time
Total NP CNS Total NP
Providing
Group
N
N Group
%
Direct Care
N
%
for Patients
1-20%
322
75 247 11%
3%
21-40%
175
54 121
6%
2%
41-60%
345 160 185 12%
6%
61-80%
549 312 237 19% 11%
81-100%
1,212 872 340 42% 30%
No response
267
53 214
9%
2%
Total
2,870 1,526 1,344 99%* 53%
CNS % 9% 4% 6% 8% 12% 7% 47%
Table 19. Number of Patients
Number of Patients
Total NP
Group
N
N
0
50
3
1
16
1
2-25
767 375
26-50
87 57
51-100
13
6
101-200
5
4
201-1000
4
3
No response
72 16
Total
1,013** 465
CNS Total N Group %
47
5%
15
1%
391 76%
30
9%
7
1%
1
0%
1
0%
56
7%
548 99%*
NP CNS
%
%
0% 5% 0% 1% 37% 39% 6% 3% 1% 1% 0% 0% 0% 0% 2% 6% 46% 54%
Table 20.Age of Patients
Age of Patients (years)
Total Group N
NP CNS Total
N
N Group
%
NP CNS
%
%
0-1
116
85
31
4% 3% 1%
2-12
262 165
97
9% 6% 3%
13-20
128
63
65
4% 2% 2%
21-45
840 480 360 29% 17% 13%
46-65
919 465 454 32% 16% 16%
Over 65
473 227 246 16% 8% 9%
No response
132
41
91
5% 1% 3%
Total
2,870 1,526 1,344 99%* 53% 47%
* Does not total to 100% due to rounding error ** This question was not included in the paper survey. National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
16 STUDY PARTICIPANTS
Employment Setting Respondents were asked to indicate the type of employment setting in which they work and to select the best response. The most common employment setting for NPs was office/private practice and the most common response for CNSs was acute care facility. Immediate Supervisor Respondents were asked to indicate who their immediate supervisor was. The most common response for NPs was a physician, but the most common response for CNSs was a nurse. Exempt or Nonexempt Respondents were asked to indicate if they were salaried (exempt) or hourly (nonexempt) employees. The results show that the majority of respondents are salaried employees. Experience Respondents were asked to indicate how many years they have worked as either an NP or a CNS. The results show that the respondents represented a wide range of experience.
Table 21.Employment Setting
Type of Employment Setting
Total Group N
NP CNS Total
N
N Group
%
NP CNS
%
%
Acute care facility
787 283 504 27% 10% 18%
Long-term care facility
114
71
43
4% 2% 1%
Office / Private practice
862 599 263 30% 21% 9%
outpatient care facility
582 302 280 20% 11% 10%
Other (specify)
484 252 232 17% 9% 8%
No responses
41
19
22
1% 1% 1%
Total
2,870 1,526 1,344 99%* 53% 47%
Table 22. Immediate Supervisor
Immediate Supervisor
Total Group N
NP CNS Total
N
N Group
%
NP CNS
%
%
Physician
1,340 1,008 332
47% 35% 12%
Nurse
646 175 471
23% 6% 16%
Facility Administrator
398 162 236
14% 6% 8%
Other
199
83 116
7% 3% 4%
None
265
91 174
9% 3% 6%
No response
22
7
15
1% 0% 1%
Total
2,870 1,526 1,344 101%* 53% 47%
Table 23.Exempt Status
Salaried or Hourly
Total Group N
NP CNS Total
N
N Group
%
NP CNS
%
%
Salaried (exempt)
2,055 1,087 968 72% 38% 34%
Hourly (nonexempt)
718
405 313 25% 14% 11%
No response
97
34
63
3% 1% 2%
Total
2,870 1,526 1,344 100% 53% 47%
Table 24.Years of Experience
Years working as NP/CNS
Total NP
Group
N
N
0-1
69
46
2-5
573 357
6-10
878 542
11-20
840 373
20+
491 201
No response
19
7
Total
2,870 1,526
CNS Total N Group %
23
2%
216 20%
336 31%
467 29%
290 17%
12
1%
1,344 100%
NP CNS
%
%
2% 1% 12% 8% 19% 12% 13% 16% 7% 10% 0% 0% 53% 47%
* Does not total to 100% due to rounding error National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 17
Activities
Frequency
The Advanced Practice Nursing Survey asked respondents to answer three questions about each activity. Question A asked if the activity was performed in their work setting. If they did perform the activity, Question B addressed the frequency of activity performance. Frequency was defined in the survey as the number of times the activity was performed on the last day of work, with choices of 0 times, 1 time, 2 times, 3 times, 4 times and 5 or more times. Question C rated the overall priority of the activity (even if they did not perform the activity) on a scale of 1-4 with 1 equaling the lowest priority and 4 representing the highest priority.
There were many activity statements that the NPs rated with higher frequency than the CNSs did. Reading the list of activities rated higher in frequency by the NPs one sees the focus of direct patient care in terms of physical examination, performing tests, differential diagnosis, prescribing and evaluating interventions, selecting treatment, prescribing medication, evaluating outcomes, revising diagnoses, patient follow-up, maintaining patient records, advocating for patients, ordering equipment, obtaining referrals and initiating consultations.
The data for the activities section of the survey was analyzed using t-test comparisons of the NP and CNS responses. Statistically significant differences were seen in the comparisons of NP and CNS data for the frequency and priority of nursing activities. There were 93 activities split across two forms of the survey. With so many comparisons, one would expect some differences to emerge due to chance. Hence, a Bonferroni correction was applied to adjust the probabilities by multiplying each probability by the number of tests conducted. Results were the same whether one used 93 (number of tasks) or 186 (number of tasks for frequency and priority). This conservative procedure favors accepting the null hypothesis, which is that there is no difference between the two roles. The specific means, standard deviations, standard errors, t-values and probabilities are reported in Appendix C.
The lists that follow in this section of the report present activities with statistically significant differences between the two roles in frequency ratings and then the activities without statistically significant differences. Shown next are lists that show statistically significant differences between the two roles in priority ratings of activities and then priority ratings without statistically significant differences.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
18 STUDY PARTICIPANTS
Table 25.Activity Statements with Frequency Rated Significantly Higher by Nurse Practitioners than Clinical Nurse Specialists
Item #
Activity
Frequency
CNS
NP
Rank
CNS
NP
Decision
47 Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses.
3.43 4.77
10
1 Statistically Significant
65 Maintains clinical records that reflect diagnostic and therapeutic
3.67 4.74
4
2 Statistically Significant
reasoning.
48 Determines appropriate pharmacological, behavioral, and other
3.57 4.73
6
3 Statistically Significant
non-pharmacological treatment modalities in developing a plan
of care.
11 Demonstrates critical thinking and diagnostic reasoning skills in
4.01 4.67
1
4 Statistically Significant
clinical decision-making.
17 Prescribes, orders, and/or implements pharmacologic and non-
3.20 4.63
17
pharmacologic interventions, treatments, and procedures for
patients and family members, as identified in the plan of care.
5 Statistically Significant
2
Designs and implements a plan of care to attain, promote,
maintain, and/or restore health.
3.46 4.58
9
6 Statistically Significant
63 Prescribes medications using principles of pharmacokinetics, drug dosage and routes, indications, interactions, and side/ adverse effects.
2.47 4.57
31
7 Statistically Significant
53 Employs appropriate diagnostic and therapeutic interventions
3.40 4.55
12
and regimens with attention to safety, cost, invasiveness, simplic-
ity, acceptability and efficacy.
8 Statistically Significant
50 Incorporates risk/benefit factors in developing a plan of care.
3.52 4.48
8
9 Statistically Significant
1
Verifies diagnoses based on findings.
3.24 4.46
15
10 Statistically Significant
58 Performs a comprehensive and/or problem-focused physical examination.
1.75 4.42
52
11 Statistically Significant
54 Assesses, diagnoses, monitors, coordinates, and manages the health/illness status of patients over time.
3.53 4.37
7
12 Statistically Significant
18 Writes and transmits correct prescriptions to minimize the risk of errors.
2.40 4.36
35
13 Statistically Significant
51 Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
3.67 4.30
3
14 Statistically Significant
52 Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated.
3.61 4.29
5
15 Statistically Significant
8
Selects, performs, and/or interprets common screening and
diagnostic laboratory tests.
2.44 4.27
32
16 Statistically Significant
6
Diagnoses and manages acute and chronic diseases while at-
tending to the illness experience.
2.74 4.20
27
17 Statistically Significant
9
Plans follow-up visits to monitor patients and evaluate health/
illness care.
3.14 4.19
19
18 Statistically Significant
55 Evaluates results of interventions using accepted outcome criteria, revises the plan of care and consults/refers when appropriate.
3.39 4.15
14
19 Statistically Significant
3
Promotes patient advocacy in patient interactions and in the
selection of treatment modalities.
3.39 4.14
13
20 Statistically Significant
49 Uses principles of ethical decision-making in selecting treatment
3.19 3.97
18
21 Statistically Significant
modalities.
7
Recognizes and provides primary care services to patients with
acute and chronic diseases.
2.14 3.93
42
23 Statistically Significant
64 Monitors therapeutic parameters including patient response and 2.67 3.93
29
22 Statistically Significant
adjusts medication dosages accordingly.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 19
Table 25.Activity Statements with Frequency Rated Significantly Higher by Nurse Practitioners than Clinical Nurse Specialists
Item #
Activity
Frequency
CNS
NP
Rank
CNS
NP
Decision
56 Develops and/or uses a follow-up system within the practice to
2.87 3.89
23
24 Statistically Significant
ensure that patients receive appropriate services.
38 Assesses, plans, implements, and evaluates health care with other health care professionals/primary care providers to meet the comprehensive needs of patients.
3.80 3.88
2
25 Statistically Significant
5
Formulates expected outcomes with patients, family members,
3.23 3.86
16
26 Statistically Significant
and the interdisciplinary healthcare team based on clinical and
scientific knowledge.
60 Describes problems in context, including variations in normal
2.93 3.84
21
27 Statistically Significant
and abnormal symptoms, functional problems, or risk behaviors
inherent in disease, illness, or developmental processes.
4
Reevaluates and revises diagnosis when additional assessment
data become available.
2.42 3.66
34
28 Statistically Significant
22 Acts as a primary care provider for individuals, families, and com- 1.43 3.43
68
29 Statistically Significant
munities within integrated health care services using accepted
guidelines and standards.
10 Collaborates with the patient and interdisciplinary team to
2.78 3.37
26
30 Statistically Significant
plan and implement diagnostic strategies and therapeutic
interventions for patients with unstable and complex health care
problems to assist patients to regain stability and restore health.
12 Applies principles of epidemiology and demography by recog-
2.25 3.24
39
33 Statistically Significant
nizing populations at risk, patterns of disease, and effectiveness
of prevention and intervention.
93 Demonstrates knowledge of legal regulations for NP/CNS prac-
2.20 3.09
40
35 Statistically Significant
tice including scope of practice and reimbursement for services.
44 Identifies expected outcomes by considering associated risks, benefits, and costs.
2.26 2.95
38
38 Statistically Significant
57 Assists patients in learning specific information or skills by designing a learning plan that is comprised of sequential, cumulative steps and that acknowledges relapse and the need for practice, reinforcement, support, and additional teaching.
2.51 2.94
30
39 Statistically Significant
21 Demonstrates knowledge of patient payment and provider reimbursement systems.
2.38 2.88
36
40 Statistically Significant
36 Obtains specialist and referral care for patients while remaining
1.09 2.74
86
42 Statistically Significant
the primary care provider.
45 Initiates appropriate and timely consultation and/or referral
1.73 2.68
53
43 Statistically Significant
when the problem exceeds the NP/CNS's scope of practice and/
or expertise.
37 Meets/maintains eligibility requirements for certification and/or
2.09 2.61
43
44 Statistically Significant
licensure.
39 Advocates for the role of the advanced practice nurse in the health care system.
1.94 2.44
45
48 Statistically Significant
25 Demonstrates knowledge of business principles that affect long-term financial viability of a practice, the efficient use of resources, and quality of care.
1.91 2.32
47
49 Statistically Significant
82 Supports socialization, education, and training of novice practi-
1.66 1.41
55
68 Statistically Significant
tioners by serving as preceptor, role model, and mentor.
20 Orders durable medical equipment.
0.79 1.16
91
79 Statistically Significant
66 Orders durable medical equipment.
0.78 1.16
92
80 Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
20 STUDY PARTICIPANTS
Table 26.Activity Statements with Frequency Rated Significantly Higher by Clinical Nurse Specialists than Nurse Practitioners
Item #
Activity
Frequency
CNS
NP
Rank
CNS
NP
Decision
42 Develops and implements educational programs to improve nursing practice and patient outcomes.
1.66
1.20
56
76 Statistically Significant
29 Contributes to the development of interdisciplinary standards
1.51
1.09
65
82 Statistically Significant
of practice and evidence-based guidelines for care (e.g. critical
pathways, care maps, benchmarks).
30 Targets and helps to reduce system-level barriers to proposed changes in nursing practice and programs of care.
1.32
0.98
74
85 Statistically Significant
75 Leads nursing and interdisciplinary groups in implementing innovative patient care programs.
1.30
0.88
76
89 Statistically Significant
76 Develops or influences system-level policies that will affect innovation and programs of care.
1.26
0.87
79
91 Statistically Significant
Table 27. No Significant Differences in Frequency of Activities Between Nurse Practitioners and Clinical Nurse Specialists
Item #
Activity
Frequency CNS NP
Rank
CNS
NP
Decision
13 Identifies the need for new or modified assessment methods or
1.68 1.94
54
54 Not Statistically Significant
instruments within a specialty area.
14 Incorporates evidence-based research into nursing interventions 3.07 3.26
20
32 Not Statistically Significant
within the specialty population.
15 Disseminates the results of innovative care.
1.81 2.12
50
52 Not Statistically Significant
16 Incorporates cultural preferences, spiritual and health beliefs and 2.82 3.07
25
36 Not Statistically Significant
behaviors, and traditional practices into the management plan.
19 Identifies, collects, and analyzes data about target populations to anticipate the impact of the NP/CNS on Program Outcomes when designing new programs.
1.04 0.93
87
86 Not Statistically Significant
23 Provides leadership in the interdisciplinary team through the de- 2.43 2.74
33
41 Not Statistically Significant
velopment of collaborative practice or innovative partnerships.
24 Maintains current knowledge of the organization and financing of the health care system as it affects delivery of care.
1.89 2.21
48
51 Not Statistically Significant
26 Assesses targeted system-level variables, such as culture, finances, regulatory requirements, and external demands that influence nursing practice and outcomes.
1.61 1.88
59
57 Not Statistically Significant
27 Assesses and draws conclusions about the effects of variance across an organization that influences the outcomes of nursing practice.
1.43 1.25
69
73 Not Statistically Significant
28 Develops innovative solutions that can be generalized across different units, populations, or specialties.
1.39 1.16
72
81 Not Statistically Significant
31 Uses organizational structure and processes to provide feedback 1.48 1.22
66
74 Not Statistically Significant
about the effectiveness of nursing practice and interdisciplinary
relationships in meeting identified outcomes of programs of
care.
32 Evaluates and documents the impact of NP/CNS practice on the 0.95 1.26
89
72 Not Statistically Significant
organization.
33 Incorporates the use of quality indicators and benchmarking in evaluating the progress of patients, family members, nursing personnel, and systems toward expected outcomes.
2.01 1.77
44
59 Not Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 21
Table 27. No Significant Differences in Frequency of Activities Between Nurse Practitioners and Clinical Nurse Specialists
Item #
Activity
Frequency
CNS
NP
Rank CNS NP
Decision
34 Articulates and interprets the NP/CNS role and scope of practice 1.14 1.40
82
69 Not Statistically Significant
to the public, policy-makers, legislators and other members of
the health care team.
35 Utilizes scientific foundations and theoretical frameworks to implement NP/CNS role.
2.68 2.49
28
47 Not Statistically Significant
40 Evaluates the relationship between community/public health issues and social problems as they impact the health care of patients.
1.58 1.94
60
55 Not Statistically Significant
41 Identifies, in collaboration with nursing personnel and other health care providers, needed changes in equipment or other products based on evidence, clinical outcomes and costeffectiveness.
1.42 1.63
70
62 Not Statistically Significant
43 Evaluates the ability of nurses and nursing personnel to implement changes in nursing practice, with individual patients and populations.
1.55 1.38
63
70 Not Statistically Significant
46 Monitors and participates in legislation and regulatory health policy-making to influence advanced practice nursing and the health of communities and populations.
0.55 0.73
93
92 Not Statistically Significant
59 Applies and/or conducts research studies pertinent to area(s) of
1.56 1.89
61
56 Not Statistically Significant
practice.
61 Evaluates effects of nursing interventions for individuals and
2.83 3.06
24
37 Not Statistically Significant
populations of patients for clinical effectiveness, patient
responses, efficiency, cost-effectiveness, consumer satisfaction,
and ethical considerations.
62 Considers the patient's needs when termination of the nurse-patient relationship is necessary and provides for a safe transition to another care provider.
1.34 1.52
73
66 Not Statistically Significant
67 Develops a quality assurance/improvement plan to evaluate and 1.31 1.17
75
78 Not Statistically Significant
modify practice.
68 Provides case management services to meet multiple patient health care needs.
1.87 1.73
49
60 Not Statistically Significant
69 Plans for systematic investigation of patient problems needing
1.93 2.30
46
50 Not Statistically Significant
clinical inquiry, including etiologies of problems, needs for
interventions, outcomes of current practice, and costs associated
with care.
70 Acts as a community consultant and/or participates in the
0.99 0.92
88
87 Not Statistically Significant
planning, development, and implementation of public and com-
munity health programs.
71 Participates in organizational decision-making, interprets variations in outcomes, and uses data from information systems to improve practice.
1.63 1.62
57
63 Not Statistically Significant
72 Uses/designs system-level assessment methods and instruments 1.23 1.03
81
84 Not Statistically Significant
to identify organization structures and functions that impact
nursing practice and nurse-sensitive patient care outcomes.
73 Identifies facilitators and barriers to achieving desired outcomes 1.62 1.54
58
65 Not Statistically Significant
of integrated programs of care across the continuum and at
points of service.
74 Plans for achieving intended system-wide change, while avoiding or minimizing unintended consequences.
1.28 1.07
78
83 Not Statistically Significant
77 Designs and implements methods, strategies and processes to
1.14 0.91
83
88 Not Statistically Significant
spread and sustain innovation and evidence-based change.
78 Evaluates organizational policies for their ability to support and
1.13 0.87
84
90 Not Statistically Significant
sustain outcomes of programs of care.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
22 STUDY PARTICIPANTS
Table 27. No Significant Differences in Frequency of Activities Between Nurse Practitioners and Clinical Nurse Specialists
Item #
Activity
Frequency CNS NP
Rank
CNS
NP
Decision
79 Disseminates to stakeholders the outcomes of system-wide changes, impact of nursing practice, and NP/CNS work.
0.86 0.65
90
93 Not Statistically Significant
80 Assesses the professional climate and interdisciplinary collabora- 1.41 1.18
71
77 Not Statistically Significant
tion within and across units for their impact on nursing practice
and outcomes.
81 Plans for systematic investigation of patient problems needing
1.46 1.71
67
61 Not Statistically Significant
clinical inquiry, including etiologies of problems, needs for
interventions, outcomes of current practice, and costs associated
with care.
83 Evaluates and applies research studies pertinent to patient care
1.80 2.09
51
53 Not Statistically Significant
management and outcomes.
84 Assesses, plans, implements, and evaluates health care with other health care professionals/primary care providers to meet the comprehensive needs of patients.
2.88 3.37
22
31 Not Statistically Significant
85 Monitors self, peers and delivery system as part of continuous quality improvement.
2.19 2.52
41
46 Not Statistically Significant
86 Functions in a variety of role dimensions; health care provider,
3.40 3.15
11
34 Not Statistically Significant
coordinator, consultant, educator, coach, advocate administrator,
researcher, and leader.
87 Evaluates implications of contemporary health policy on health
1.13 1.27
85
71 Not Statistically Significant
care providers and consumers.
88 Uses/designs appropriate methods and instruments to assess
1.30 1.21
77
75 Not Statistically Significant
knowledge, skills, and practice competencies of nurses and nurs-
ing personnel to advance the practice of nursing.
89 Mentors nurses and assists them to critique and apply research
1.52 1.61
64
64 Not Statistically Significant
evidence to nursing practice.
90 Assists members of the health care team to develop innovative,
1.23 1.45
80
67 Not Statistically Significant
cost-effective patient programs of care.
91 Develops and uses data collection tools that have been established as reliable and valid.
1.56 1.78
62
58 Not Statistically Significant
92 Works collaboratively to develop a plan of care that is individual- 2.28 2.54
37
45 Not Statistically Significant
ized and dynamic and that can be applied across different health
care settings.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 23
Priority The activity statements that were distinguished by the role of the nurse in the priority of their performance are presented below. Reading the list of activities rated higher in priority by the NPs one again sees the focus of direct patient care in terms of physical examination, performing tests, differential diagnosis, prescribing and evaluating interventions, selecting treatment, prescribing medication, evaluating outcomes, revising diagnoses, patient follow-up, maintaining patient records, advocating for patients, ordering equipment, obtaining referrals and initiating consultations.
Table 28.Activity Statements with Priority Rated Significantly Higher by Nurse Practitioners than Clinical Nurse Specialists
Item #
Activity
Importance
CNS
NP
Rank
CNS
NP
Decision
11 Demonstrates critical thinking and diagnostic reasoning skills in
3.63 3.78
1
1 Statistically Significant
clinical decision-making.
47 Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses.
3.27 3.77
15
2 Statistically Significant
63 Prescribes medications using principles of pharmacokinetics, drug dosage and routes, indications, interactions, and side/ adverse effects.
2.65 3.77
64
3 Statistically Significant
17 Prescribes, orders, and/or implements pharmacologic and non-
3.13 3.72
24
pharmacologic interventions, treatments, and procedures for
patients and family members, as identified in the plan of care.
4 Statistically Significant
48 Determines appropriate pharmacological, behavioral, and other
3.34 3.71
7
5 Statistically Significant
non-pharmacological treatment modalities in developing a plan
of care.
37 Meets/maintains eligibility requirements for certification and/or
3.57 3.69
2
7 Statistically Significant
licensure.
65 Maintains clinical records that reflect diagnostic and therapeutic
3.24 3.69
19
reasoning.
6 Statistically Significant
2
Designs and implements a plan of care to attain, promote,
maintain, and/or restore health.
3.37 3.68
5
8 Statistically Significant
18 Writes and transmits correct prescriptions to minimize the risk of errors.
2.64 3.68
67
9 Statistically Significant
58 Performs a comprehensive and/or problem-focused physical examination.
2.39 3.64
86
10 Statistically Significant
53 Employs appropriate diagnostic and therapeutic interventions
3.23 3.61
20
11 Statistically Significant
and regimens with attention to safety, cost, invasiveness, simplic-
ity, acceptability and efficacy.
50 Incorporates risk/benefit factors in developing a plan of care.
3.33 3.60
9
12 Statistically Significant
1
Verifies diagnoses based on findings.
3.03 3.58
31
14 Statistically Significant
64 Monitors therapeutic parameters including patient response and 2.81 3.58
46
13 Statistically Significant
adjusts medication dosages accordingly.
45 Initiates appropriate and timely consultation and/or referral
3.30 3.57
13
15 Statistically Significant
when the problem exceeds the NP/CNS's scope of practice and/
or expertise.
6
Diagnoses and manages acute and chronic diseases while at-
tending to the illness experience.
2.93 3.54
40
16 Statistically Significant
54 Assesses, diagnoses, monitors, coordinates, and manages the health/illness status of patients over time.
3.24 3.52
18
18 Statistically Significant
4
Reevaluates and revises diagnosis when additional assessment
data become available.
2.96 3.49
39
20 Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
24 STUDY PARTICIPANTS
Table 28.Activity Statements with Priority Rated Significantly Higher by Nurse Practitioners than Clinical Nurse Specialists
Item #
Activity
Importance
CNS
NP
Rank
CNS
NP
Decision
8
Selects, performs, and/or interprets common screening and
diagnostic laboratory tests.
2.77 3.49
47
21 Statistically Significant
55 Evaluates results of interventions using accepted outcome criteria, revises the plan of care and consults/refers when appropriate.
3.27 3.49
16
19 Statistically Significant
5
Formulates expected outcomes with patients, family members,
3.25 3.39
17
26 Statistically Significant
and the interdisciplinary health care team based on clinical and
scientific knowledge.
9
Plans follow-up visits to monitor patients and evaluate health/
illness care.
3.03 3.38
30
27 Statistically Significant
7
Recognizes and provides primary care services to patients with
acute and chronic diseases.
2.50 3.36
81
28 Statistically Significant
56 Develops and/or uses a follow-up system within the practice to
2.99 3.33
35
30 Statistically Significant
ensure that patients receive appropriate services.
93 Demonstrates knowledge of legal regulations for NP/CNS prac-
3.02 3.33
32
31 Statistically Significant
tice including scope of practice and reimbursement for services.
39 Advocates for the role of the advanced practice nurse in the health care system.
3.15 3.31
22
32 Statistically Significant
60 Describes problems in context, including variations in normal
2.98 3.23
37
34 Statistically Significant
and abnormal symptoms, functional problems, or risk behaviors
inherent in disease, illness, or developmental processes.
22 Acts as a primary care provider for individuals, families, and communities within integrated health care services using accepted guidelines and standards.
2.06 3.11
91
37 Statistically Significant
12 Applies principles of epidemiology and demography by recog-
2.69 3.07
56
41 Statistically Significant
nizing populations at risk, patterns of disease, and effectiveness
of prevention and intervention.
36 Obtains specialist and referral care for patients while remaining
2.15 3.06
90
42 Statistically Significant
the primary care provider.
40 Evaluates the relationship between community/public health issues and social problems as they impact the health care of patients.
2.70 2.82
54
51 Statistically Significant
20 Orders durable medical equipment.
1.84 2.28
92
85 Statistically Significant
66 Orders durable medical equipment.
1.82 2.18
93
89 Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 25
Table 29.Activity Statements with Priority Rated Significantly Higher by Clinical Nurse Specialists than Nurse Practitioners
Item #
Activity
Importance
CNS
NP
Rank
CNS
NP
Decision
86 Functions in a variety of role dimensions; health care provider,
3.41 3.16
coordinator, consultant, educator, coach, advocate administrator,
researcher, and leader.
3
36 Statistically Significant
42 Develops and implements educational programs to improve nursing practice and patient outcomes.
3.08 2.65
26
58 Statistically Significant
35 Utilizes scientific foundations and theoretical frameworks to implement NP/CNS role.
3.05 2.83
29
50 Statistically Significant
82 Supports socialization, education, and training of novice practi-
3.00 2.97
34
46 Statistically Significant
tioners by serving as preceptor, role model, and mentor.
33 Incorporates the use of quality indicators and benchmarking in evaluating the progress of patients, family members, nursing personnel, and systems toward expected outcomes.
2.89 2.57
42
66 Statistically Significant
15 Disseminates the results of innovative care.
2.84 2.65
43
59 Statistically Significant
29 Contributes to the development of interdisciplinary standards
2.82 2.33
44
79 Statistically Significant
of practice and evidence-based guidelines for care (e.g. critical
pathways, care maps, benchmarks).
31 Uses organizational structure and processes to provide feedback 2.72 2.31
52
80 Statistically Significant
about the effectiveness of nursing practice and interdisciplinary
relationships in meeting identified outcomes of programs of care.
28 Develops innovative solutions that can be generalized across different units, populations, or specialties.
2.68 2.30
57
82 Statistically Significant
75 Leads nursing and interdisciplinary groups in implementing innovative patient care programs.
2.67 2.29
61
84 Statistically Significant
76 Develops or influences system-level policies that will affect innovation and programs of care.
2.67 2.30
60
83 Statistically Significant
77 Designs and implements methods, strategies and processes to
2.67 2.35
59
78 Statistically Significant
spread and sustain innovation and evidence-based change.
74 Plans for achieving intended system-wide change, while avoiding or minimizing unintended consequences.
2.54 2.27
74
86 Statistically Significant
88 Uses/designs appropriate methods and instruments to assess
2.52 2.45
78
75 Statistically Significant
knowledge, skills, and practice competencies of nurses and nurs-
ing personnel to advance the practice of nursing.
78 Evaluates organizational policies for their ability to support and
2.51 2.24
80
87 Statistically Significant
sustain outcomes of programs of care.
27 Assesses and draws conclusions about the effects of variance across an organization that influences the outcomes of nursing practice.
2.46 2.14
83
91 Statistically Significant
19 Identifies, collects, and analyzes data about target populations to anticipate the impact of the NP/CNS on program outcomes when designing new programs.
2.33 2.04
87
93 Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
26 STUDY PARTICIPANTS
No Significant Differences in Priority of Activities Between Nurse Practitioners and Clinical Nurse Specialists The survey activity statements for which the t-tests showed no significant differences in priority between NPs and CNSs are listed below. Priority was defined in the survey as overall priority of the activity in the role and work setting. The ratings were lowest, low, high and highest.
Table 30. No Significant Differences in Priority of Activities Between Nurse Practitioners and Clinical Nurse Specialists
Item #
Activity
Importance CNS NP
Rank CNS NP
Decision
3
Promotes patient advocacy in patient interactions and in the
selection of treatment modalities.
3.31 3.43
11
24 Not Statistically Significant
10 Collaborates with the patient and interdisciplinary team to
3.23 3.35
21
29 Not Statistically Significant
plan and implement diagnostic strategies and therapeutic
interventions for patients with unstable and complex health care
problems to assist patients to regain stability and restore health.
13 Identifies the need for new or modified assessment methods or
2.63 2.56
69
68 Not Statistically Significant
instruments within a specialty area.
14 Incorporates evidence-based research into nursing interventions 3.31 3.18
12
35 Not Statistically Significant
within the specialty population.
16 Incorporates cultural preferences, spiritual and health beliefs and behaviors, and traditional practices into the management plan.
3.14 3.09
23
39 Not Statistically Significant
21 Demonstrates knowledge of patient payment and provider reimbursement systems.
2.56 2.64
73
60 Not Statistically Significant
23 Provides leadership in the interdisciplinary team through the de- 3.07 2.97
27
45 Not Statistically Significant
velopment of collaborative practice or innovative partnerships.
24 Maintains current knowledge of the organization and financing
2.71 2.72
53
56 Not Statistically Significant
of the health care system as it affects delivery of care.
25 Demonstrates knowledge of business principles that affect long-term financial viability of a practice, the efficient use of resources, and quality of care.
2.66 2.76
62
54 Not Statistically Significant
26 Assesses targeted system-level variables, such as culture, finances, regulatory requirements, and external demands that influence nursing practice and outcomes.
2.53 2.47
76
74 Not Statistically Significant
30 Targets and helps to reduce system-level barriers to proposed changes in nursing practice and programs of care.
2.70 2.31
55
81 Not Statistically Significant
32 Evaluates and documents the impact of NP/CNS practice on the 2.53 2.57
75
67 Not Statistically Significant
organization.
34 Articulates and interprets the NP/CNS role and scope of practice 2.65 2.79
65
53 Not Statistically Significant
to the public, policy-makers, legislators and other members of
the health care team.
38 Assesses, plans, implements, and evaluates health care with other health care professionals/primary care providers to meet the comprehensive needs of patients.
3.38 3.46
4
23 Not Statistically Significant
41 Identifies, in collaboration with nursing personnel and other health care providers, needed changes in equipment or other products based on evidence, clinical outcomes and costeffectiveness.
2.67 2.69
58
57 Not Statistically Significant
43 Evaluates the ability of nurses and nursing personnel to implement changes in nursing practice, with individual patients and populations.
2.82 2.51
45
71 Not Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 27
Table 30. No Significant Differences in Priority of Activities Between Nurse Practitioners and Clinical Nurse Specialists
Item #
Activity
Importance CNS NP
Rank CNS NP
Decision
44 Identifies expected outcomes by considering associated risks, benefits, and costs.
3.01 3.07
33
40 Not Statistically Significant
46 Monitors and participates in legislation and regulatory health policy-making to influence advanced practice nursing and the health of communities and populations.
2.51 2.60
79
65 Not Statistically Significant
49 Uses principles of ethical decision-making in selecting treatment 3.34 3.46 modalities.
8
22 Not Statistically Significant
51 Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
3.33 3.40
10
25 Not Statistically Significant
52 Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated.
3.35 3.53
6
17 Not Statistically Significant
57 Assists patients in learning specific information or skills by designing a learning plan that is comprised of sequential, cumulative steps and that acknowledges relapse and the need for practice, reinforcement, support, and additional teaching.
2.97 3.03
38
43 Not Statistically Significant
59 Applies and/or conducts research studies pertinent to area(s) of
2.49 2.44
82
76 Not Statistically Significant
practice.
61 Evaluates effects of nursing interventions for individuals and
3.07 2.95
28
48 Not Statistically Significant
populations of patients for clinical effectiveness, patient
responses, efficiency, cost-effectiveness, consumer satisfaction,
and ethical considerations.
62 Considers the patient's needs when termination of the nurse-patient relationship is necessary and provides for a safe transition to another care provider.
2.74 2.89
50
49 Not Statistically Significant
67 Develops a quality assurance/improvement plan to evaluate and 2.63 2.52
68
70 Not Statistically Significant
modify practice.
68 Provides case management services to meet multiple patient health care needs.
2.52 2.55
77
69 Not Statistically Significant
69 Plans for systematic investigation of patient problems needing clinical inquiry, including etiologies of problems, needs for interventions, outcomes of current practice, and costs associated with care.
2.73 2.79
51
52 Not Statistically Significant
70 Acts as a community consultant and/or participates in the
2.32 2.21
88
88 Not Statistically Significant
planning, development, and implementation of public and com-
munity health programs.
71 Participates in organizational decision-making, interprets varia-
2.74 2.62
49
62 Not Statistically Significant
tions in outcomes, and uses data from information systems to
improve practice.
72 Uses/designs system-level assessment methods and instruments 2.45 2.14
84
92 Not Statistically Significant
to identify organization structures and functions that impact
nursing practice and nurse-sensitive patient care outcomes.
73 Identifies facilitators and barriers to achieving desired outcomes 2.66 2.48
63
73 Not Statistically Significant
of integrated programs of care across the continuum and at
points of service.
79 Disseminates to stakeholders the outcomes of system-wide changes, impact of nursing practice, and NP/CNS work.
2.32 2.17
89
90 Not Statistically Significant
80 Assesses the professional climate and interdisciplinary collabora- 2.58 2.37
72
77 Not Statistically Significant
tion within and across units for their impact on nursing practice
and outcomes.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
28 STUDY PARTICIPANTS
Table 30. No Significant Differences in Priority of Activities Between Nurse Practitioners and Clinical Nurse Specialists
Item #
Activity
Importance CNS NP
Rank CNS NP
Decision
81 Plans for systematic investigation of patient problems needing clinical inquiry, including etiologies of problems, needs for interventions, outcomes of current practice, and costs associated with care.
2.62 2.60
70
64 Not Statistically Significant
83 Evaluates and applies research studies pertinent to patient care
2.99 3.00
36
44 Not Statistically Significant
management and outcomes.
84 Assesses, plans, implements, and evaluates health care with other health care professionals/primary care providers to meet the comprehensive needs of patients.
3.30 3.29
14
33 Not Statistically Significant
85 Monitors self, peers and delivery system as part of continuous quality improvement.
3.08 3.10
25
38 Not Statistically Significant
87 Evaluates implications of contemporary health policy on health
2.43 2.49
85
72 Not Statistically Significant
care providers and consumers.
89 Mentors nurses and assists them to critique and apply research
2.75 2.74
48
55 Not Statistically Significant
evidence to nursing practice.
90 Assists members of the health care team to develop innovative,
2.61 2.61
71
63 Not Statistically Significant
cost-effective patient programs of care.
91 Develops and uses data collection tools that have been established as reliable and valid.
2.64 2.63
66
61 Not Statistically Significant
92 Works collaboratively to develop a plan of care that is individual- 2.93 2.96
41
47 Not Statistically Significant
ized and dynamic and that can be applied across different health
care settings.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 29
Criticality It is common in role delineation studies to combine the frequency and importance ratings into one dimension of criticality, especially when the data will be used for further study within a profession. For this study, criticality ratings were created by a simple multiplication of the frequency ratings times the importance ratings. A criticality variable was created for each survey respondent, and each of these was averaged for the NPs and for the CNSs. Ratings by the NPs are presented first, followed by the ratings from CNSs.
Table 31.Activity Statements with Criticality Rated Significantly Higher by Nurse Practitioners than Clinical Nurse Specialists
Item #
Activity
Criticality
CNS
NP
Rank
CNS
NP
Decision
47 Analyzes and interprets history, presenting symptoms, physical
12.25 18.13
10
findings, and diagnostic information to formulate differential
diagnoses.
1 Statistically Significant
11 Demonstrates critical thinking and diagnostic reasoning skills in 15.07 17.82
1
2 Statistically Significant
clinical decision-making.
48 Determines appropriate pharmacological, behavioral, and other 13.00 17.80
3
3 Statistically Significant
non-pharmacological treatment modalities in developing a plan
of care.
65 Maintains clinical records that reflect diagnostic and therapeutic 13.12 17.68
2
4 Statistically Significant
reasoning.
63 Prescribes medications using principles of pharmacokinetics, drug dosage and routes, indications, interactions, and side/ adverse effects.
9.37 17.60
28
5 Statistically Significant
17 Prescribes, orders, and/or implements pharmacologic and non-
11.74 17.47
14
pharmacologic interventions, treatments, and procedures for
patients and family members, as identified in the plan of care.
6 Statistically Significant
2
Designs and implements a plan of care to attain, promote,
maintain, and/or restore health.
12.51 17.10
7
7 Statistically Significant
53 Employs appropriate diagnostic and therapeutic interventions
11.98 16.80
11
and regimens with attention to safety, cost, invasiveness, simplic-
ity, acceptability and efficacy.
8 Statistically Significant
58 Performs a comprehensive and/or problem-focused physical examination.
6.20 16.71
47
9 Statistically Significant
18 Writes and transmits correct prescriptions to minimize the risk of errors.
9.12 16.60
30
10 Statistically Significant
50 Incorporates risk/benefit factors in developing a plan of care.
12.40 16.41
9
11 Statistically Significant
1
Verifies diagnoses based on findings.
10.91 16.29
18
12 Statistically Significant
54 Assesses, diagnoses, monitors, coordinates, and manages the health/illness status of patients over time.
12.66 15.89
6
13 Statistically Significant
6
Diagnoses and manages acute and chronic diseases while at-
tending to the illness experience.
9.74 15.59
26
14 Statistically Significant
52 Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated.
12.82 15.49
4
15 Statistically Significant
8
Selects, performs, and/or interprets common screening and
diagnostic laboratory tests.
8.20 15.35
34
16 Statistically Significant
51 Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
12.76 14.96
5
17 Statistically Significant
55 Evaluates results of interventions using accepted outcome criteria, revises the plan of care and consults/refers when appropriate.
11.86 14.86
12
18 Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
30 STUDY PARTICIPANTS
Table 31.Activity Statements with Criticality Rated Significantly Higher by Nurse Practitioners than Clinical Nurse Specialists
Item #
Activity
Criticality
CNS
NP
Rank
CNS
NP
Decision
9
Plans follow-up visits to monitor patients and evaluate health/
10.91 14.71
19
19 Statistically Significant
illness care.
64 Monitors therapeutic parameters including patient response and 9.97 14.70
21
20 Statistically Significant
adjusts medication dosages accordingly.
3
Promotes patient advocacy in patient interactions and in the
selection of treatment modalities.
11.77 14.68
13
21 Statistically Significant
7
Recognizes and provides primary care services to patients with
acute and chronic diseases.
7.33 14.51
41
22 Statistically Significant
49 Uses principles of ethical decision-making in selecting treatment 11.34 14.38
15
23 Statistically Significant
modalities.
5
Formulates expected outcomes with patients, family members,
11.20 13.62
16
24 Statistically Significant
and the interdisciplinary healthcare team based on clinical and
scientific knowledge.
56 Develops and/or uses a follow-up system within the practice to
9.83 13.52
23
25 Statistically Significant
ensure that patients receive appropriate services.
60 Describes problems in context, including variations in normal
9.79 13.26
25
26 Statistically Significant
and abnormal symptoms, functional problems, or risk behaviors
inherent in disease, illness, or developmental processes.
4
Reevaluates and revises diagnosis when additional assessment
data become available.
8.30 13.25
33
27 Statistically Significant
22 Acts as a primary care provider for individuals, families, and communities within integrated health care services using accepted guidelines and standards.
4.99 12.68
65
28 Statistically Significant
38 Assesses, plans, implements, and evaluates health care with
10.40 12.23
20
29 Statistically Significant
other health care professionals/primary care providers to meet
the comprehensive needs of patients.
10 Collaborates with the patient and interdisciplinary team to
9.91 11.97
22
30 Statistically Significant
plan and implement diagnostic strategies and therapeutic
interventions for patients with unstable and complex health care
problems to assist patients to regain stability and restore health.
93 Demonstrates knowledge of legal regulations for NP/CNS prac-
7.63 11.14
38
32 Statistically Significant
tice including scope of practice and reimbursement for services.
12 Applies principles of epidemiology and demography by recog-
7.38 10.93
40
34 Statistically Significant
nizing populations at risk, patterns of disease, and effectiveness
of prevention and intervention.
44 Identifies expected outcomes by considering associated risks, benefits, and costs.
7.64 10.07
37
37 Statistically Significant
37 Meets/maintains eligibility requirements for certification and/or
7.71 9.89
36
39 Statistically Significant
licensure.
45 Initiates appropriate and timely consultation and/or referral
6.17 9.82
48
40 Statistically Significant
when the problem exceeds the NP/CNS's scope of practice and/
or expertise.
36 Obtains specialist and referral care for patients while remaining
3.57 9.43
85
41 Statistically Significant
the primary care provider.
39 Advocates for the role of the advanced practice nurse in the health care system.
6.81 8.87
43
43 Statistically Significant
21 Demonstrates knowledge of patient payment and provider reimbursement systems.
7.27 8.77
42
46 Statistically Significant
25 Demonstrates knowledge of business principles that affect long-term financial viability of a practice, the efficient use of resources, and quality of care.
6.08 7.53
50
49 Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 31
Table 32.Activity Statements with Criticality Rated Significantly Higher by Clinical Nurse Specialists than Nurse Practitioners
Item #
Activity
Criticality
CNS
NP
Rank
CNS
NP
Decision
29 Contributes to the development of interdisciplinary standards
5.25 3.41
57
81 Statistically Significant
of practice and evidence-based guidelines for care (e.g. critical
pathways, care maps, benchmarks).
30 Targets and helps to reduce system-level barriers to proposed changes in nursing practice and programs of care.
4.31 2.95
77
85 Statistically Significant
42 Develops and implements educational programs to improve nursing practice and patient outcomes.
5.93 3.89
51
73 Statistically Significant
75 Leads nursing and interdisciplinary groups in implementing innovative patient care programs.
4.55 2.75
71
88 Statistically Significant
76 Develops or influences system-level policies that will affect innovation and programs of care.
4.24 2.74
78
89 Statistically Significant
Table 33. No Significant Differences in Criticality of Activities Between Nurse Practitioners and Clinical Nurse Specialists
Item #
Activity
Criticality
CNS
NP
Rank
CNS
NP
Decision
14 Incorporates evidence-based research into nursing interventions 10.95 11.34
17
31 Not Statistically Significant
within the specialty population.
86 Functions in a variety of role dimensions; health care provider, coordinator, consultant, educator, coach, advocate administrator, researcher, and leader.
12.44 11.08
8
33 Not Statistically Significant
16 Incorporates cultural preferences, spiritual and health beliefs and behaviors, and traditional practices into the management plan.
9.66 10.37
27
35 Not Statistically Significant
61 Evaluates effects of nursing interventions for individuals and
9.82 10.27
24
36 Not Statistically Significant
populations of patients for clinical effectiveness, patient
responses, efficiency, cost-effectiveness, consumer satisfaction,
and ethical considerations.
57 Assists patients in learning specific information or skills by designing a learning plan that is comprised of sequential, cumulative steps and that acknowledges relapse and the need for practice, reinforcement, support, and additional teaching.
8.58 9.92
31
38 Not Statistically Significant
23 Provides leadership in the interdisciplinary team through the de- 8.32 9.24
32
42 Not Statistically Significant
velopment of collaborative practice or innovative partnerships.
85 Monitors self, peers and delivery system as part of continuous quality improvement.
7.62 8.84
39
44 Not Statistically Significant
92 Works collaboratively to develop a plan of care that is individual- 7.88 8.81
35
45 Not Statistically Significant
ized and dynamic and that can be applied across different
health care settings.
35 Utilizes scientific foundations and theoretical frameworks to implement NP/CNS role.
9.24 8.50
29
47 Not Statistically Significant
69 Plans for systematic investigation of patient problems needing clinical inquiry, including etiologies of problems, needs for interventions, outcomes of current practice, and costs associated with care.
6.48 7.87
45
48 Not Statistically Significant
83 Evaluates and applies research studies pertinent to patient care
6.15 7.08
49
50 Not Statistically Significant
management and outcomes.
24 Maintains current knowledge of the organization and financing
5.89 7.05
52
51 Not Statistically Significant
of the health care system as it affects delivery of care.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
32 STUDY PARTICIPANTS
Table 33. No Significant Differences in Criticality of Activities Between Nurse Practitioners and Clinical Nurse Specialists
Item #
Activity
Criticality
CNS
NP
Rank
CNS
NP
Decision
15 Disseminates the results of innovative care.
5.88 6.75
53
52 Not Statistically Significant
40 Evaluates the relationship between community/public health issues and social problems as they impact the health care of patients.
5.10 6.44
61
53 Not Statistically Significant
59 Applies and/or conducts research studies pertinent to area(s) of
5.06 6.04
64
54 Not Statistically Significant
practice.
13 Identifies the need for new or modified assessment methods or
5.31 6.03
56
55 Not Statistically Significant
instruments within a specialty area.
26 Assesses targeted system-level variables, such as culture, finances, regulatory requirements, and external demands that influence nursing practice and outcomes.
5.10 6.01
62
56 Not Statistically Significant
91 Develops and uses data collection tools that have been established as reliable and valid.
5.06 5.86
63
57 Not Statistically Significant
33 Incorporates the use of quality indicators and benchmarking in
6.68 5.76
44
58 Not Statistically Significant
evaluating the progress of patients, family members, nursing
personnel, and systems toward expected outcomes.
81 Plans for systematic investigation of patient problems needing
4.89 5.76
66
59 Not Statistically Significant
clinical inquiry, including etiologies of problems, needs for
interventions, outcomes of current practice, and costs associ-
ated with care.
68 Provides case management services to meet multiple patient health care needs.
6.21 5.65
46
60 Not Statistically Significant
89 Mentors nurses and assists them to critique and apply research
5.19 5.31
59
61 Not Statistically Significant
evidence to nursing practice.
71 Participates in organizational decision-making, interprets varia-
5.39 5.27
55
62 Not Statistically Significant
tions in outcomes, and uses data from information systems to
improve practice.
41 Identifies, in collaboration with nursing personnel and other health care providers, needed changes in equipment or other products based on evidence, clinical outcomes and costeffectiveness.
4.57 5.19
70
63 Not Statistically Significant
62 Considers the patient's needs when termination of the nurse-patient relationship is necessary and provides for a safe transition to another care provider.
4.48 5.13
73
64 Not Statistically Significant
73 Identifies facilitators and barriers to achieving desired outcomes 5.24 4.91
58
65 Not Statistically Significant
of integrated programs of care across the continuum and at
points of service.
82 Supports socialization, education, and training of novice practi-
5.87 4.76
54
66 Not Statistically Significant
tioners by serving as preceptor, role model, and mentor.
34 Articulates and interprets the NP/CNS role and scope of prac-
3.68 4.72
83
67 Not Statistically Significant
tice to the public, policy-makers, legislators and other members
of the health care team.
90 Assists members of the health care team to develop innovative,
4.16 4.71
79
68 Not Statistically Significant
cost-effective patient programs of care.
43 Evaluates the ability of nurses and nursing personnel to implement changes in nursing practice, with individual patients and populations.
5.16 4.32
60
69 Not Statistically Significant
32 Evaluates and documents the impact of NP/CNS practice on the 3.01 4.11
88
70 Not Statistically Significant
organization.
87 Evaluates implications of contemporary health policy on health
3.60 4.03
84
71 Not Statistically Significant
care providers and consumers.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 33
Table 33. No Significant Differences in Criticality of Activities Between Nurse Practitioners and Clinical Nurse Specialists
Item #
Activity
Criticality
CNS
NP
Rank
CNS
NP
Decision
88 Uses/designs appropriate methods and instruments to assess knowledge, skills, and practice competencies of nurses and nursing personnel to advance the practice of nursing.
4.42 3.90
74
72 Not Statistically Significant
67 Develops a quality assurance/improvement plan to evaluate and 4.38 3.84
75
74 Not Statistically Significant
modify practice.
31 Uses organizational structure and processes to provide feedback 4.82 3.72
67
75 Not Statistically Significant
about the effectiveness of nursing practice and interdisciplinary
relationships in meeting identified outcomes of programs of
care.
80 Assesses the professional climate and interdisciplinary collaboration within and across units for their impact on nursing practice and outcomes.
4.64 3.66
68
76 Not Statistically Significant
27 Assesses and draws conclusions about the effects of variance across an organization that influences the outcomes of nursing practice.
4.52 3.66
72
77 Not Statistically Significant
28 Develops innovative solutions that can be generalized across different units, populations, or specialties.
4.58 3.53
69
78 Not Statistically Significant
20 Orders durable medical equipment.
2.41 3.53
90
79 Not Statistically Significant
66 Orders durable medical equipment.
2.38 3.47
91
80 Not Statistically Significant
74 Plans for achieving intended system-wide change, while avoid-
4.32 3.35
76
82 Not Statistically Significant
ing or minimizing unintended consequences.
72 Uses/designs system-level assessment methods and instruments 4.11 3.21
80
83 Not Statistically Significant
to identify organization structures and functions that impact
nursing practice and nurse-sensitive patient care outcomes.
19 Identifies, collects, and analyzes data about target populations
3.34 2.97
86
84 Not Statistically Significant
to anticipate the impact of the NP/CNS on program outcomes
when designing new programs.
77 Designs and implements methods, strategies and processes to
3.91 2.90
81
86 Not Statistically Significant
spread and sustain innovation and evidence-based change.
70 Acts as a community consultant and/or participates in the
3.11 2.84
87
87 Not Statistically Significant
planning, development, and implementation of public and com-
munity health programs.
78 Evaluates organizational policies for their ability to support and
3.73 2.65
82
90 Not Statistically Significant
sustain outcomes of programs of care.
46 Monitors and participates in legislation and regulatory health policy-making to influence advanced practice nursing and the health of communities and populations.
1.76 2.41
92
91 Not Statistically Significant
79 Disseminates to stakeholders the outcomes of system-wide changes, impact of nursing practice, and NP/CNS work.
2.80 2.09
89
92 Not Statistically Significant
84 Assesses, plans, implements, and evaluates health care with other health care professionals/primary care providers to meet the comprehensive needs of patients.
93
93 Not Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
34 STUDY PARTICIPANTS
Statistical Significance Versus Practical Significance An important consideration in analyzing these data is the issue of practical versus statistical significance. To call a result meaningful or of practical significance, we need to look beyond the statistical tests of significance themselves. Several other forms of statistical analysis can be used to make judgments about the importance of research results. Just because the differences between scores are statistically significant does not mean the differences have practical significance or are of real importance. In practice the difference between the two mean scores may be relatively small to the point of having no real practical significance. For example, CNSs gave the activity "Demonstrates critical thinking and diagnostic reasoning skills in clinical decision-making" an importance score of 3.63 whereas NPs gave it a score of 3.78. Despite the fact that the difference in importance scores between CNSs and NPs for this activity is statistically significant, this activity was ranked as the most important activity by both NPs and CNSs. The differences in this importance score are therefore statistically significant but for practical purposes not different. Although NPs and CNSs had statistically significant importance ratings for 50 activities, a comparison of the average importance ratings of NPs compared to CNSs shows a rating discrepancy of one or more points for only four out of 93 activity items. In terms of criticality, the findings indicate that CNSs and NPs tend to agree on what the 15 most critical activities are. CNSs and NPs place nine (60%) of the same items in the top 15 most critical activities. Three of the top four activities are common to the two roles: Demonstrates critical thinking and diagnostic reasoning skills in clinical decision making. Maintains clinical records that reflect diagnostic and therapeutic reasoning. Determines appropriate pharmacological, behavioral, and other nonpharmacological treatment modalities in developing a plan of care.
In addition to the three activities listed above, the following 11 activities were highly critical to both NPs and CNSs: Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses. Prescribes, orders, and/or implements pharma- cologic and nonpharmacologic interventions, treatments, and procedures for patients and family members, as identified in the plan of care. Designs and implements a plan of care to attain, promote, maintain and/or restore health. Employs appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy. Incorporates risk/benefit factors in developing a plan of care. Verifies diagnoses based on findings. Assesses, diagnoses, monitors, coordinates and manages the health/illness status of patients over time. Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated. Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members. Evaluates results of interventions using ac- cepted outcome criteria, revises the plan of care and consults/refers when appropriate. Plans follow-up visits to monitor patients and evaluate health/illness care. Only six of the 20 highest criticality ratings from NPs did not appear in the top 20 activities for CNSs. They were: Prescribes medications using principles of pharmacokinetics, drug dosage and routes, indications, interactions and side/adverse effects. Performs a comprehensive and/or problem- focused physical examination.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
STUDY PARTICIPANTS 35
Writes and transmits correct prescriptions to minimize the risk of errors. Diagnoses and manages acute and chronic dis- eases while attending to the illness experience. Selects, performs, and/or interprets common screening and diagnostic laboratory tests. Monitors therapeutic parameters including pa- tient response and adjusts medication dosages accordingly. The six highest criticality ratings from CNSs that did not appear in the top 20 activities for NPs were: Functions in a variety of role dimensions: health care provider, coordinator, consultant, educator, coach, advocate administrator, researcher and leader. Promotes patient advocacy in patient in- teractions and in the selection of treatment modalities. Uses principles of ethical decision making in selecting treatment modalities. Formulates expected outcomes with patients, family members and the interdisciplinary health care team based on clinical and scientific knowledge. Incorporates evidence-based research into nurs- ing interventions within the specialty population. Assesses, plans, implements and evaluates health care with other health care professionals/ primary care providers to meet the comprehensive needs of patients. This does not mean the statistically significant results are completely insignificant. Rather, it means the reader needs to be very careful about the conclusions drawn from the statistics. Knowledge Category Results The SME panel for the Role Delineation Study of Nurse Practitioners and Clinical Nurse Specialists identified and defined 16 categories of knowledge necessary for the performance of NPs and CNSs (see Table 34).
Survey respondents were asked to indicate how important each knowledge category was for their nursing role and setting on a scale ranging from knowledge was "Not Important" to knowledge was "Very Important" for their work. Like the activities section, the data for the knowledge section of the survey was analyzed using t-test comparisons of the NP and CNS responses. The Bonferroni correction was used again to ensure that differences were not a function of the number of comparisons. The tables that follow present knowledge statements with statistically significant differences in importance, then knowledge statements without statistically significant differences in importance. The specific means, standard deviations, standard errors, t-values and probabilities are reported in Appendix D. There were eight knowledge statements that were distinguished by the role of the nurse in the importance ratings (Table 34). As seen previously, the following six knowledge areas rated as having a statistically significant higher importance by NPs than CNSs relate to patient care: health promotion and disease prevention, advanced pharmacology, physiology and pathophysiology, advanced assessment, diagnosis and treatment of health care problems and diseases, critical thinking, diagnostic reasoning and clinical decision making, and diagnostic procedural techniques and interpretation/evaluation of results. The two knowledge statements whose importance rating was significantly higher (statistically speaking) for CNSs than NPs were program planning and principles of teaching and learning. Although some of the differences in importance scores are statistically significant, the rankings in terms of importance by the two groups of nurses are quite similar. For example, critical thinking, diagnostic reasoning and clinical decision making is ranked as the most important area of knowledge by both NPs and CNSs. Overall, the ratings were very similar with differences ranging from as little as 0.01 to as high as 0.70.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
36 STUDY PARTICIPANTS
Table 34. Importance in Knowledge Categories Knowledge Critical thinking, diagnostic reasoning and clinical decision making Advanced assessment, diagnosis and treatment of health care problems and diseases Physiology and pathophysiology Advanced pharmacology Health promotion and disease prevention Diagnostic procedural techniques and interpretation/evaluation of results Principles of teaching and learning Program planning Ethics Professional role development including knowledge of scope of practice Evidence-based practice and outcome Collaboration, consultation, change agent Human diversity and social issues including risk assessment Research study design and application of results Organizational Policy Health Care Financing and Business Management
All Respondents
Rank
CNS NP CNS NP
Decision
3.43 3.61
1
1
Statistically Significant
3.07 3.58
6
2
Statistically Significant
3.05 3.5 2.82 3.46 3.05 3.38 2.65 3.35
7
3
11
4
8
6
12
8
Statistically Significant Statistically Significant Statistically Significant Statistically Significant
3.03 2.84 2.5 2.26 3.39 3.44 3.3 3.37
9 12
15 16
2
5
3
7
Statistically Significant Statistically Significant Not Statistically Significant Not Statistically Significant
3.25 3.3 3.27 3.28 2.91 2.96 2.52 2.45 2.52 2.43 2.28 2.39
5
9
4 10
10 11
13 13
14 14
16 15
Not Statistically Significant Not Statistically Significant Not Statistically Significant Not Statistically Significant Not Statistically Significant Not Statistically Significant
Additional analysis was undertaken to determine if nurses in acute care and psychiatric and mental health settings were masking any differences between NPs and CNSs. Excluding nurses in acute care and psychiatric and mental health settings from the analysis did not alter the results appreciably. Tables in Appendix E present the results for frequency and priority responses for 20 of the activities. Complete tables are available upon request. Appendix F presents the results for the knowledge questions.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
LIMITATIONS OF THE STUDY 37
Limitations of the Study
An important limitation of the study is the low response rate (30%) despite offering various incentives for completion of the questionnaire. Low response rates are a continuing problem for surveys because the sample is less likely to represent the overall target population. The postcards with the incorrect Web site address at the beginning of the study may have dissuaded some APRNs from taking part in the survey who may have participated if the error had not been made. The Web survey did not track respondents. Therefore, it was possible for someone to answer both the online survey as well as the mail survey. Given the length of the questionnaire, it is highly unlikely that the participants filled out the survey twice. Nevertheless, there remains the possibility of some of the answers being duplicated.
A few variables of the study were dropped due to error in coding the data. Respondents were asked to indicate the type(s) of license they hold. Many respondents selected "other" as their response, and were invited to write in their type of license. There may have been some confusion about licensure versus certification, as some respondents listed certifications or degrees here. This data was not presented in the tables of the demographic section. Another question asked if English is the primary language of the respondent but a coding error precluded its inclusion in the analysis. The response rates for the paper survey and the electronic survey suggest that future studies should include both modes. If cost considerations lead to the selection of only one mode, this study suggests that a paper survey should be used.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
38 SUMMARY OF FINDINGS
Summary of Findings
The findings show some statistically significant differences in ratings, but these differences are sometimes found in activities that both roles rated relatively highly or lowly. One way to focus on important differences across the two roles is to look at activities that are rated highly by one role but not the other. The highest criticality ratings from NPs that were not the highest for CNSs were prescribing medications, using laboratory tests, adjusting medications and performing physical examinations. The highest criticality ratings from CNSs that were not highest for NPs were functioning in a variety of role dimensions, promoting patient advocacy, working in interdisciplinary teams and using evidence-based research.
Both roles emphasize critical thinking and diagnostic reasoning skills in clinical decision making, maintaining clinical records that reflect diagnostic and therapeutic reasoning, and determining appropriate pharmacological, behavioral and other nonpharmacological treatment modalities in developing a plan of care. Both roles also analyze and interpret patient history; present symptoms, physical findings and diagnostic information to formulate differential diagnoses; design and implement a plan of care to attain, promote, maintain and/or restore health; and employ appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy.
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix A: Advisory Panel Members
Appendix A.Advisory Panel Members Member Joyce Blood, PhD, ARNP, CNS Pamela DeWitt, RN, MN, CNS Charlene Hanson, EdD, FNP, FAA Mary Knudtson, NP, MSN, FNP, PNP, DNSc Ann Kratz, MSN, RN, APRN-BC, APNP Paula Lusardi, PhD, RN, CCRN, CCNS
Specialty NP: Psychiatric CNS: Pediatrics NP: Family NP: Family CNS: Women CNS: Medical-Surgical
APPENDIX A 39 State/NCSBN Area New Hampshire, Area IV Arizona, Area I Georgia, Area III California, Area I Wisconsin, Area II Massachusetts, Area IV
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
40 APPENDIX B
Appendix B: Subject Matter Expert (SME) Panels
Nurse Practitioner Panel Name Penny Borsage, MSN, CRNP Carolyn Buppert, MSN, CRNP, JD Christine Clayton, RN, MS, CNS, CNP Gene Harkless, DNSc, ARNP Linda Lindeke, PhD, RN, CNP Kathy Marquis, JD, MSN, FNP-C Elizabeth Partin, ND, CFNP Linda Pearson, DNSc, APRN, BC, FNP, FPMHNP Cheryl Stegbauer, PhD, RN, APN Cecilia West, MSN, RN, APN C, CDE
State/NCSBN Area Alabama, Area III Maryland, Area IV South Dakota, Area II New Hampshire, Area IV Minnesota, Area II Wyoming, Area I Kentucky, Area III Colorado, Area I Tennessee, Area III New Jersey, Area IV
Practice Women's Health NP, Attorney Hospital & CNS Family Pediatrics Family Family, Rural Health Clinic Psych/Mental Health Associate Dean, University of Tennessee Health Science Center College of Nursing Adult NP, Diabetes Educator
Clinical Nurse Specialist Panel Name Debra Broadnax, MSN, RN, CNS, CNN Diane Brosseau-Pizzi, PCNS Frederick M. Brown, Jr., RN, MS, ONC, APN Michelle Buck, CNS, ONC Nancy Cisar, MSN, RN, CCRN, APRN, CS Jodi Groot, RN, PhD, CS Marilyn Noettl, RN, APN, ONC Marybeth O'Neil, RN, MS, CNS Cathy Thompson, RN, PhD, CNS
State/NCSBN Area Ohio, Area II Rhode Island, Area IV Illinois, Area II Illinois, Area II Arizona, Area I Oregon, Area I Illinois, Area II Minnesota, Area II Colorado, Area I
Practice Pediatric Ortho Oncology Medical-Surgical ­ Mayo CAP Orthopedic Nursing Psych/Mental Health Assistant Professor
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix C: Tests of Significance Frequency and Importance of Activities
Appendix C. Tests of Significance Frequency and Importance of Activities
Item #
Activity Statement
Activity Frequency or Activity Performance
Mean CNS
Mean NP
Method
Variances Probt
t-
DF Probt
Decision STD Effect
(Bonf. Value
(Bonf.
Size
Adjust. =
Adjust. =
(CNS
.0005)
.0002)
- NP)
47 Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses.
Frequency 3.4323 4.769 Satterthwaite Unequal
<.0001 -16.03 699
<.0001 Statistically 1.2893 -1.03652 Significant
48 Determines appropriate pharmacological, behavioral, and other non-pharmacological treatment modalities in developing a plan of care.
Frequency 3.5725 4.732 Satterthwaite Unequal
<.0001 -14.15 740
<.0001 Statistically 1.2908 -0.89808 Significant
49 Uses principles of ethical decision-mak- Frequency 3.1917 3.971 Pooled ing in selecting treatment modalities.
Equal
0.0041
-8.3 1205
<.0001 Statistically 1.6303 Significant
-0.478
50 Incorporates risk/benefit factors in developing a plan of care.
Frequency 3.5171 4.479 Satterthwaite Unequal
<.0001 -11.98 918
<.0001 Statistically 1.3397 -0.7178 Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
51 Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
Frequency 3.6708 4.301 Satterthwaite Unequal
<.0001
-8.1 1025
<.0001 Statistically 1.3249 -0.4755 Significant
52 Evaluates patient outcomes in relation Frequency 3.6119 4.289 Satterthwaite Unequal to the plan of care and modifies the plan when indicated.
<.0001 -8.17 965
<.0001 Statistically 1.3915 -0.48676 Significant
53 Employs appropriate diagnostic
Frequency 3.3974 4.55 Satterthwaite Unequal
and therapeutic interventions and
regimens with attention to safety, cost,
invasiveness, simplicity, acceptability
and efficacy.
<.0001 -13.49 830
<.0001 Statistically 1.3867 Significant
-0.831
54 Assesses, diagnoses, monitors, coordi- Frequency 3.5327 4.366 Satterthwaite Unequal nates, and manages the health/illness status of patients over time.
<.0001 -9.07 883
<.0001 Statistically 1.5028 -0.55443 Significant
55 Evaluates results of interventions using Frequency 3.3857 4.152 Satterthwaite Unequal accepted outcome criteria, revises the plan of care and consults/refers when appropriate.
<.0001 -8.84 980
<.0001 Statistically 1.4578 -0.52535 Significant
APPENDIX C 41
56
Develops and/or uses a follow-up sys-
Frequency 2.8715 3.89 Satterthwaite Unequal
tem within the practice to ensure that
patients receive appropriate services.
<.0001 -10.32 969
<.0001 Statistically 1.6449 -0.61916 Significant
42 Appendix c National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix C. Tests of Significance Frequency and Importance of Activities
Item #
Activity Statement
Activity Frequency or Activity Performance
Mean CNS
Mean NP
Method
57 Assists patients in learning specific
Frequency 2.5095 2.944 Pooled
information or skills by designing a
learning plan that is comprised of
sequential, cumulative steps and that
acknowledges relapse and the need for
practice, reinforcement, support, and
additional teaching.
58 Performs a comprehensive and/or
Frequency 1.7483 4.417 Satterthwaite
problem-focused physical examination.
60 Describes problems in context, includ- Frequency 2.9259 3.836 Satterthwaite ing variations in normal and abnormal symptoms, functional problems, or risk behaviors inherent in disease, illness, or developmental processes.
63 Prescribes medications using principles Frequency 2.4646 4.572 Satterthwaite of pharmacokinetics, drug dosage and routes, indications, interactions, and side/adverse effects.
64 Monitors therapeutic parameters
Frequency 2.6719 3.93 Satterthwaite
including patient response and adjusts
medication dosages accordingly.
65 Maintains clinical records that reflect
Frequency 3.6705 4.735 Satterthwaite
diagnostic and therapeutic reasoning.
20 Orders durable medical equipment.
Frequency 0.7931 1.162 Pooled
75 Leads nursing and interdisciplinary groups in implementing innovative patient care programs.
Frequency 1.3032 0.879 Satterthwaite
76 Develops or influences system-level policies that will affect innovation and programs of care.
Frequency 1.2593 0.867 Pooled
93 Demonstrates knowledge of legal reg- Frequency 2.196 3.087 Pooled ulations for NP/CNS practice including scope of practice and reimbursement for services.
1
Verifies diagnoses based on findings.
Frequency 3.2419 4.46 Satterthwaite
Variances Equal Unequal Unequal Unequal Unequal Unequal Equal Unequal Equal Equal Unequal
Probt (Bonf. Adjust. = .0005) 0.2946 <.0001 <.0001 <.0001 <.0001 <.0001 0.0096 0.0002 0.0036 0.7585 <.0001
tValue -4.04 -24.23 -9.34 -17.46 -10.4 -12.34 -3.91 4.15 3.99 -7.7 -14.4
DF Probt Decision (Bonf. Adjust. = .0002)
1152
<.0001 Statistically Significant
691 1057
<.0001 Statistically Significant <.0001 Statistically Significant
556 <.0001 Statistically Significant
749 <.0001 Statistically Significant
691 <.0001 Statistically Significant 929 <.0001 Statistically Significant 903 <.0001 Statistically Significant
924 <.0001 Statistically Significant
1164
<.0001 Statistically Significant
955 <.0001 Statistically Significant
STD 1.8218 1.6726 1.6497 1.7191 1.882 1.3279 1.4127 1.5416 1.4855 1.97 1.496
Effect Size (CNS - NP) -0.23864 -1.5954 -0.55163 -1.22582 -0.66857 -0.80201 -0.26106 0.27515 0.26404 -0.45234 -0.81438
APPENDIX C 43 National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix C. Tests of Significance Frequency and Importance of Activities
Item #
Activity Statement
Activity Frequency or Activity Performance
Mean CNS
Mean NP
2
Designs and implements a plan of care Frequency 3.4556 4.575
to attain, promote, maintain, and/or
restore health.
3
Promotes patient advocacy in patient
Frequency 3.3909 4.138
interactions and in the selection of
treatment modalities.
4
Reevaluates and revises diagnosis
when additional assessment data
become available.
Frequency 2.418 3.658
5
Formulates expected outcomes with
Frequency 3.2279 3.86
patients, family members, and the
interdisciplinary healthcare team based
on clinical and scientific knowledge.
6
Diagnoses and manages acute and
Frequency 2.7359 4.205
chronic diseases while attending to the
illness experience.
7
Recognizes and provides primary care
Frequency 2.1361 3.929
services to patients with acute and
chronic diseases.
8
Selects, performs, and/or interprets
common screening and diagnostic
laboratory tests.
Frequency 2.435 4.267
9
Plans follow-up visits to monitor pa-
Frequency 3.1413 4.19
tients and evaluate health/illness care.
10 Collaborates with the patient and
Frequency 2.778 3.373
interdisciplinary team to plan and
implement diagnostic strategies and
therapeutic interventions for patients
with unstable and complex health care
problems to assist patients to regain
stability and restore health.
11 Demonstrates critical thinking and diagnostic reasoning skills in clinical decision-making.
Frequency 4.0097 4.667
Method Satterthwaite Satterthwaite Satterthwaite Satterthwaite Satterthwaite Satterthwaite Satterthwaite Satterthwaite Pooled Satterthwaite
Variances Unequal Unequal Unequal Unequal Unequal Unequal Unequal Unequal Equal Unequal
Probt (Bonf. Adjust. = .0005) <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 0.061 <.0001
tValue -13.85 -9.79 -12.48 -7.7 -13.83 -15.73 -18.53 -11.39 -5.88 -10.64
DF Probt Decision (Bonf. Adjust. = .0002) 886 <.0001 Statistically Significant
1337
<.0001 Statistically Significant
1066
<.0001 Statistically Significant
1391
<.0001 Statistically Significant
833 <.0001 Statistically Significant
893 <.0001 Statistically Significant
841 <.0001 Statistically Significant
1066 1199
<.0001 Statistically Significant <.0001 Statistically Significant
1149
<.0001 Statistically Significant
STD 1.359 1.4642 1.7166 1.5764 1.7272 1.8923 1.6186 1.6647 1.752 1.1602
Effect Size (CNS - NP) -0.8239 -0.51043 -0.72261 -0.40084 -0.85039 -0.94749 -1.13203 -0.63012 -0.33989 -0.56692
44 APPENDIX C National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix C. Tests of Significance Frequency and Importance of Activities
Item #
Activity Statement
Activity Frequency or Activity Performance
Mean CNS
Mean NP
Method
Variances Probt
t-
DF
Probt
Decision STD Effect
(Bonf. Value
(Bonf.
Size
Adjust. =
Adjust. =
(CNS
.0005)
.0002)
- NP)
12 Applies principles of epidemiol-
Frequency 2.2505 3.244 Pooled
ogy and demography by recognizing
populations at risk, patterns of disease,
and effectiveness of prevention and
intervention.
Equal
0.0931 -9.54 1184
<.0001 Statistically 1.7885 -0.55568 Significant
17 Prescribes, orders, and/or implements Frequency 3.1993 4.634 Satterthwaite Unequal pharmacologic and non-pharmacologic interventions, treatments, and procedures for patients and family members, as identified in the plan of care.
<.0001 -15.93 772
<.0001 Statistically 1.491 -0.96189 Significant
18 Writes and transmits correct prescriptions to minimize the risk of errors.
Frequency 2.3945 4.355 Satterthwaite Unequal
<.0001
-16 639
<.0001 Statistically 1.8435 -1.06356 Significant
66 Orders durable medical equipment.
Frequency 0.7792 1.158 Pooled
Equal
0.1406 -3.97 918
<.0001 Statistically 1.4237 -0.26593 Significant
21 Demonstrates knowledge of patient
Frequency 2.3764 2.877 Pooled
payment and provider reimbursement
systems.
Equal
0.5771 -4.85 1343
<.0001 Statistically 1.8879 -0.26539 Significant
22 Acts as a primary care provider for
Frequency 1.4286 3.435 Pooled
individuals, families, and communi-
ties within integrated health care
services using accepted guidelines and
standards.
Equal
0.346 -14.82 921
<.0001 Statistically 2.0207 -0.99292 Significant
25 Demonstrates knowledge of business
Frequency 1.913 2.325 Pooled
principles that affect long-term financial
viability of a practice, the efficient use
of resources, and quality of care.
Equal
0.2578 -4.11 1329
<.0001 Statistically 1.8235 -0.22569 Significant
29 Contributes to the development of
Frequency
interdisciplinary standards of practice
and evidence-based guidelines for
care (e.g. critical pathways, care maps,
benchmarks).
1.51 1.093 Pooled
Equal
0.0464 4.41 1177
<.0001 Statistically 1.6196 0.25752 Significant
30 Targets and helps to reduce system-
Frequency 1.3192 0.976 Pooled
level barriers to proposed changes in
nursing practice and programs of care.
Equal
0.2464 3.64 983
0.0003 Statistically 1.4814 Significant
0.232
36 Obtains specialist and referral care for Frequency 1.0869 2.738 Pooled patients while remaining the primary care provider.
Equal
0.0108 -14.94 962
<.0001 Statistically 1.6735 -0.98661 Significant
APPENDIX C 45 National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix C. Tests of Significance Frequency and Importance of Activities
Item #
Activity Statement
Activity Frequency or Activity Performance
Mean CNS
Mean NP
37 Meets/maintains eligibility require-
Frequency 2.085 2.607
ments for certification and/or licensure.
84 Assesses, plans, implements, and
Frequency 2.8808 3.368
evaluates health care with other health
care professionals/primary care provid-
ers to meet the comprehensive needs
of patients.
39 Advocates for the role of the advanced Frequency 1.9351 2.443 practice nurse in the health care system.
42
Develops and implements educational Frequency 1.6596
1.2
programs to improve nursing practice
and patient outcomes.
44 Identifies expected outcomes by
Frequency 2.255 2.948
considering associated risks, benefits,
and costs.
45 Initiates appropriate and timely
Frequency 1.7321 2.677
consultation and/or referral when the
problem exceeds the NP/CNS's scope
of practice and/or expertise.
59 Applies and/or conducts research stud- Frequency 1.5612 1.889 ies pertinent to area(s) of practice.
61 Evaluates effects of nursing interventions for individuals and populations of patients for clinical effectiveness, patient responses, efficiency, costeffectiveness, consumer satisfaction, and ethical considerations.
Frequency 2.833 3.06
62 Considers the patient's needs when
Frequency 1.3412 1.516
termination of the nurse-patient rela-
tionship is necessary and provides for a
safe transition to another care provider.
67 Develops a quality assurance/improve- Frequency 1.3126 1.171 ment plan to evaluate and modify practice.
Method Pooled Pooled Pooled Pooled Pooled Pooled Pooled Pooled Pooled Pooled
Variances Probt
t-
DF
Probt
Decision STD Effect
(Bonf. Value
(Bonf.
Size
Adjust. =
Adjust. =
(CNS
.0005)
.0002)
- NP)
Equal
0.0505 -4.77 1485
<.0001 Statistically 2.1007 -0.24846 Significant
Equal
0.2392 -5.06 1262
<.0001 Statistically 1.7064 -0.28543 Significant
Equal Equal Equal Equal
0.0134 -5.03 1478
<.0001 Statistically 1.932 -0.26315 Significant
0.5613 4.52 1058
<.0001 Statistically 1.6545 Significant
0.2778
0.9062 -6.32 1165
<.0001 Statistically 1.8692 -0.3707 Significant
0.4235 -11.13 1491
<.0001 Statistically 1.6314 -0.57893 Significant
Equal Equal
0.0138 -2.9 1010 0.679 -2.04 1116
0.0038 0.0416
Not Statistically Significant Not Statistically Significant
1.7908 1.8558
-0.18297 -0.12221
Equal Equal
0.2833 -1.65 1094 0.7956 1.4 1028
0.0996
Not Statistically Significant
1.7483
-0.10005
0.1609
Not
1.6145
Statistically
Significant
0.08749
46 APPENDIX C National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix C. Tests of Significance Frequency and Importance of Activities
Item #
Activity Statement
Activity Frequency or Activity Performance
Mean CNS
Mean NP
68 Provides case management services to meet multiple patient health care needs.
Frequency 1.8683 1.727
69 Plans for systematic investigation of
Frequency 1.9291 2.301
patient problems needing clinical in-
quiry, including etiologies of problems,
needs for interventions, outcomes of
current practice, and costs associated
with care.
70 Acts as a community consultant and/or Frequency 0.9892 0.924 participates in the planning, development, and implementation of public and community health programs.
71 Participates in organizational decision- Frequency 1.6292 1.621 making, interprets variations in outcomes, and uses data from information systems to improve practice.
72 Uses/designs system-level assessment Frequency 1.2291 1.032 methods and instruments to identify organization structures and functions that impact nursing practice and nursesensitive patient care outcomes.
73 Identifies facilitators and barriers
Frequency 1.6163 1.54
to achieving desired outcomes of
integrated programs of care across the
continuum and at points of service.
74 Plans for achieving intended system-
Frequency 1.2782 1.071
wide change, while avoiding or
minimizing unintended consequences.
77 Designs and implements methods,
Frequency 1.1372 0.907
strategies and processes to spread and
sustain innovation and evidence-based
change.
78 Evaluates organizational policies for their ability to support and sustain outcomes of programs of care.
Frequency 1.1307 0.874
Method Pooled Pooled Pooled Pooled Pooled Pooled Pooled Pooled Pooled
Variances Probt
t-
DF
Probt
Decision STD Effect
(Bonf. Value
(Bonf.
Size
Adjust. =
Adjust. =
(CNS
.0005)
.0002)
- NP)
Equal
0.7431 1.17 941
0.2438
Not
1.8549
Statistically
Significant
0.07603
Equal
0.2819 -3.18 1055
0.0015
Not Statistically Significant
1.8968
-0.19581
Equal Equal Equal
0.866
0.7 910
0.4865
Not
1.4082
Statistically
Significant
0.0461
0.2246 0.08 1022
0.9377
Not
1.6985
Statistically
Significant
0.00489
0.9974 1.82 893
0.0692
Not
1.6221
Statistically
Significant
0.12165
Equal Equal Equal Equal
0.3098 0.71 975
0.4799
Not
1.6867
Statistically
Significant
0.04523
0.9845
2 940
0.1949 2.37 929
0.046
Not
1.5908
Statistically
Significant
0.018
Not
1.4808
Statistically
Significant
0.1302 0.15569
0.2427
2.6 892
0.0095
Not
1.4762
Statistically
Significant
0.1742
APPENDIX C 47 National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix C. Tests of Significance Frequency and Importance of Activities
Item #
Activity Statement
Activity Frequency or Activity Performance
Mean CNS
Mean NP
79
Disseminates to stakeholders the out-
Frequency 0.8591 0.652
comes of system-wide changes, impact
of nursing practice, and NP/CNS work.
80
Assesses the professional climate and
Frequency 1.4137 1.176
interdisciplinary collaboration within
and across units for their impact on
nursing practice and outcomes.
81 Plans for systematic investigation of
Frequency 1.4599 1.713
patient problems needing clinical in-
quiry, including etiologies of problems,
needs for interventions, outcomes of
current practice, and costs associated
with care.
82 Supports socialization, education,
Frequency 1.661 1.411
and training of novice practitioners by
serving as preceptor, role model, and
mentor.
83 Evaluates and applies research studies Frequency 1.8026 2.089 pertinent to patient care management and outcomes.
38 Assesses, plans, implements, and
Frequency 3.7977 3.883
evaluates health care with other health
care professionals/ primary care provid-
ers to meet the comprehensive needs
of patients.
85 Monitors self, peers and delivery systems as part of continuous quality improvement.
Frequency 2.1858 2.522
86 Functions in a variety of role dimen-
Frequency 3.3996 3.147
sions: health care provider, coordinator,
consultant, educator, coach, advocate
administrator, researcher, and leader.
87 Evaluates implications of contemporary Frequency 1.126 1.274 health policy on health care providers and consumers.
Method Pooled Pooled Pooled Pooled Pooled Pooled Pooled Pooled Pooled
Variances
Probt (Bonf. Adjust. = .0005)
tValue
Equal
0.1855 2.29
Equal
0.3553 2.27
DF Probt Decision STD (Bonf. Adjust. = .0002)
840
0.022
Not
1.3069
Statistically
Significant
911 0.0234
Not
1.5814
Statistically
Significant
Effect Size (CNS - NP) 0.15865 0.15048
Equal
0.0078 -2.19 943
0.0287
Not Statistically Significant
1.7753
-0.14277
Equal Equal Equal
0.3719 2.38 1100
0.0177
Not
Statistically
Significant
1.745
0.14317
0.1933 -2.73 1122 -0.61 654
0.0064
Not Statistically Significant
1.7493
-0.16348
0.5412
Not Statistically Significant
0.9332
-0.04871
Equal Equal Equal
0.1064 -2.98 1133 0.1058 2.34 1125 0.0246 -1.43 957
0.003 0.0195
Not Statistically Significant Not Statistically Significant
1.8985 1.8067
-0.17719 0.13969
0.1542
Not Statistically Significant
1.6019
-0.09217
48 APPENDIX C National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix C. Tests of Significance Frequency and Importance of Activities
Item #
Activity Statement
Activity Frequency or Activity Performance
Mean CNS
Mean NP
88 Uses/designs appropriate methods and Frequency 1.3035 1.215 instruments to assess knowledge, skills, and practice competencies of nurses and nursing personnel to advance the practice of nursing.
89 Mentors nurses and assists them to
Frequency 1.5161 1.611
critique and apply research evidence to
nursing practice.
90 Assists members of the health care team to develop innovative, costeffective patient programs of care.
Frequency
1.23 1.449
91 Develops and uses data collection tools that have been established as reliable and valid.
Frequency 1.558 1.783
92 Works collaboratively to develop a plan Frequency 2.2821 2.544 of care that is individualized and dynamic and that can be applied across different health care settings.
13 Identifies the need for new or modified Frequency 1.6828 1.943 assessment methods or instruments within a specialty area.
14 Incorporates evidence-based research Frequency 3.0691 3.261 into nursing interventions within the specialty population.
15 Disseminates the results of innovative care.
Frequency 1.8089 2.122
16 Incorporates cultural preferences,
Frequency 2.821 3.071
spiritual and health beliefs and behav-
iors, and traditional practices into the
management plan.
19 Identifies, collects, and analyzes data
Frequency 1.0428 0.929
about target populations to anticipate
the impact of the NP/CNS on program
outcomes when designing new
programs.
Method Pooled Pooled Pooled Pooled Pooled Pooled Pooled Pooled Pooled Pooled
Variances
Probt (Bonf. Adjust. = .0005)
tValue
Equal
0.6108 0.79
DF Probt Decision STD (Bonf. Adjust. = .0002)
898 0.4307
Not
1.6852
Statistically
Significant
Effect Size (CNS - NP) 0.05255
Equal Equal Equal Equal Equal Equal Equal Equal Equal
0.8921 -0.87 1002 0.2105 -2.06 971 0.0264 -1.95 990 0.2801 -2.2 1049
0.3852
Not Statistically Significant
1.7253
-0.05484
0.0394
Not
1.6522
Statistically
Significant
-0.1323
0.0512
Not Statistically Significant
1.8119
-0.12399
0.0281
Not Statistically Significant
1.9289
-0.13586
0.5021 -2.81 1391 0.8432 -1.94 1254 0.0259 -3.34 1392 0.4732 -2.46 1267
0.005
Not Statistically Significant
1.7225
-0.15081
0.0523
Not Statistically Significant
1.7476
-0.10975
0.0009
Not Statistically Significant
1.7487
-0.17928
0.014
Not
Statistically
Significant
1.806
-0.1384
0.9647 1.19 1050
0.2344
Not
1.5456
Statistically
Significant
0.07339
Appendix C. Tests of Significance Frequency and Importance of Activities
Item #
Activity Statement
Activity Frequency or Activity Performance
Mean CNS
Mean NP
Method
Variances Probt
t-
DF
Probt
Decision STD Effect
(Bonf. Value
(Bonf.
Size
Adjust. =
Adjust. =
(CNS
.0005)
.0002)
- NP)
23 Provides leadership in the interdisci-
Frequency 2.4303 2.74 Pooled
plinary team through the development
of collaborative practice or innovative
partnerships.
Equal
0.1313 -3.13 1365
0.0018
Not
Statistically
Significant
1.8226
-0.16964
24 Maintains current knowledge of the
Frequency 1.8897 2.209 Pooled
organization and financing of the
health care system as it affects delivery
of care.
Equal
0.0384 -3.05 1187
0.0023
Not Statistically Significant
1.7953
-0.17782
26 Assesses targeted system-level
Frequency 1.6122 1.882 Pooled
variables, such as culture, finances,
regulatory requirements, and external
demands that influence nursing prac-
tice and outcomes.
Equal
0.0199 -2.39 1038
0.0169
Not Statistically Significant
1.8096
-0.14886
APPENDIX C 49 National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
27 Assesses and draws conclusions about Frequency 1.4246 1.252 Pooled the effects of variance across an organization that influences the outcomes of nursing practice.
Equal
0.481
1.8 1123
0.0719
Not
1.6037
Statistically
Significant
0.10745
28 Develops innovative solutions that can Frequency 1.3884 1.155 Pooled be generalized across different units, populations, or specialties.
Equal
0.6868 2.38 1029
0.0173
Not
1.5717
Statistically
Significant
0.14845
31 Uses organizational structure and processes to provide feedback about the effectiveness of nursing practice and interdisciplinary relationships in meeting identified outcomes of programs of care.
Frequency 1.4807 1.217 Pooled
Equal
0.9291 2.85 1167
0.0044
Not
1.5825
Statistically
Significant
0.1668
32 Evaluates and documents the impact of Frequency 0.9487 1.258 Satterthwaite Unequal NP/CNS practice on the organization.
0.0005 -3.19 1015
0.0014
Not Statistically Significant
1.5486
-0.20002
33
Incorporates the use of quality indica-
Frequency 2.0142 1.772
Pooled
tors and benchmarking in evaluating
the progress of patients, family mem-
bers, nursing personnel, and systems
toward expected outcomes.
Equal
0.1888 2.36 1253
0.0182
Not
1.8163
Statistically
Significant
0.13352
34 Articulates and interprets the NP/CNS Frequency 1.1402 1.402 Pooled role and scope of practice to the public, policy-makers, legislators and other members of the health care team.
Equal
0.004 -2.77 1129
0.0057
Not Statistically Significant
1.5839
-0.16552
50 APPENDIX C National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix C. Tests of Significance Frequency and Importance of Activities
Item #
Activity Statement
Activity Frequency or Activity Performance
Mean CNS
Mean NP
Method
Variances Probt
t-
DF
Probt
Decision STD Effect
(Bonf. Value
(Bonf.
Size
Adjust. =
Adjust. =
(CNS
.0005)
.0002)
- NP)
35 Utilizes scientific foundations and theoretical frameworks to implement NP/CNS role.
Frequency 2.6812 2.487 Pooled
Equal
0.1672 1.81 1410
0.071
Not
2.0177
Statistically
Significant
0.09631
40 Evaluates the relationship between community/public health issues and social problems as they impact the health care of patients.
Frequency 1.5811 1.939 Pooled
Equal
0.0187 -3.39 1116
0.0007
Not Statistically Significant
1.7553
-0.20375
41 Identifies, in collaboration with nursing personnel and other health care providers, needed changes in equipment or other products based on evidence, clinical outcomes and cost-effectiveness.
Frequency 1.4243 1.635 Pooled
Equal
0.0243 -2.34 1301
0.0192
Not Statistically Significant
1.6087
-0.13066
43 Evaluates the ability of nurses and nurs- Frequency 1.5498 1.383 Pooled ing personnel to implement changes in nursing practice, with individual patients and populations.
Equal
0.7159 1.69 1155
0.0917
Not
1.6847
Statistically
Significant
0.09926
46 Monitors and participates in legislation Frequency 0.5529 0.725 Satterthwaite Unequal and regulatory health policy-making to influence advanced practice nursing and the health of communities and populations.
<.0001 -2.33 1039
0.0201
Not
1.2016
Statistically
Significant
-0.1435
APPENDIX D 51 Appendix D: Tests of Significance for Importance of Knowledge Categories National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
Appendix D. Tests of Significance for Importance of Knowledge Categories
Knowledge Statement
Mean CNS
Mean NP
Method
Research study design and application 2.52
2.45
of results
Pooled
Evidence-based practice and outcome 3.25
3.30
Pooled
Variances Equal Equal
tValue 1.91 -1.9
Organizational Policy
2.52
2.43
Pooled
Equal
2.52
Health Care Financing and Business Management Ethics
2.28
2.39
3.39
3.44
Pooled Pooled
Equal Equal
-3.19 -2.2
Professional role development includ-
3.30
ing knowledge of scope of practice
Collaboration, consultation, change
3.27
agent
Human diversity and social issues
2.91
including risk assessment
Health promotion and disease
3.05
prevention
Advanced pharmacology
2.82
3.37
Pooled
Equal
-2.84
3.28
Pooled
Equal
-0.32
2.96
Pooled
Equal
-1.39
3.38
Satterthwaite Unequal -11.29
3.46
Satterthwaite Unequal -19.48
Physiology and pathophysiology
3.05
3.50
Satterthwaite Unequal -16.62
Advanced assessment, diagnosis and
3.07
treatment of health care problems and
diseases
Critical thinking, diagnostic reasoning
3.43
and clinical decision making
Program planning
2.50
3.58
Satterthwaite Unequal -18.22
3.61
Satterthwaite Unequal -8.02
2.26
Satterthwaite Unequal
6.48
Principles of teaching and learning
3.03
2.84
Pooled
Equal
6.04
Diagnostic procedural techniques and
2.65
interpretation/evaluation of results
3.35
Satterthwaite Unequal -21.08
DF 2818 2833 2828 2827 2834 2837 2835 2829 2603 2181 2367 2156 2617 2689 2833 2396
Probt
Difference
Probv STD
0.0561 0.0576 0.0116 0.0014 0.0277 0.0046 0.7489 0.1647 <.0001 <.0001 <.0001 <.0001
Not Statistically Sgnificant Not Statistically Sgnificant Not Statistically Sgnificant Not Statistically Sgnificant Not Statistically Sgnificant Not Statistically Sgnificant Not Statistically Sgnificant Not Statistically Sgnificant Statistically Sgnificant Statistically Sgnificant Statistically Sgnificant Statistically Sgnificant
0.576 0.064 0.061 0.762 0.535 0.378 0.607 0.350 <.0001 <.0001 <.0001 <.0001
0.972 0.754 0.947 0.932 0.658 0.692 0.733 0.838 0.778 0.843 0.706 0.721
Effect Size 0.072 -0.071 0.095 -0.120 -0.083 -0.107 -0.012 -0.052 -0.429 -0.762 -0.641 -0.714
<.0001 <.0001 <.0001 <.0001
Statistically Sgnificant Statistically Sgnificant Statistically Sgnificant Statistically Sgnificant
<.0001 0.584 -0.304 <.0001 0.984 0.245 0.602 0.846 0.228 <.0001 0.859 -0.811
52 APPENDIX E
Appendix E: Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
CNS
Frequency
All
No Psych/Mental No Psych/Mental
Health
Health/Other
Item #
Activity
Frequency Rank Frequency Rank Frequency Rank
11 Demonstrates critical thinking and diagnostic reasoning skills in clinical decision-making.
4.01
1
3.87
1
3.87
1
65 Assesses, plans, implements, and evaluates health care with other health care professionals/primary care providers to meet the comprehensive needs of patients.
3.80
2
2.96
18
2.96
18
48 Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
3.67
3
3.53
3
3.53
3
52 Maintains clinical records that reflect diagnostic and therapeutic reasoning.
3.67
4
3.50
4
3.50
4
51 Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated.
3.61
5
3.49
5
3.49
5
54 Determines appropriate pharmacological, behavioral, and other non-pharmacological treatment modalities in developing a plan of care.
3.57
6
3.41
8
3.41
8
2
Assesses, diagnoses, monitors, coordi-
nates, and manages the health/illness
status of patients over time.
3.53
7
3.45
6
3.45
6
86 Incorporates risk/benefit factors in developing a plan of care.
3.52
8
3.28
11
3.28
11
50 Designs and implements a plan of care to attain, promote, maintain, and/or restore health.
3.46
9
3.29
10
3.29
10
47 Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses.
3.43
10
3.41
7
3.41
7
53 Functions in a variety of role dimensions; health care provider, coordinator, consultant, educator, coach, advocate administrator, researcher, and leader.
3.40
11
3.79
2
3.79
2
55 Employs appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy.
3.40
12
3.18
14
3.18
14
3
Promotes patient advocacy in patient
interactions and in the selection of
treatment modalities.
3.39
13
3.28
12
3.28
12
No Acute Care
Frequency Rank
4.18
1
2.82
28
3.82
5
4.15
2
3.79
6
3.91
3
3.89
4
3.72
8
3.75
7
3.66
10
3.24
18
3.71
9
3.61
13
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
APPENDIX E 53
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
CNS
Frequency
All
No Psych/Mental No Psych/Mental
No Acute Care
Health
Health/Other
Item #
Activity
Frequency Rank Frequency Rank Frequency Rank Frequency Rank
17 Evaluates results of interventions using accepted outcome criteria, revises the plan of care and consults/refers when appropriate.
3.39
14
3.37
9
3.37
9
3.54
14
49 Verifies diagnoses based on findings.
3.24
15
2.93
21
2.93
21
3.51
16
5
Formulates expected outcomes with
patients, family members, and the
interdisciplinary healthcare team based
on clinical and scientific knowledge.
3.23
16
3.23
13
3.23
13
3.30
17
14 Prescribes, orders, and/or implements pharmacologic and non-pharmacologic interventions, treatments, and procedures for patients and family members, as identified in the plan of care.
3.20
17
2.87
23
2.87
23
3.62
12
1
Uses principles of ethical decision-mak-
ing in selecting treatment modalities.
3.19
18
2.94
20
2.94
20
3.52
15
9
Plans follow-up visits to monitor pa-
tients and evaluate health/illness care.
3.14
19
2.70
24
2.70
24
3.63
11
38 Incorporates evidence-based research into nursing interventions within the specialty population.
3.07
20
2.88
22
2.88
22
3.13
21
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
CNS
Importance
All
No Psych/Mental No Psych/Mental
No Acute Care
Health
Health/Other
Item #
Activity
Importance Rank Importance Rank Importance Rank Importance Rank
11 Demonstrates critical thinking and diagnostic reasoning skills in clinical decision-making.
3.63
1
3.61
2
3.61
2
3.66
1
38 Assesses, plans, implements, and evaluates health care with other health care professionals/primary care providers to meet the comprehensive needs of patients.
3.38
4
3.44
4
3.44
4
3.35
13
51 Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
3.33
10
3.35
6
3.35
6
3.37
12
65 Maintains clinical records that reflect diagnostic and therapeutic reasoning.
3.24
19
3.18
21
3.18
21
3.42
6
52 Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated.
3.35
6
3.35
7
3.35
7
3.40
8
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
54 APPENDIX E
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
CNS
Importance
All
No Psych/Mental No Psych/Mental
No Acute Care
Health
Health/Other
Item #
Activity
Importance Rank Importance Rank Importance Rank Importance Rank
48 Determines appropriate pharmacological, behavioral, and other non-pharmacological treatment modalities in developing a plan of care.
3.34
7
3.24
17
3.24
17
3.51
3
54 Assesses, diagnoses, monitors, coordinates, and manages the health/illness status of patients over time.
3.24
18
3.18
22
3.18
22
3.39
9
50 Incorporates risk/benefit factors in developing a plan of care.
3.33
9
3.24
16
3.24
16
3.42
7
2
Designs and implements a plan of care
to attain, promote, maintain, and/or
restore health.
3.37
5
3.33
8
3.33
8
3.48
4
47 Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses.
3.27
15
3.22
20
3.22
20
3.39
10
86 Functions in a variety of role dimensions; health care provider, coordinator, consultant, educator, coach, advocate administrator, researcher, and leader.
3.41
3
3.63
1
3.63
1
3.26
19
53 Employs appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy.
3.23
20
3.16
24
3.16
24
3.32
16
3
Promotes patient advocacy in patient
interactions and in the selection of treat-
ment modalities.
3.31
11
3.31
10
3.31
10
3.34
15
55 Evaluates results of interventions using accepted outcome criteria, revises the plan of care and consults/refers when appropriate.
3.27
16
3.30
11
3.30
11
3.34
14
1
Verifies diagnoses based on findings.
3.03
31
2.85
47
2.85
47
3.14
25
5
Formulates expected outcomes with
patients, family members, and the
interdisciplinary healthcare team based
on clinical and scientific knowledge.
3.25
17
3.28
13
3.28
13
3.27
17
17 Prescribes, orders, and/or implements pharmacologic and non-pharmacologic interventions, treatments, and procedures for patients and family members, as identified in the plan of care.
3.13
24
2.90
44
2.90
44
3.25
20
49 Uses principles of ethical decision-making in selecting treatment modalities.
3.34
8
3.25
14
3.25
14
3.44
5
9
Plans follow-up visits to monitor patients
and evaluate health/illness care.
3.03
30
2.85
50
2.85
50
3.23
21
14 Incorporates evidence-based research into nursing interventions within the specialty population.
3.31
12
3.37
5
3.37
5
3.20
23
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
APPENDIX E 55
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
CNS
Criticality
All
No Psych/Mental No Psych/Mental
Health
Health/Other
Item #
Activity
Criticality Rank Criticality Rank Criticality Rank
11 Demonstrates critical thinking and diagnostic reasoning skills in clinical decision-making.
15.07
1
14.48
1
14.49
1
38 Assesses, plans, implements, and evaluates health care with other health care professionals/primary care providers to meet the comprehensive needs of patients.
10.40
20
10.59
17
10.81
15
51 Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
12.76
5
12.20
4
12.49
5
65 Maintains clinical records that reflect diagnostic and therapeutic reasoning.
13.12
2
12.04
5
12.75
3
52 Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated.
12.82
4
12.31
3
12.54
4
48 Determines appropriate pharmacological, behavioral, and other non-pharmacological treatment modalities in developing a plan of care.
13.00
3
11.64
6
12.40
6
54 Assesses, diagnoses, monitors, coordinates, and manages the health/illness status of patients over time.
12.66
6
11.57
8
12.29
7
50 Incorporates risk/benefit factors in developing a plan of care.
12.40
9
11.42
11
11.53
11
2
Designs and implements a plan of care
to attain, promote, maintain, and/or
restore health.
12.51
7
11.57
7
11.80
10
47 Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses.
12.25
10
11.51
9
12.27
8
86 Functions in a variety of role dimensions; health care provider, coordinator, consultant, educator, coach, advocate administrator, researcher, and leader.
12.44
8
13.81
2
14.32
2
53 Employs appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy.
11.98
11
10.99
14
11.27
13
3
Promotes patient advocacy in patient
interactions and in the selection of treat-
ment modalities.
11.77
13
11.24
13
11.36
12
55 Evaluates results of interventions using accepted outcome criteria, revises the plan of care and consults/refers when appropriate.
11.86
12
11.50
10
12.03
9
1
Verifies diagnoses based on findings.
10.91
18
9.82
22
9.74
23
No Acute Care
Criticality Rank
15.71
1
10.09
27
13.35
8
14.93
2
13.47
6
14.57
3
14.04
4
13.21
10
13.71
5
13.20
11
11.64
18
13.21
9
12.51
14
12.46
15
11.94
16
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
56 APPENDIX E
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
CNS
Criticality
All
No Psych/Mental No Psych/Mental
Health
Health/Other
Item #
Activity
Criticality Rank Criticality Rank Criticality Rank
5
Formulates expected outcomes with
patients, family members, and the
interdisciplinary healthcare team based
on clinical and scientific knowledge.
11.20
16
11.29
12
11.26
14
17 Prescribes, orders, and/or implements pharmacologic and non-pharmacologic interventions, treatments, and procedures for patients and family members, as identified in the plan of care.
11.74
14
10.13
19
10.22
21
49 Uses principles of ethical decision-making in selecting treatment modalities.
11.34
15
10.00
20
10.42
19
9
Plans follow-up visits to monitor patients
and evaluate health/illness care.
10.91
19
9.21
25
9.18
26
14 Incorporates evidence-based research into nursing interventions within the specialty population.
10.95
17
10.87
15
10.57
18
No Acute Care
Criticality Rank
11.38
20
13.38
7
12.70
12
12.68
13
10.90
23
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
NP
Frequency
All
No Psych/Mental No Psych/Mental
No Acute Care
Health
Health/Other
Item #
Activity
Frequency Rank Frequency Rank Frequency Rank Frequency Rank
47 Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses.
4.77
1
4.83
1
4.83
1
4.79
1
65 Maintains clinical records that reflect diagnostic and therapeutic reasoning.
4.74
2
4.76
2
4.76
2
4.76
3
48 Determines appropriate pharmacological, behavioral, and other non-pharmacological treatment modalities in developing a plan of care.
4.73
3
4.76
3
4.76
3
4.77
2
11 Demonstrates critical thinking and diagnostic reasoning skills in clinical decision-making.
4.67
4
4.67
4
4.67
4
4.70
4
17 Prescribes, orders, and/or implements pharmacologic and non-pharmacologic interventions, treatments, and procedures for patients and family members, as identified in the plan of care.
4.63
5
4.64
5
4.64
5
4.68
5
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
APPENDIX E 57
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
NP
Frequency
All
No Psych/Mental No Psych/Mental
Health
Health/Other
Item #
Activity
Frequency Rank Frequency Rank Frequency Rank
2
Designs and implements a plan of care
to attain, promote, maintain, and/or
restore health.
4.58
6
4.58
8
4.58
8
63 Prescribes medications using principles of pharmacokinetics, drug dosage and routes, indications, interactions, and side/adverse effects.
4.57
7
4.61
6
4.61
6
53 Employs appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy.
4.55
8
4.56
9
4.56
9
50 Incorporates risk/benefit factors in developing a plan of care.
4.48
9
4.47
11
4.47
11
1
Verifies diagnoses based on findings.
4.46
10
4.49
10
4.49
10
58 Performs a comprehensive and/or problem-focused physical examination.
4.42
11
4.58
7
4.58
7
54 Assesses, diagnoses, monitors, coordinates, and manages the health/illness status of patients over time.
4.37
12
4.34
14
4.34
14
18 Writes and transmits correct prescriptions to minimize the risk of errors.
4.36
13
4.38
12
4.38
12
51 Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
4.30
14
4.28
15
4.28
15
52 Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated.
4.29
15
4.27
16
4.27
16
8
Selects, performs, and/or interprets
common screening and diagnostic
laboratory tests.
4.27
16
4.37
13
4.37
13
6
Diagnoses and manages acute and
chronic diseases while attending to the
illness experience.
4.20
17
4.23
17
4.23
17
9
Plans follow-up visits to monitor pa-
tients and evaluate health/illness care.
4.19
18
4.15
18
4.15
18
55 Evaluates results of interventions using accepted outcome criteria, revises the plan of care and consults/refers when appropriate.
4.15
19
4.14
19
4.14
19
3
Promotes patient advocacy in patient
interactions and in the selection of
treatment modalities.
4.14
20
4.14
20
4.14
20
No Acute Care
Frequency Rank
4.64
6
4.64
7
4.58
8
4.52
10
4.53
9
4.44
12
4.41
13
4.48
11
4.35
15
4.28
16
4.25
18
4.27
17
4.40
14
4.14
20
4.25
19
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
58 APPENDIX E
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
NP
Importance
All
No Psych/Mental No Psych/Mental
No Acute Care
Health
Health/Other
Item #
Activity
Importance Rank Importance Rank Importance Rank Importance Rank
47 Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses.
3.77
2
3.79
1
3.79
1
3.79
2
65 Maintains clinical records that reflect diagnostic and therapeutic reasoning.
3.69
6
3.69
7
3.69
7
3.71
6
48 Determines appropriate pharmacological, behavioral, and other non-pharmacological treatment modalities in developing a plan of care.
3.71
5
3.72
5
3.72
5
3.74
4
11 Demonstrates critical thinking and diagnostic reasoning skills in clinical decision-making.
3.78
1
3.78
2
3.78
2
3.79
1
17 Prescribes, orders, and/or implements pharmacologic and non-pharmacologic interventions, treatments, and procedures for patients and family members, as identified in the plan of care.
3.72
4
3.71
6
3.71
6
3.74
5
2
Designs and implements a plan of care to
attain, promote, maintain, and/or restore
health.
3.68
8
3.68
8
3.68
8
3.70
7
63 Prescribes medications using principles of pharmacokinetics, drug dosage and routes, indications, interactions, and side/ adverse effects.
3.77
3
3.77
3
3.77
3
3.78
3
53 Employs appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy.
3.61
11
3.61 11
3.61
11
3.62
11
50 Incorporates risk/benefit factors in developing a plan of care.
3.60
12
3.59 13
3.59
13
3.61
13
1
Verifies diagnoses based on findings.
3.58
14
3.60 12
3.60
12
3.61
12
58 Performs a comprehensive and/or problem-focused physical examination.
3.64
10
3.72
4
3.72
4
3.64
10
54 Assesses, diagnoses, monitors, coordinates, and manages the health/illness status of patients over time.
3.52
18
3.50 19
3.50
19
3.55
17
18 Writes and transmits correct prescriptions to minimize the risk of errors.
3.68
9
3.67 10
3.67
10
3.69
9
51 Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
3.40 25
3.40 25
3.40
25
3.41
27
52 Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated.
3.53 17
3.52 17
3.52
17
3.53
18
8
Selects, performs, and/or interprets com-
mon screening and diagnostic laboratory
tests.
3.49 21
3.52 18
3.52
18
3.48 21
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
APPENDIX E 59
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
NP
Importance
All
No Psych/Mental No Psych/Mental
No Acute Care
Health
Health/Other
Item #
Activity
Importance Rank Importance Rank Importance Rank Importance Rank
6
Diagnoses and manages acute and
chronic diseases while attending to the
illness experience.
3.54 16
3.53 16
3.53
16
3.55 16
9
Plans follow-up visits to monitor patients
and evaluate health/illness care.
3.38 27
3.36 28
3.36
28
3.46 24
55 Evaluates results of interventions using accepted outcome criteria, revises the plan of care and consults/refers when appropriate.
3.49 19
3.49 20
3.49
20
3.50 19
3
Promotes patient advocacy in patient
interactions and in the selection of treat-
ment modalities
3.43 24
3.43 24
3.43
24
3.47 23
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
NP
Criticality
All
No Psych/Mental No Psych/Mental
Health
Health/Other
Item #
Activity
Criticality Rank Criticality Rank Criticality Rank
47 Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to formulate differential diagnoses.
18.13
1
18.27
1
18.35
1
65 Maintains clinical records that reflect diagnostic and therapeutic reasoning.
17.68
4
17.66
4
17.72
4
48 Determines appropriate pharmacological, behavioral, and other non-pharmacological treatment modalities in developing a plan of care.
17.80
3
17.80
2
17.92
2
11 Demonstrates critical thinking and diagnostic reasoning skills in clinical decision-making.
17.82
2
17.80
2
17.82
3
17 Prescribes, orders, and/or implements pharmacologic and non-pharmacologic interventions, treatments, and procedures for patients and family members, as identified in the plan of care.
17.47
6
17.46
6
17.39
6
2
Designs and implements a plan of care to
attain, promote, maintain, and/or restore
health.
17.10
7
17.14
8
17.10
8
63 Prescribes medications using principles of pharmacokinetics, drug dosage and routes, indications, interactions, and side/ adverse effects.
17.60
5
17.59
5
17.68
5
No Acute Care
Criticality Rank
18.26
1
17.84
5
18.07
2
17.97
3
17.74
6
17.41
7
17.88
4
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
60 APPENDIX E
Appendix E.Analysis Excluding Nurses in Psychiatric, Mental Health and Acute Care Settings
NP
Criticality
All
No Psych/Mental No Psych/Mental
Health
Health/Other
Item #
Activity
Criticality Rank Criticality Rank Criticality Rank
53 Employs appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability and efficacy.
16.80
8
16.75
9
16.80
9
50 Incorporates risk/benefit factors in developing a plan of care.
16.41
11
16.42
11
16.40
12
1
Verifies diagnoses based on findings.
16.29
12
16.32
12
16.47
11
58 Performs a comprehensive and/or problem-focused physical examination.
16.71
9
17.26
7
17.34
7
54 Assesses, diagnoses, monitors, coordinates, and manages the health/illness status of patients over time.
15.89
13
15.85
13
15.77
13
18 Writes and transmits correct prescriptions to minimize the risk of errors.
16.60
10
16.56
10
16.67
10
51 Identifies and analyzes factors that enhance or hinder the achievement of desired outcomes for patients and family members.
14.96
17
14.93
17
14.91
17
52 Evaluates patient outcomes in relation to the plan of care and modifies the plan when indicated.
15.49
15
15.46
16
15.38
16
8
Selects, performs, and/or interprets com-
mon screening and diagnostic laboratory
tests.
15.35
16
15.83
14
15.75
14
6
Diagnoses and manages acute and
chronic diseases while attending to the
illness experience.
15.59
14
15.60
15
15.68
15
9
Plans follow-up visits to monitor patients
and evaluate health/illness care.
14.71
19
14.56
21
14.61
21
55 Evaluates results of interventions using accepted outcome criteria, revises the plan of care and consults/refers when appropriate.
14.86
18
14.89
18
14.84
19
3
Promotes patient advocacy in patient
interactions and in the selection of treat-
ment modalities.
14.68
21
14.74
20
14.68
20
No Acute Care
Criticality Rank
16.98
9
16.61
12
16.65
11
16.83
10
16.07
13
17.17
8
15.18
19
15.43
16
15.32
17
15.90
14
15.60
15
14.83
22
15.20
18
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
APPENDIX F 61
Appendix F: Knowledge Questions
Appendix F. Knowledge Questions
Psychiatric & Mental Health Nurses Removed
Knowledge Critical thinking, diagnostic reasoning and clinical decision making Ethics Evidence-based practice and outcome Collaboration, consultation, change agent Professional role development including knowledge of scope of practice Principles of teaching and learning Physiology and pathophysiology Advanced assessment, diagnosis and treatment of health care problems and diseases Health promotion and disease prevention Human diversity and social issues including risk assessment Program planning Research study design and application of results Organizational policy Diagnostic procedural techniques and interpretation/evaluation of results Advanced pharmacology Health care financing and business management
CNS 3.402 3.34 3.336 3.313 3.294 3.121 3.109 2.981 2.967 2.791 2.717 2.697 2.663 2.621 2.615 2.263
Rank
NP CNS NP
3.608
11
3.427 3.308 3.273 3.37 2.84
25 39 4 10 57 6 12
3.511
73
3.585
82
3.388
96
2.947
10 11
2.263
11 16
2.453
12 13
2.441
13 14
3.367
14 8
3.449
15 4
2.38
16 15
Statistically Significant Differences Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
62 APPENDIX F
Appendix F. Knowledge Questions
Psychiatric, Mental Health, & Other Nurses Removed
Rank
Knowledge Critical thinking, diagnostic reasoning and clinical decision making
CNS 3.399
NP CNS NP
3.601
11
Evidence-based practice and outcome Ethics Collaboration, consultation, change agent Professional role development including knowledge of scope of practice Physiology and pathophysiology
3.338 3.334 3.305 3.276 3.105
3.295 3.412 3.269 3.363 3.505
29 35 4 10 57 63
Principles of teaching and learning
3.092
2.83
7 12
Advanced assessment, diagnosis and treatment of health care problems and diseases 3.035 3.579
82
Health promotion and disease prevention
3.025
3.39
96
Human diversity and social issues including risk assessment Research study design and application of results
2.846 2.701
2.936 2.434
10 11 11 14
Advanced pharmacology
2.69 3.445
12 4
Diagnostic procedural techniques and interpretation/evaluation of results
2.649 3.357
13 8
Program planning
2.649 2.238
14 16
Organizational policy
2.64 2.442
15 13
Health care financing and business management
2.282
2.38
16 15
Statistically Significant Differences Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant Statistically Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
APPENDIX F 63
Appendix F. Knowledge Questions
Nurses in Acute Care Settings Removed
Knowledge Critical thinking, diagnostic reasoning and clinical decision making Evidence-based practice and outcome Ethics Collaboration, consultation, change agent Professional role development including knowledge of scope of practice Physiology and pathophysiology Principles of teaching and learning Advanced assessment, diagnosis and treatment of health care problems and diseases Health promotion and disease prevention Human diversity and social issues including risk assessment Research study design and application of results Advanced pharmacology Diagnostic procedural techniques and interpretation/evaluation of results Program planning Organizational policy Health care financing and business management
CNS 2.35 2.38 3.17 2.35 3.41 3.27 3.19 2.98 3.16 2.94 3.03 3.14 3.43 2.31 2.93 2.68
Rank
NP CNS NP
3.61
14 13
3.57
13 12
3.49
5 11
3.46
15 10
3.45
29
3.44
35
3.37
46
3.32
9 16
Statistically Significant Differences
3.28
6 2 Statistically
Significant
3.25
10 7 Statistically
Significant
2.98
8 8 Statistically
Significant
2.85
7 15 Statistically
Significant
2.43
14
2.43
16 1
2.42
11 3
2.26
12 14 Statistically
Significant
National Council of State Boards of Nursing, Inc. (NCSBN) | 2007
64 REFERENCES References 1 Bankert, M. (1989). Watchful care: A history of America's nurse anesthetists. New York: Continuum. 2 Rooks, J. (1997). Midwifery and childbirth in America. Philadelphia: Temple University Press. 3 Redekopp, MA. (1997). Clinical nurse specialist role confusion: The need for identity. Clinical Nurse Specialist, 11(2): 87-91. 4 Scott, RA. (1999). A description of the roles, activities, and skills of clinical nurse specialists in the United States. Clinical Nurse Specialist, 13(4): 183-189. 5 NCSBN. (2002). Profiles of Member Boards. Chicago: National Council of State Boards of Nursing, Inc. 6 Kane, M. (1997). Model-based practice analysis and test specifications. Applied Measurement in Education. 10(1), 5-18. 7 U.S. Department of Health and Human Services, Health Resources & Services Administration. (1998). Curriculum Guidelines & Regulatory Criteria for Family Nurse Practitioners Seeking Prescriptive Authority to Manage Pharmacotherapeutics in Primary Care, Summary Report. Washington, D.C.: Author. 8 American Association of Colleges of Nursing. (1996). The essentials of master's education for advanced nursing practice. Washington, D.C.: Author. 9 National Organization of Nurse Practitioner Faculties. (2000). Domains and Core Competencies of Nurse Practitioner Practice: Newly Revised. Washington, DC: Author. 10 National Organization of Nurse Practitioner Faculties in partnership with The American Association of Colleges of Nursing. (2002). Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric, and Women's Health. Submitted to the U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions Division of Nursing. 11 National Association of Clinical Nurse Specialists. (2004). Statement on Clinical Nurse Specialist Practice and Education. 2nd Edition. Harrisburg, PA: Author. 12 American Nurses' Association & American Association of Critical Care Nurses. (1995). Standards of Clinical Practice and Scope of Practice for Acute Care Nurse Practitioners. 13 U.S. Department of Health and Human Services, Health Resources & Services Administration. (1998). Curriculum Guidelines & Regulatory Criteria for Family Nurse Practitioners Seeking Prescriptive Authority to Manage Pharmacotherapeutics in Primary Care, Summary Report. Washington, D.C.: Prepared by National Council of State Boards of Nursing and National Organization of Nurse Practitioner Faculties. National Council of State Boards of Nursing, Inc. (NCSBN) | 2007

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