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2006;15:130-148Am J Crit Care

Deborah Becker, Roberta Kaplow, Patricia M. Muenzen and Carol HartiganNurses: American Association of Critical-Care Nurses Study of PracticeActivities Performed by Acute and Critical Care Advanced Practice

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130 AMERICAN JOURNAL OF CRITICAL CARE, March 2006, Volume 15, No. 2

BACKGROUND Accreditation standards for certication programs require use of a testing mechanismthat is job-related and based on the knowledge and skills needed to function in the discipline.

OBJECTIVES To describe critical care advanced practice by revising descriptors to encompass the work of both acute care nurse practitioners and clinical nurse specialists and to explore differences in the practice of clinical nurse specialists and acute care nurse practitioners. METHODS A national task force of subject matter experts was appointed to create a comprehensivedelineation of the work of critical care nurses. A survey was designed to collect validation data on 65advanced practice activities, organized by the 8 nurse competencies of the American Association of Crit-ical-Care Nurses Synergy Model for Patient Care, and an experience inventory. Activities were rated onhow critical they were to optimizing patients outcomes, how often they were performed, and toward which sphere of inuence they were directed. How much time nurses devoted to specic care problemswas analyzed. Frequency ratings were compared between clinical nurse specialists and acute care nurse

practitioners. R ESULTS Both groups of nurses encountered all items on the experience inventory. Clinical nurse spe-cialists were more experienced than acute care nurse practitioners. The largest difference was that clini-cal nurse specialists rated as more critical activities involving clinical judgment and clinical inquirywhereas acute care nurse practitioners focused primarily on clinical judgment. CONCLUSIONS Certication initiatives should reect differences between clinical nurse specialists and acute care nurse practitioners. (American Journal of Critical Care. 2006;15:130-148)

ACTIVITIES P ERFORMED BY ACUTE AND C RITICAL C AREADVANCED P RACTICE NURSES : A MERICAN ASSOCIATIONOF C RITICAL -C ARE NURSES STUDY OF P RACTICE

To purchase electronic or print reprints, contact The InnoVision Group, 101Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050(ext 532); fax, (949) 362-2049; e-mail, [email protected].

By Deborah Becker, MSN, CRNP, BC, Roberta Kaplow, RN, PhD, Patricia M. Muenzen, MA, and Carol Hartigan, RN, MA. From University of Pennsylvania School of Nursing, Philadelphia, Pa (DB), DeKalb Medical Center, Decatur, Ga (RK), Professional Examination Service, New York, NY (PMM), and AACN Certication Corpora-tion, Aliso Viejo, Calif (CH).

A n essential component of a certication pro-gram is the ability to use a testing mechanismthat is job related and based on the currentknowledge and skills needed to function in the discipline. Between 2001 and 2003, Professional Exami-nation Service undertook a comprehensive study of the practice of acute and critical care nursing on

behalf of the AACN Certification Corporation, the

credentialing arm of the American Association of Critical-Care Nurses (AACN). The study was under-taken in support of all of the corporations current and

future nursing certification initiatives in acute and critical care nursing.This article presents the studys findings about

advanced practice nurses working with acute and crit-ically ill patients. In this report, we describe and dis-cuss the activities performed by advanced practicenurses, the spheres of influence upon which theydirect their practice, and the percentage of time theydevote to specic problems related to patients care.

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

BackgroundThe specialty certication programs in neonatal,

pediatric, and adult critical care nursing were last

revised by using data collected in a 1992 role delin-eation study of critical care nursing practice. 1 In thatstudy, subject matter experts delineated and validated the domains and tasks in critical care nursing practiceand the associated knowledge and skills. Eight sys-temscardiovascular, pulmonary, endocrine, hema-tology/immunology, neurology, gastrointestinal, renal,and multisystemprovided the context for the delin-eation of more than 75 problems related to patientscare. Test specifications were published in terms of

percentages of questions related to systems, problemswith patients care, and associated knowledge and

skills.In a 1997 study, subject matter experts developed 5-point rating scales to behaviorally anchor the mid-

point and endpoints of a continuum describing eachcharacteristic of patients and nurses as outlined in theAACN Synergy Model for Patient Care (described inthe next section). The 5-point rating scales for thecharacteristics of patients were developed to includedescriptors for the most compromised patients (level1) and the least compromised patients (level 5), aswell as for midpoint patients (level 3). Similarly, eachrating scale for characteristics of nurses included descriptors reflecting novice (level 1), competent(level 3), and expert (level 5) performance by a criti-cal care nurse providing direct care to a patientcon-sistent with the pattern of skill acquisition described

by Benner. 2

In 1998, Professional Examination Service under-took a study to delineate the practice of acute and criti-cal care CNSs in terms of the 8 competencies of nursesof the Synergy Model. Expansion of the SynergyModel to reect CNS practice involved the identica-tion of activities performed by CNSs. These activitieswere labeled level 7 competencies. 3,4 No study, to date,had been done to delineate the roles and responsibili-ties of the nurse practitioner within the context of theSynergy Model.

The AACN Synergy Model for Patient CareDuring the 1990s, the AACN Certication Corpo-

ration convened a think tank that developed a conceptualframework for certied practice. The framework was

based on the premise that certied practice is more thantasks and should be grounded in nurses meeting the

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

The central concept of the AACN Synergy Modelfor Patient Care is that the needs or characteristics of

patients and patients families inuence and drive thecharacteristics or competencies of nurses. 6 Synergyresults when the needs and characteristics of a patient,clinical unit, or system are matched with a nursescompetencies. Further, when patient characteristicsmatch nurse characteristics, patients outcomes areoptimized. 7

Each patient brings a unique set of characteristics tothe healthcare situation. Among the many characteris-tics, 8 are consistently associated with patients who areexperiencing critical events: resiliency, vulnerability, sta-

bility, complexity, resource availability, participation incare, participation in decision making, and predictability(Table 1). These characteristics underlie the needs of the

patients. 5,8 Each characteristic exists on a continuumfrom low (level 1) to high (level 5) (Table 2).

Depending on the needs of each patient, certaincompetencies of nurses are required for providing careto acute and critically ill patients and their families.

Table 1 Characteristics of patients from the American Asso-ciation of Critical-Care Nurses Synergy Model for PatientCare

Characteristic

Resiliency

Vulnerability

Stability

Complexity

Resource availability

Participation in care

Participation indecision making

Predictability

Denition

Patients capacity to return to arestorative level of functioning byusing compensatory and coping

mechanismsSusceptibility to actual or potentialstressors that may adversely affectpatients outcomes

Ability to maintain a steady-stateequilibrium

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

Extent of resources (personalnancial, social, psychological,technical, etc) that the patient, thepatients family, and the communitybring to the current situation

Extent to which the patient andthe patients family engage in care

Extent to which the patient and thepatients family engage in decisionmaking with respect to care

A summative characteristic thatallows one to expect a certaincourse of illness

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As with the patient characteristics, each competencyexists on a continuum from low (level 1) to high (level5). The 8 competencies reect an integration of knowl-edge, skills, and experience of the nurse. The nursecharacteristics of the Synergy Model are clinical judg-ment, advocacy and moral agency, caring practices, col-laboration, systems thinking, response to diversity,clinical inquiry, and facilitator of learning 5,8 (Table 3).

Synergy occurs and optimal outcomes may resultwhen the competencies of the nurse complement theneeds of the patient. Implicit in the interactions between

patients and nurses is the notion that the patients withthe greatest level of need require the nurses with thehighest degree of competency.

The Synergy Model was initially based on 5assumptions 9:

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

2. Each patient, the patients family, and thecommunity contribute to providing a contextfor the nurse-patient relationship.

3. Patients can be described by a number of characteristics. All characteristics are con-nected and contribute to each other. Charac-teristics cannot be looked at in isolation.

4. Nurses can be described in a number of

Table 2 Clinical continuum of characteristics of patients from the American Association for Critical-Care Nurses SynergyModel for Patient Care

Characteristic

Resiliency

Vulnerability

Stability

Complexity

Resource availability

Participation in care

Participation indecision making

Predictability

Explanation of continuum

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

Level 3: Moderately resilientable to mount a moderate response, able to initiate some degree ofcompensation, moderate reserves

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

Level 1: Highly vulnerablesusceptible, unprotected, fragileLevel 3: Moderately vulnerablesomewhat susceptible, somewhat protectedLevel 5: Minimally vulnerablesafe, out of the woods, protected, not fragile

Level 1: Minimally stablelabile, unstable, unresponsive to therapies, high risk of deathLevel 3: Moderately stableable to maintain steady state for limited period of time, some responsiveness

to therapiesLevel 5: Highly stableconstant, responsive to therapies, low risk of death

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

Level 3: Moderately complexmoderately involved patient-family dynamicsLevel 5: Minimally complexstraightforward, routine patient-family dynamics, simple or clear-cut,

typical presentation

Level 1: Few resourcesnecessary knowledge and skills not available, necessary nancial support notavailable, minimal personal/psychological supportive resources, few social systems resources

Level 3: Moderate resourceslimited knowledge and skills available, limited nancial support available,limited personal/psychological supportive resources, limited social systems resources

Level 5: Many resourcesextensive knowledge and skills available and accessible, nancial resources readilyavailable, strong personal/psychological supportive resources, strong social systems resources

Level 1: No participationpatient and patients family unable or unwilling to participate in careLevel 3: Moderate level of participationpatient and patients family need assistance in careLevel 5: Full participationpatient and patients family fully able to participate in care

Level 1: No participationpatient and patients family have no capacity for decision making, requiressurrogacy

Level 3: Moderate level of participationpatient and patients family have limited capacity, seeksinput or advice from others in decision making

Level 5: Full participationpatient and patients family have capacity and make decisions for selvesLevel 1: Not predictableuncertain, uncommon population of patients or uncommon illness, unusual

or unexpected course, does not follow critical pathway or no critical pathway developedLevel 3: Moderately predictablewavering, occasionally noted population of patients or occasionally

occurring illnessLevel 5: Highly predictablecertain, common population of patients or common illness, usual and

expected course, follows critical pathway

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

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

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

In February 2002, a practice analysis task forcewas created by the AACN Certication Corporation.The group consisted of advanced practice nurses fromacross the United States who worked in a variety of

practice settings. The task force expanded the assump-tions of the Synergy Model to include 4 more assump-tions 5,10 :

1. Nurses create the environment for the careof patients. The context or environment of care also affects what a nurse can do.

2. Impact areas are interrelated, and the nature of the interrelatedness may change as a functionof experience, situation, or setting changes.

3. Nurses may work to optimize outcomes for patients, patients families, healthcare pro-viders, and the healthcare system/organization.

4. Nurses bring their background to each situ-ation, including various levels of education/knowledge and skills/experience.

Outcomes are considered patients conditionsmeasured along a continuum. 6 Six major quality indi-cators were identied: (1) satisfaction of patients and their families, (2) rate of adverse incidents, (3) com-

plication rate, (4) adherence to the discharge plan, (5)mortality rate, and (6) each patients length of stay.

The Synergy Model was congruent with outcomesderived from 3 sources: patients, nurses, and thehealthcare system (see Figure). Outcomes derived fromthe patient include functional changes, behavioralchanges, trust, satisfaction, comfort, and quality of life.Outcomes derived from nursing competencies include

physiological changes, the presence or absence of complications, and the extent to which treatment goals werereached. Outcome data derived from the healthcare sys-tem include readmission rates, length of stay, and costutilization per case. 5,6,8

Advanced Practice NursingAdvanced practice nursing is the application of an

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

practice role.More than 2 decades ago, the initial delineation of

CNS practice was based on job specications or roles.

Table 3 Characteristics of nurses from the American Association of Critical-Care Nurses Synergy Model for Patient Care

Characteristic

Clinical judgment

Advocacy and

moral agency

Caring practices

Collaboration

Systems thinking

Response to diversity

Clinical inquiry

Facilitator of learning

Denition

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

Working on anothers behalf and representing the concerns of patients, patients families, and/or

nursing staff and serving as a moral agent in identifying and resolving ethical and clinical concernswithin or outside the clinical setting.

A constellation of nursing activities that creates a compassionate, supportive, and therapeutic environmentwith patients and staff. The aim is to promote comfort, heal, and prevent unnecessary suffering.

Working with others, including physicians, patients families, and other healthcare providers, in a waythat promotes and encourages each persons contributions toward achieving optimal, realistic goalsfor the patient. Collaboration involves intradisciplinary and interdisciplinary work with colleagues.

A body of knowledge and tools that allow nurses to manage whatever environmental and systemresources exist for the patient, the patients family, and staff within or across healthcare andnonhealthcare systems.

The sensitivity to recognize, appreciate, and incorporate differences into the provision of care.Differences may include, but are not limited to, individuality, cultural differences, spiritual beliefs,sex, race, ethnicity, disability, family conguration, lifestyle, socioeconomic status, age, values,

and alternative medicine involving patients families and members of the healthcare team.The ongoing process of questioning and evaluating practice and providing informed practice andcreating practice changes through research utilization and experiential knowledge.

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




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

published subroles and competencies of the CNS weremodied to include clinical practice and direct care of

patients, consultation, education, research, collabora-tion, and clinical leadership. 7,13

Consistent with the National Association of Clini-cal Nurse Specialists Statement on Clinical NurseSpecialist Practice and Education, 14 the roles of a CNSare currently described on the basis of 3 spheres of

inuence: (1) patients and patients families, (2) nurse-to-nurse, and (3) system. 4,14,15

The multifaceted role of a CNS who cares for acuteand critically ill patients and their families, workingwithin an organization and with nursing staff, can also

be described according to the Synergy Model. Themodel aligns not only the 8 characteristics of patientsand the 8 competencies of nurses but also the role of the CNS in relation to the 3 spheres of influence. 16

CNSs manage, support, and coordinate the care of acutely and critically ill patients with episodic illness or acute exacerbation of chronic illness 7 while addressing

both system and staff interaction. In Standards of Practice and Professional Performance for the Acuteand Critical Care Clinical Nurse Specialist, 17 AACNdelineates several activities of CNSs in relation to eachof the competencies inherent in the Synergy Model and the 3 spheres of inuence.

ACNP is a second advanced practice role that has

existed for approximately 12 years. In the early 1990s,the nursing profession recognized that the needs of patients were not being adequately met. 18 It becameevident that nurse practitioners had a scope of practicethat could be maximized to meet both the medical and nursing needs of these vulnerable acutely ill patients. 19,20

The American Nurses Association and the AACNformed a task force of experts to delineate the scopeof practice for adult ACNPs. According to the docu-

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

Nurse

competencies

Patientcharacteristics

Functional change,behavioral change,

trust, ratings, satisfaction,comfort, quality of life

Patient

SystemRecidivism,costs/resourceutilization

Physiologicalchanges,presence or

absence ofcomplications,extent to whichcare or treatment

objectiveswere attained

Nurse




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ment dening the scope, 21 the purpose of the ACNPis to provide advanced nursing care across the contin-uum of acute care services to patients who are acutelyand critically ill. ACNPs focus on the stabilization of acute medical problems, prevention and managementof complications, comprehensive management of injury and/or illness, and restoration to maximal levels

of health within an interdisciplinary and collaborativehealthcare team. 21

Since development of the ACNP scope and stan-dards and the subsequent offering of a national certica-tion examination by the American Nurses CredentialingCenter (ANCC) starting in 1996, Kleinpell has surveyed those ACNPs who sought certification to determine

practice habits, practice environments, and emergingroles. 22-26 Since 1997, Kleinpells reporting of longitudi-nal survey results has served as a means of keeping

practitioners, educators, administrators, and colleaguesinformed of changes in the role. At the inception of therole, it was thought that ACNPs would work primarilyin intensive care units (ICUs). Results of Kleinpellsmost recent survey 26 indicate that most ACNPs dowork in ICUs; however, nearly 50% of the respondentsreported a practice environment other than the traditionalICU or urgent/acute care practice setting. Although the

practice setting may vary among ACNPs, the mainfocus of their practice remains direct management of

patients care, with 85% to 88% of time reportedly spenton this responsibility. 26

Recognizing the need for consensus on the corecompetencies of ACNPs, the National Organization of

Nurse Practitioner Faculties convened a national panelof ACNPs to identify ACNP competencies. The paneldescribed entry-level competencies for graduates of masters and post-masters ACNP programs. 27 The

panels report describes for educators, practitioners,and the public the unique philosophy of ACNPs and theneeds of the populations served. Further, the descrip-tions of the competencies include the role componentsof ACNPs within the 7 core domains outlined in thesection on domains and core competencies of nurse

practitioner practice of the same document. 27

Research Design and MethodThe practice analysis task force of the AACN

Certification Corporation was conducting the studyreported in this article at the same time as the compe-tencies were being developed by the National Organiza-tion of Nurse Practitioner Faculties. Advanced practicenursing in acute and critical care has existed for morethan 20 years. However, no study had been conducted on a national level to dene the activities of both CNSsand ACNPs for the purposes of certication. The goals

of the study we report here were to dene the uniqueactivities performed by ACNPs and to conrm that CNSactivities have not changed.

Specic aims of the study were to obtain criticalityand frequency ratings for each of 65 advanced practiceactivities, as determined by the practice analysis task force; compare the spheres of inuence of the individ-

ual activities when performed by either the CNS or ACNP; compare the percentage of time that CNSs and ACNPs devote to specic problems related to patientscare; and obtain frequency ratings for the items on theexperience inventory that are unique to critical care.

Development of a ComprehensiveDescription of Critical Care Nursing PracticeSubject Matter Expert Committee

The standard approach to job analysis used bylicensure and certication agencies involves 2 phases:(1) obtaining and describing job information and (2)

validating the job description. The second phase of the job analysis is usually accomplished by surveying per-sons doing the job. In the following section, we describethis process as it was undertaken by AACN. 28

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

bers were drawn from rural, suburban, and urban practicesettings across the United States.

The task force met 4 times during the course of the project. The focus was on developing a comprehensivedelineation of practice in acute and critical care. At eachmeeting, time was spent both in full-group discussionsand in small-group work. Two nurse staff membersfrom the AACN Certication Corporation attended allmeetings of the task force. Staff from ProfessionalExamination Service, the corporations testing com-

pany at the time, facilitated all of the meetings.

Sampling PlanA sampling plan was designed to permit compari-

son of the populations of patients and the techniques and tools of advanced practice nurses and to allow validationof the competencies required for advanced level practicein acute and critical care nursing. The CNS sample con-sisted of all holders of the CCNS credential (N= 332)




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plus 168 holders of the CCRN credential who indicated that they were working as CNSs. The ACNP sampleconsisted of 500 ACNPs selected randomly from the

population of currently certied ACNPs. A total of 75%of this combined CNS/ACNP pool received the Surveyof Advanced Practice in Acute and Critical Care Nurs-ing, and 25% of the pool received the Survey of Patient

Care Problems in Acute and Critical Care.

MeasuresThe Survey of Advanced Practice in Acute and

Critical Care Nursing was designed to collect data thatwould validate advanced practice activities, the 8competencies of nurses, and the experience inventory.For each of the 65 advanced practice activities (Table 4),organized according to the 8 competencies of nursesof the Synergy Model, 3 rating scales were used:

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

1 = Not critical2 = Minimally critical3 = Moderately critical4 = Highly critical

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

practitioner?1 = Never 2 = Less than once a month3 = At least once a month, but less than every

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

a week 5 = At least 3 times a week

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

1 = Individual patients2 = Populations of patients3 = Nursing staff 4 = Other disciplines, organizations, or systems

Complementary Data Collection InitiativesThree additional data collection initiatives were

conducted to complement and extend the work of the practice analysis task force: focus panels, critical inci-dent telephone interviews, and independent reviews.

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

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

Critical Incident Telephone Interviews. Each mem- ber of the task force was asked to nominate ACNPs and CNSs who would be willing to participate in a telephone

interview. Nomination parameters included emphasis oncreating a diverse pool of interviewees with experienceworking with different populations of patients (neonatal,

pediatric, and adult) and nurses working in diverse geo-graphical areas. Interviewees were contacted by e-mailand telephone to establish a time for the interview and were sent materials to review. All interviewees received the list of problems related to patients care that wasused in the CCNS examination program and were asked to review the list appropriate to the age of the patientswith whom they worked. CNSs and ACNPs received theadvanced practice competencies.

A total of 21 interviews were conducted in June2002. Each interviews was conducted by telephoneand lasted from 25 to 50 minutes. A protocol was cre-ated to guide the interviews.

Independent Reviews. Subject matter experts inde- pendently reviewed the various aspects of the practicedelineation. In September 2002, materials for inde-

pendent review were mailed. The advanced practicecompetency list was disseminated to 9 CNSs and 8ACNPs. The advanced practice competencies werereturned by 3 CNSs and 4 ACNPs.

ResultsSurvey of Advanced Practicein Acute and Critical Care Nursing

The Survey of Advanced Practice in Acute and Critical Care Nursing was distributed to 750 advanced

practice nurses (375 CNSs and 375 ACNPs) and wascompleted and returned by 261 respondents, for a 35%response rate. The group of respondents comprised 158CNSs (42% response rate), 77 ACNPs (21% responserate), and 26 individuals who worked in either a blended CNS/ACNP role or in an other role. Because the pri-mary goal of data analyses was to compare and contrastthe practice of CNSs and ACNPs, the 26 respondentswho could not be assigned unambiguously to either group were eliminated from subsequent quantitativeanalysis. Thus, the results reported in the remainder of this section are for the 158 CNSs and 77 ACNPs whoresponded to the survey.

Characteristics of the Sample Nearly all ACNP respondents (95%) indicated

that they worked in the role of a nurse practitioner;




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

Characteristic

Clinical judgment

Advocacy and moralagency

Caring practices

Activities of advanced practice nurses

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

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

Develops, implements, evaluates, and modies plans of care for individual patients, patients families,

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

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

Develops proactive interventions; implements/directs others to act on actual or potential clinical problems

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

Formally and informally evaluates the clinical practice of other members of the healthcare team (eg,nursing staff, medical staff, other healthcare providers)

Evaluates ones own clinical practice through self-reection and feedback from others

Facilitates patients and patients families, healthcare professionals, and payors to understand a broadperspective (ie, the big picture)

Elicits comprehensive history and performs physical examinations on the basis of each patients initial signsand symptoms

Develops a list of differential diagnoses on the basis of ndings obtained from each patients medicalhistory and ndings on physical examination

Orders appropriate diagnostic studies and interprets ndings to manage patients care in collaborationwith physicians and other members of the healthcare team as necessary

Initiates appropriate referrals and performs consultations

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

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

Participates in problem solving to anticipate and prevent recurrences of dissatisfaction or concernamong patients or patients families

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

Promotes an environment for ethical decision making and advocacy for patients

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

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

Empowers patients and patients families to act as their own advocates

Integrates concerns and value systems of each patient and the patients family, nursing staff, and otherhealthcare team members, administrators, and payors into the patients plan of care

Promotes a caring and supportive environmentSupports the implementation of complementary therapies

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

Cares for the caregivers (eg, conict resolution, debrieng, crisis intervention)

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

Interprets and communicates needs of complex patients and their families and administrative needs toother caregivers

continued




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Table 4 continued

Characteristic

Collaboration

Systems thinking

Response todiversity

Clinical inquiry


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

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

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

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

Serves as a role model, teacher, coach, and mentor for both professional leadership and accountabilityfor nursings role within the healthcare team and community

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

Facilitates development, implementation, and evaluation of professional practice models for nursing

Creates, coordinates, implements, and evaluates formal and informal intradisciplinary andinterdisciplinary education to improve patients outcomes and quality of care

Interprets and facilitates integration of organizational mission, goals, and systems into practices related topatients care

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

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

Identies and communicates resources, both internal and external (eg, consultants, referrals, communityprograms, and other healthcare systems) to optimize outcomes for patients and patients families

Develops, implements, and evaluates strategies to optimize outcomes for patients , patients families,and payors

Develops strategies to facilitate transitional movement of patients through the healthcare system

Continually evaluates the care delivery model and recommends modications based on outcomes data

Facilitates processes of change within the healthcare system to provide evidence-based, cost-effective care

Models and mentors innovative systems thinking and resource use among the healthcare team

Identies diversity issues and facilitates awareness of these issues

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

Serves as a role model, teacher, coach, and/or mentor for acceptance of and responsiveness to diversity

Promotes and incorporates research and experiential knowledge into plans of care related to diversepopulations

Identies clinical problems amenable to research

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

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

research, and experiential knowledgeDevelops processes to evaluate outcomes data

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

Critiques research ndings and determines applicability to practice

Communicates research results and develops a means to incorporate research ndings into practice

Reviews, evaluates, and facilitates incorporation of new products and technologies into practice

continued




11/20

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

primary role was as a staff nurse.The most typical employment setting for both CNS

respondents and ACNP respondents was communitynonprot hospitals; 50% of CNS respondents and 26%of ACNP respondents worked in that setting. About onefourth of both groups worked at a university medicalcenter. Ten percent of the ACNP respondents worked in

private industry, whereas no CNS respondents worked in that setting. Finally, ACNP respondents were morelikely than CNS respondents to work in a for-profitcommunity hospital and in other settings.

The type of unit(s) worked in as the primaryemployment setting of CNS respondents and ACNPrespondents was obtained. CNS respondents were morethan twice as likely as ACNP respondents to work in amedical ICU, neuro/neurosurgical ICU, progressivecare unit, surgical ICU, or trauma unit. ACNP respon-dents were more than twice as likely as CNS respon-dents to work in catheterization laboratories, burn

units, medical cardiology unit, outpatient clinics, pri-vate practice, subacute care and other units (Table 5).In addition, ACNPs primarily cared for patients whowere adults (60%) and geriatric (22%). For CNS respon-dents, 72% of the patients cared for were adults and 15% were geriatric.

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

respondents were women. The CNS respondents weremore experienced than the ACNP respondents. CNSrespondents had a mean of 22 years of experience, 19years working in acute/critical care, and 9 years as aCNS. ACNPs had a mean of 16 years of experience,13 years in acute/critical care, and 5 years as an ACNP.A total of 86% of the CNS respondents and 76% of the ACNP respondents indicated that they were 35 to54 years old. However, the ACNP respondents were 4times as likely to indicate they were 25 to 34 years old (24% of ACNPs and 6% of CNSs). No respondentsfrom either cohort were less than 25 years old or morethan 65 years old. The CNS sample was slightly older than the ACNP sample, consistent with the data on yearsof experience.

For the highest degree earned by respondents, 74%of the CNS respondents indicated they had earned amasters degree as a CNS; 8%, an unspecied mastersdegree; and 7%, a doctorate. No more than 3% indi-cated any other advanced degree earned. Of the ACNPrespondents, 65% indicated that they had earned a mas-ters as an ACNP; 14% earned 2 masters 1 as a CNSand 1 as an ACNP, and 14% were educated as ACNPsin a post-masters certicate program. No more than 3%of the respondents indicated earning any other advanced degree.

Table 6 indicates the states or territories where CNS

and ACNP respondents practice. The CNS respondentsworked in 33 different jurisdictions. California con-tributed the largest percentage of CNS respondents(12%). Another 5 states (Illinois, Minnesota, Missouri,

New Jersey, and Texas), contributed 6% each, and Ohiocontributed 5%. The ACNP respondents worked in 27different jurisdictions. A total of 8% each worked in Illi-nois and Texas, 6% worked in Maryland, and 5% eachworked in Arkansas, New York, Pennsylvania, South

Table 4 continued

Characteristic

Facilitator oflearning


Conducts needs assessment before developing educational plans and programs

Develops, implements, and evaluates programs on the basis of the needs of learners

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

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

Facilitates and/or mentors professional advancement of nursing staff

Deliver formal and informal intradisciplinary and interdisciplinary education to improve patientsoutcomes and quality of care

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




12/20

Table 5 Type of unit(s) reported as primary employment set-ting by clinical nurse specialists (CNSs) and acute care nurse

practitioners (ACNPs)*

Unit

Acute hemodialysis

BurnCardiac rehabilitation

Cardiac surgery/operatingroom

Cardiovascular/surgical ICU

Catheterization laboratory

CCU

Combined adult/pediatric ICU

Combined ICU/CCU

Corporate industry

Critical care transport/ight

Emergency department

General medical/surgical

Home care ICU

Interventional cardiology

Long-term care

Medical cardiology

Medical ICU

Neonatal ICU

Neurological/neurosurgical ICU

Oncology unit

Operating room

Outpatient clinic

Pediatric ICU

Private practice

Progressive care

Recovery room/PACU

Respiratory ICU

Step-down unit

Subacute care

Surgical ICU

Telemetry unit

Trauma

Other

CNS (n = 158) ACNP (n = 77)

%

1

43

8

27

19

26

1

14

0

0

19

12

0

12

5

26

16

0

8

5

3

17

1

14

6

5

0

26

10

16

27

4

30

1

32

6

21

15

20

1

11

0

0

15

9

0

9

4

20

12

0

6

4

2

13

1

11

5

4

0

20

8

12

21

3

23

%

2

15

6

27

8

23

4

24

0

1

14

13

0

9

1

11

27

6

12

2

0

3

6

1

15

8

5

21

1

30

31

13

15

3

28

9

42

12

36

7

38

0

2

22

21

0

15

1

17

42

9

19

3

0

4

10

1

23

12

8

33

2

48

49

21

24

*Responses do not total 100% because multiple responses werepermitted.

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

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

State/territory

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexas

UtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

CNS (n = 158) ACNP (n = 77)

%

300511300430080000406341330000405404105005058

0150010

200411200320060000305231220000304303104004046

0140010

%

2010

123110440061011103436160000614305124000026

0013031

3010

19511067009101120565919000092650813600003

10

0025051

No. No.

No. No.




13/20

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

Criticality and FrequencyThe list of 65 advanced practice nursing activities

performed in the care of acutely and critically ill patientsis organized within the 8 characteristics of nurses of theSynergy Model as shown in Table 4. Respondents wereasked to rate the criticality and frequency of each activity.

Criticality describes how critical the activity is tooptimizing the outcomes for acute and critically ill

patients. The mean criticality rating for each nursecharacteristic for CNS and ACNP respondents wasobtained. The criticality ratings for the CNS respon-dents indicated that the 8 characteristics of nurses are

generally moderately to highly critical to optimizingoutcomes for acute and critically ill patients. Withonly a single exception, the criticality ratings of theACNP respondents were slightly lower than those of the CNS respondents. For collaboration, both the CNSand the ACNP respondents rated the characteristic asmoderately to highly critical.

The advanced practice activities that the CNSrespondents rated highest on the criticality scale wereassociated with the characteristics of clinical judg-ment and clinical inquiry. The advanced practiceactivities that ACNP respondents rated highest on thecriticality rating scale were associated with clinical

judgment and reected the primary role of ACNPs indirectly providing care to patients (Tables 7 and 8).

Table 7 Activities rated most critical by clinical nurse specialists (mean score on the criticality scale = 3.5)

Activity

Clinical judgment Synthesizes, interprets, makes decisions and recommendations, and evaluates responses on the basis of complex, sometimesconicting, sources of data

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

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

Caring practicesPromotes a caring and supportive environment

Facilitator of learningPromotes value of lifelong learning and evidence-based practice while continually acquiring knowledge and skills needed toaddress questions arising in practice to improve patients care

Clinical inquiry Evaluates current and innovative practices in patients care on the basis of evidence-based practice, research, and experientialknowledge

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

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

Activity

Clinical judgment Orders appropriate diagnostic studies and interprets ndings to manage patients care in collaboration with physicians and othermembers of the healthcare team as necessary

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

Elicits comprehensive history and performs physical examinations on the basis of each patients initial signs and symptoms

Develops a list of differential diagnoses on the basis of ndings obtained from each patients medical history and ndings onphysical examination

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


Advocacy and moral agency Empowers patients and patients families to act as their own advocates




14/20

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

Of the 65 activities, both the CNS and ACNPrespondents performed all but 1 activity at least once amonth. The remaining activity, Performs invasive pro-cedures (eg, placement of pulmonary artery catheters,central venous catheters, arterial catheters; thoracente-sis; lumbar punctures), was performed less than oncea month by the CNS respondents. However, 2% of theCNSs who responded reported performing invasive

procedures, although much less often then the ACNPrespondents (Table 9).

Spheres of InuenceThe Survey of Patient Care Problems in Acute and

Critical Care Nursing Practice was conducted to col-lect data that would validate the 65 advanced clinicalactivities identied by the practice analysis task force.Each respondent was asked to assign a sphere of inu-ence (individual patient, populations of patients, nursingstaff, or others) to each of the activities as it related tothe respondents practice.

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

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

Ratings of Problems Related toPatients Care by CNSs and ACNPs

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

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

Activity

Clinical judgment Develops, implements, evaluates, and modies plans of care for individual patients and patients families andcohorts

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

Elicits comprehensive history and performs physical examinations on the basis of each patients initial signsand symptoms

Develops a list of differential diagnoses on the basis of ndings obtained from each patients medical historyand ndings on physical examination

Orders appropriate diagnostic studies and interprets ndings to manage patients care in collaborationwith physician and other members of the healthcare team as necessary


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

Advocacy and moral agency Empowers patients and patients families to act as their own advocates

CNS

3.9

2.7

2.8

2.5

2.4

3.1

1.2

3.3

ACNP

4.9

4.9

4.7

4.8

4.9

4.7

2.2

4.3

Mean frequencyscore




15/20

At least 20% of the CNS cohort indicated each of 6 primary employment settings: combined ICU/coronarycare unit (29%), medical ICU (28%), telemetry unit(23%), cardiovascular/surgical ICU (23%), step-downunit (20%), and surgical ICU (20%). Three employ-

ment settings were indicated by more than 20% of ACNP respondents: step-down unit (27%), medicalcardiology unit (22%), and telemetry unit (22%).

CNS respondents reported that the acuity levels of the majority of their patients were critical; however, aboutone fourth of their patients require acute care, and about6% require subacute care. Conversely, for the ACNPrespondents, the acuity levels of their patients werealmost equally distributed among the 3 acuity levels.

Table 11 lists the problems related to patients careorganized by systems. The percentages of time thatCNS and ACNP respondents devoted to such problemsin each system was calculated. Table 12 lists those

problems for which the percentages of time allocated to the problem differed by 5% or more between ACNPsand CNSs. CNSs most often provided care for patientswith life-threatening coagulopathies, acute renal fail-ure, diabetic ketoacidosis, chronic renal failure, and septic shock. ACNP respondents reported caring mostoften for patients with acute hypoglycemia, life-threat-ening coagulopathies, stroke, chronic lung disease, gas-troesophageal reux, acute renal failure, chronic renalfailure, and septic shock. Four problems required largeamounts of time for both CNSs and ACNPs: acute and chronic renal failure, life-threatening coagulopathies,and septic shock.

Experience InventoryFor comparison purposes, respondents were asked

to provide a frequency rating for each item on theexperience inventory (Table 13). Respondents wereasked this question: During the past year, how frequentlydid you provide direct bedside care to patients receiv-ing this intervention, test, procedure, medication,

and/or monitoring device? The following scale wasused:

0 = Never 1 = Less than once a month2 = At least once a month, but less than every

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

week 4 = At least 3 times a week.Mean frequency ratings for the CNS and ACNP

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

DiscussionIn order for the AACN Certication Corporation to

support its current and future certication initiatives, astudy of practice of acute and critical care nursing wasconducted between 2001 and 2003. Only that part of the study relative to advanced practice nurses is pre-sented here.

A practice analysis task force set out to dene theactivities performed by ACNPs and to conrm that theactivities performed by CNSs remained as previouslydened. In addition, frequency ratings for the activitiesof advanced practice nurses, an experience inventory,and problems related to patients care were obtained from the study respondents.

As the term ACNP denotes, care provided bythese practitioners occurs in areas where acute or criticalcare is provided. Indeed, respondents reported that thecare provided by these practitioners occurred in areasoutside of traditional critical care units, such as cardiaccatheterization laboratories, burn units, private practice,outpatient clinics, and medical cardiology areas. InKleinpells most recent study, 26 similar practice areaswere identied; however, the ndings are in contrastto the care provided by CNSs in our study, which was

provided primarily in ICUs and reflected the studysample.

Table 10 Mean percentage of practice directed toward eachsphere of inuence by clinical nurse specialists (CNSs) and acute care nurse practitioners (ACNPs) responding to theadvanced practice survey

Sphere of inuence

Individual patientsPopulations of patients

Nursing personnel

Other disciplines,organizations, or systems

Mean SDCNS

25.8

21.4

36.2

16.7

20.8

13.5

21.2

14.6

Mean SDACNP

73.9

9.4

9.6

7.3

20.5

12.4

7.9

10.5

Percentage




16/20

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

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

Moloney-Harmon 4 described the practice of theCNS by using the 8 competencies of nurses of the

Table 11 Problems related to patients care, organized by system

CardiovascularMyocardial conduction system defectsAcute congestive heart failure/pulmonary edemaCardiogenic shockCongenital heart defect/diseaseHypovolemic shockDysrhythmiasAcute myocardial infarction/ischemiaAcute inammatory diseaseCardiomyopathiesCardiac traumaAcute coronary syndromesConduction defectsHeart failurePulmonary edemaHypertensive crisisShock statesStructural heart defectsRuptured or dissecting aneurysmAcute peripheral vascular insufciencyCardiac tamponadeCardiac surgery

Pulmonary hypertensionPulmonary

Acute respiratory infectionsRespiratory distress syndromeTransient tachypnea of the newbornPulmonary hypertensionPulmonary traumaPulmonary aspirationsAir-leak syndromesChronic lung diseaseApnea of prematurityCongenital anomaliesAcute respiratory failureThoracic traumaAcute respiratory distress syndromeRespiratory distressStatus asthmaticus, exacerbation of chronic obstructive

pulmonary disease, emphysema, bronchitisAcute pulmonary embolusThoracic surgeryAspirationsBronchopulmonary dysplasia

EndocrineInborn errors of metabolismInfant of diabetic motherAcute hypoglycemiaSyndrome of inappropriate secretion of antidiuretic

hormoneDiabetes insipidusDiabetic ketoacidosisAdrenal disordersSyndrome of inappropriate diuresisHyperglycemic hyperosmolar nonketotic coma

HematologyLife-threatening coagulopathiesImmunosuppressionHyperbilirubinemiaAnemia of prematurityOrgan transplantationSickle cell crisisHELLP syndrome

NeurologyHydrocephalusNeurological infectious diseasesSeizure disordersEncephalopathySpinal fusionAcute spinal cord injuryCongenital neurological abnormalitiesNeuromuscular disordersAneurysmSpace-occupying lesionsStroke (embolic events, hemorrhagic)Intracranial hemorrhage/intraventricular hemorrhage

NeurosurgeryNeuromuscular disorders

GastrointestinalGastrointestinal abnormalitiesBowel infarction/obstruction/perforationGastroesophageal reuxHepatic failure/comaAcute abdominal traumaAcute hemorrhagePancreatitisGastrointestinal surgeries

RenalAcute renal failureCongenital renal-genitourinary abnormalities

Renal traumaAcute and chronic renal failureLife-threatening electrolyte imbalancesNear-drowning

MultisystemSeptic shock/infectious diseasesExposure to toxic agentsAsphyxiaLow birth weight/prematurityLife-threatening maternal-fetal complicationsIngestions and inhalations of toxic agentsBurnsHemolytic uremic syndromeMultisystem traumaSystemic inammatory response syndrome, sepsis,

multiorgan dysfunction syndrome




17/20

Synergy Model. Interventions were delineated on the basis of the 3 spheres of inuence: patients and patientsfamilies, nurse-nurse, and system. As noted, CNS prac-tice had historically been delineated on the basis of roles, including clinician, educator, researcher, and consultant. 12 Nurse practitioner practice has also beendefined by using the same roles. 30 However, in thestudy we report here, the majority of ACNP time wasspent in the role of clinician, directing practice toward the individual patient sphere of inuence. This ndingis consistent with Kleinpells nding that 85% to 88%of ACNPs time is spent directly providing care to

patients. 26 CNS respondents reported directing their practice fairly evenly across all 4 spheres of inuenceasked about in the survey.

In 2003, the ANCC conducted a role delineationstudy 31 of nurse practitioners in 7 different specialties:

acute care, adult, family, gerontology, pediatric, adult psychiatric, and mental health. In that study, 31 data werecollected on the roles and responsibilities of nurse prac-titioners working in each of these specialties. Responserates ranged among specialties from 17% to 51.4%.

Similar to the ndings in our study, the majorityof the respondents in the ANCC study were women(93%). A total of 43% of the respondents were betweenthe ages 41 and 50 years, a nding that parallels theACNP respondents in our study, 76% of whom indi-cated that they were 35 to 54 years old.

The ANCC assessed frequency (how often an activ-ity was performed, ranging from never to daily or approximately every other day), performance expecta-tion (when the ACNP was expected to perform thisactivity on the job, ranging from never to within therst 6 months as an ACNP), and consequence (what

Table 12 Problems related to care of adult patients for which the percentage of time allocated by clinical nurse specialists(CNSs) and acute care nurse specialists (ACNPs) differed by 5% or more

Problem

CardiovascularAcute congestive heart failure/pulmonary edema

PulmonaryAcute respiratory distress syndromeChronic lung diseasePulmonary hypertension (eg, persistent pulmonary hypertension of the newborn)Respiratory distress (eg, emphysema, bronchitis)

EndocrineAcute hypoglycemiaAdrenal disorders (eg, adrenal insufciency)Diabetic ketoacidosisSyndrome of inappropriate diuresis

Hematology/immunologyImmunosuppression (eg, Rh incompatibilities, blood group incompatibilities, hydrops fetalis, congenital,

acquired [HIV infection, AIDS, neoplasms])Life-threatening coagulopathies (eg, idiopathic thrombocytopenia purpura, disseminated intravascular

coagulation, hemophilia, heparin-induced thrombocytopenia, ReoPro-induced)Organ transplantation (eg, liver, bone marrow, kidney, heart, pancreas, lung)

NeurologyHead trauma (blunt, penetrating)Neurosurgery (eg, evacuation of hematoma, tumor resection)Stroke (embolic events, hemorrhagic)

GastrointestinalGastroesophageal reuxGastrointestinal surgeries (eg, Whipple procedure, esophagogastrectomy, gastric bypass)

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

Multisystem

Septic shock/infectious diseases (eg, congenital viral, bacterial, catheter sepsis, nosocomial infections,immunosuppression)Systemic inammatory response syndrome, sepsis, multiorgan dysfunction syndromeIngestions and inhalations of toxic agents (eg, drug/alcohol overdose, poisoning)

CNS

11.9

12.79.31.05.4

14.46.3

46.32.8

23.8

54.3

8.8

13.710.119.9

5.915.7

43.331.0

31.0

23.210.5

4.5

4.118.9

6.610.7

36.212.2

9.27.9

9.5

63.1

16.8

5.13.7

40.9

32.99.1

31.742.2

53.6

12.93.9

ACNP

Percentage oftime




18/20

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

The respondents in our study were asked to ratethe 65 advanced practice activities on how criticaleach activity is to optimizing the outcomes of acuteand critically ill patients. The CNSs rated 8 activitiesin the nurse characteristics of clinical judgment and

clinical inquiry as most critical, and the ACNPs rated 8 activities in the nurse characteristic of clinical judg-ment as most critical. Again, this focus on clinical

judgment corresponds to the main focus of patientscare. The 8 activities rated highest in frequency by theACNPs (Table 8) were also reported to be performed

by the ACNPs in the Kleinpell study. 26

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

invasive procedures (eg, placement of pulmonary arterycatheters, central venous catheters, arterial catheters;thoracentesis; lumbar punctures). Although CNSs aregenerally not thought of as performing invasive proce-dures, 2% of the CNS respondents reported performingan invasive activity less than once a month. ACNPs areoften thought of as spending a majority of their time

performing invasive procedures; however, we found this idea to be untrue. Kleinpell 26 also found thatACNPs do not spend most of their time performing

invasive procedures. Nurse practitioner respondents in the ANCC studywho worked as ACNPs or adult nurse practitionersreported spending 73% and 76%, respectively, of thetime with direct care of patients. This nding is consis-tent with the ndings of our study, in which ACNPsreported spending most of their time with activitiesassociated with clinical judgment. ACNPs and adultnurse practitioners in the ANCC study spent 12% and

Table 13 Experience inventory items

CardiovascularElectrocardiographic monitoring12-Lead electrocardiogramHemodynamic and/or pulmonary monitoringPercutaneous transluminal coronary angioplastyTranscutaneous (external) pacemakersExternal pacemakers (eg, transesophageal)Temporary pacemakersProgrammable pacemakersInternal pacemakersAutomatic implantable cardioverter debrillatorsPhosphodiesterase inhibitors (eg, amrinone, milrinone)Cardiac assist devices (eg, intra-aortic balloon pump, right

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

PericardiocentesisNeonatal resuscitationArterial pressure monitoringCentral venous pressure monitoringPulmonary artery pressure monitoringInvasive cardiac output/index determinationDirect right atrial, left atrial, pulmonary artery pressure

monitoringUmbilical arterial and venous pressure monitoring

Hematology/immunologyBlood product administrationBlood screening and typingImmunizationsExchange transfusionsModes of phototherapy (eg, ber-optic blanket,

halogen lights)Plasmapheresis

RenalUltraltrationRenal replacement therapies

PulmonaryPulse oximeterPulmonary monitorContinuous respiratory monitorsEnd-tidal carbon dioxide monitorNasal/facial continuous positive airway pressure, bilevel

positive airway pressureConventional mechanical ventilationHelioxPressure control/support ventilationNonconventional mechanical ventilation

(eg, high frequency, jet/oscillating)SurvantaSurfactant replacement therapyRapid ventilation systems, pediatric high frequencyOscillating ventilators, pediatric jet oscillatingHigh-frequency ventilationSynchronized ventilationTrain-of-four (peripheral nerve stimulator)Nitric oxideExtracorporeal membrane oxygenationAirway management (eg, new tracheostomy, endotracheal

tube)Chest tubes

NeurologyIntracranial pressure monitoring devicesVentriculostomyExtraventricular drainBrain resuscitationVentricular reservoirs/shunt

GastrointestinalSclerosing therapiesTrophic feedingsParenteral and enteral feeding systems

MultisystemImmunoglobulin therapy




19/20

13% of their time, respectively, with management,supervision, and administrative issues, and they spent10% and 11%, respectively, teaching. Both groups spent7% of their time with research activities and 11% per-forming consultation with staff. However, in the ANCCstudy, data for acute care, adult, family, gerontological,

pediatric, adult and family psychiatric, and mental

health nurse practitioners were evaluated and reported collectively; hence, ANCC data cannot be directly compared with the data from our study of ACNPs.

The problems related to patients care identied bythe participants in the current study reect the settingsin which care is provided by advanced practice nurses inacute and critical care. Both CNSs and ACNPs reported focusing much of their attention on problems such aslife-threatening coagulopathies, acute and chronicrenal failure, and sepsis or problems stemming frominfectious diseases. CNSs focus more of their timethan their ACNP counterparts do on diabetic ketoacido-sis, immunosuppression, and ingestions of toxic agents.ACNPs focus more of their time on problems such asstroke, acute hypoglycemia, and gastroesophageal reuxdisease. Interestingly, the last 3 problems have a compo-nent of chronicity, a characteristic that either may indi-cate that the care provided by ACNPs goes beyond theacute episode or may reect the recidivism of acute care

patients. No comparison data are available.Study respondents were asked to rate how fre-

quently each item was performed in their practice. Sixitems were rated at greater than 90% by the participantsas unique to critical care. Of the 6 items, 4 involved hemodynamic monitoring. All of the items on the inven-tory were reported to be unique to critical care by therespondents. Many of these items were also reported to

be performed by ACNPs in the Kleinpell study. 26

LimitationsThe most signicant limitation of our study is the

limited number of ACNP respondents. Therefore, theresults of this study specically related to the roles of ACNPs reect the subset of certied ACNPs who par-ticipated in the study. However, despite the number of

participants, the results of our study are consistentwith the results of both the ANCC study 31 and Klein-

pells most recently reported study. 26AACN Certification Corporation recognizes the

effect of the dynamic healthcare environment on criticalcare nursing practice. Although high-acuity patients arestill cared for in intensive care settings, many patientstraditionally cared for in those areas may now be admit-ted to or cared for in other units. The corporationacknowledges that critical care nursing is not limited tothe walls of traditional intensive care settings, and so

the CCNS certication examination program certiesclinical nurse specialists in acute and critical care. Study

participants were asked where they were employed, butmore importantly, the study concentrated on the typesof patients being cared for by CNSs and ACNPs, and the competencies needed by those advanced practicenurses to provide that care, regardless of the clinical

setting in which the nurses practiced.

SummaryThe activities performed by advanced practice

nurses who work with acute and critically ill patientshave been described and discussed on the basis of thenurse competencies of the Synergy Model. Definitedifferences in the roles and practices of the ACNPsand CNSs were found. Findings from this study have

been and will be incorporated into the AACN Certi-cation Corporations certication initiatives.

ACKNOWLEDGMENTS We thank the members of the practice analysis task force: Patricia J. Atkins,RN, MS,CCRN, CCNS,Deborah E. Becker,RN, MSN, CRNP, CS, CCRN,Deborah Bingaman,RN, MSN, CCRN,CCNS, CPNP,Nancy T. Blake,RN, MN, CCRN, CNAA, Jo Ellen Craghead,RN, MSN, CCRN,Beth C.Diehl-Svrjcek,RN, MS, CCRN, NP,Sonya R. Hardin,RN, PhD, CCRN,Melissa L. Hutchinson,RN,CCRN,Linda D. Jackson,RN, MS, CCRN,Roberta Kaplow,RN, PhD, CCRN, CCNS,Marthe J. Mose-ley,RN, PhD, CCRN, CCNS,Marlene Roman,RN, MSN, ARNP,Daphne E. Stannard,RN, PhD, CCRN,Karen K. Thomason,RN, MSN, CCRN,and Darla R. Ura,RN, BSN, MA, ANP.

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