Activities Performed by Acute and Critical Care Advanced Practice

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

Am J Crit Care 2006;15:130-148
2006 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
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ACTIVITIES PERFORMED BY ACUTE AND CRITICAL CARE ADVANCED PRACTICE NURSES: AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES STUDY OF PRACTICE
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 Corporation, Aliso Viejo, Calif (CH).
BACKGROUND Accreditation standards for certication programs require use of a testing mechanism that is job-related and based on the knowledge and skills needed to function in the discipline. OBJECTIVES To describe critical care advanced practice by revising descriptors to encompass the work of both acute care nurse practitioners and clinical nurse specialists and to explore differences in the practice of clinical nurse specialists and acute care nurse practitioners. METHODS A national task force of subject matter experts was appointed to create a comprehensive delineation of the work of critical care nurses. A survey was designed to collect validation data on 65 advanced practice activities, organized by the 8 nurse competencies of the American Association of Critical-Care Nurses Synergy Model for Patient Care, and an experience inventory. Activities were rated on how critical they were to optimizing patients outcomes, how often they were performed, and toward which sphere of inuence they were directed. How much time nurses devoted to specic care problems was analyzed. Frequency ratings were compared between clinical nurse specialists and acute care nurse practitioners. RESULTS Both groups of nurses encountered all items on the experience inventory. Clinical nurse specialists were more experienced than acute care nurse practitioners. The largest difference was that clinical nurse specialists rated as more critical activities involving clinical judgment and clinical inquiry whereas 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)
n essential component of a certication program is the ability to use a testing mechanism that is job related and based on the current knowledge and skills needed to function in the discipline. Between 2001 and 2003, Professional Examination Service undertook a comprehensive study of the practice of acute and critical care nursing on behalf of the AACN Certification Corporation, the
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credentialing arm of the American Association of Critical-Care Nurses (AACN). The study was undertaken 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 critically ill patients. In this report, we describe and discuss the activities performed by advanced practice nurses, the spheres of influence upon which they direct their practice, and the percentage of time they devote to specic problems related to patients care.
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AMERICAN JOURNAL OF CRITICAL CARE, March 2006, Volume 15, No. 2
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Items on an experience inventory were validated and rated relative to their uniqueness to acute and critical care.
Table 1 Characteristics of patients from the American Association of Critical-Care Nurses Synergy Model for Patient Care
Characteristic Resiliency Denition Patients capacity to return to a restorative level of functioning by using compensatory and coping mechanisms Susceptibility to actual or potential stressors that may adversely affect patients outcomes Ability to maintain a steady-state equilibrium The intricate entanglement of two or more systems (eg, body, family, therapies) Extent of resources (personal nancial, social, psychological, technical, etc) that the patient, the patients family, and the community bring to the current situation Extent to which the patient and the patients family engage in care Extent to which the patient and the patients family engage in decision making with respect to care A summative characteristic that allows one to expect a certain course of illness
Background
The specialty certication programs in neonatal, pediatric, and adult critical care nursing were last revised by using data collected in a 1992 role delineation study of critical care nursing practice.1 In that study, subject matter experts delineated and validated the domains and tasks in critical care nursing practice and the associated knowledge and skills. Eight systemscardiovascular, pulmonary, endocrine, hematology/immunology, neurology, gastrointestinal, renal, and multisystemprovided the context for the delineation of more than 75 problems related to patients care. Test specifications were published in terms of percentages of questions related to systems, problems with patients care, and associated knowledge and skills. In a 1997 study, subject matter experts developed 5-point rating scales to behaviorally anchor the midpoint and endpoints of a continuum describing each characteristic of patients and nurses as outlined in the AACN Synergy Model for Patient Care (described in the next section). The 5-point rating scales for the characteristics of patients were developed to include descriptors for the most compromised patients (level 1) and the least compromised patients (level 5), as well as for midpoint patients (level 3). Similarly, each rating scale for characteristics of nurses included descriptors reflecting novice (level 1), competent (level 3), and expert (level 5) performance by a critical care nurse providing direct care to a patientconsistent with the pattern of skill acquisition described by Benner.2 In 1998, Professional Examination Service undertook a study to delineate the practice of acute and critical care CNSs in terms of the 8 competencies of nurses of the Synergy Model. Expansion of the Synergy Model to reect CNS practice involved the identication of activities performed by CNSs. These activities were labeled level 7 competencies.3,4 No study, to date, had been done to delineate the roles and responsibilities of the nurse practitioner within the context of the Synergy Model.
Vulnerability
Stability Complexity
Resource availability
Participation in care Participation in decision making Predictability
The AACN Synergy Model for Patient Care

During the 1990s, the AACN Certication Corporation convened a think tank that developed a conceptual framework for certied practice. The framework was based on the premise that certied practice is more than tasks and should be grounded in nurses meeting the
needs of patients and optimizing patients outcomes. The model has 3 major components: patient characteristics, nurse competencies, and outcomes.5 The central concept of the AACN Synergy Model for Patient Care is that the needs or characteristics of patients and patients families inuence and drive the characteristics or competencies of nurses.6 Synergy results when the needs and characteristics of a patient, clinical unit, or system are matched with a nurses competencies. Further, when patient characteristics match nurse characteristics, patients outcomes are optimized.7 Each patient brings a unique set of characteristics to the healthcare situation. Among the many characteristics, 8 are consistently associated with patients who are experiencing critical events: resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability (Table 1). These characteristics underlie the needs of the patients.5,8 Each characteristic exists on a continuum from low (level 1) to high (level 5) (Table 2). Depending on the needs of each patient, certain competencies of nurses are required for providing care to acute and critically ill patients and their families.
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Table 2 Clinical continuum of characteristics of patients from the American Association for Critical-Care Nurses Synergy Model for Patient Care
Characteristic Resiliency 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 of compensation, moderate reserves Level 5: Highly resilientable to mount and maintain a response, intact compensatory/coping mechanisms, strong reserves, endurance Level 1: Highly vulnerablesusceptible, unprotected, fragile Level 3: Moderately vulnerablesomewhat susceptible, somewhat protected Level 5: Minimally vulnerablesafe, out of the woods, protected, not fragile Level 1: Minimally stablelabile, unstable, unresponsive to therapies, high risk of death Level 3: Moderately stableable to maintain steady state for limited period of time, some responsiveness to therapies Level 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 dynamics Level 5: Minimally complexstraightforward, routine patient-family dynamics, simple or clear-cut, typical presentation
Vulnerability
Stability
Complexity
Resource availability Level 1: Few resourcesnecessary knowledge and skills not available, necessary nancial support not available, 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 readily available, strong personal/psychological supportive resources, strong social systems resources Participation in care Level 1: No participationpatient and patients family unable or unwilling to participate in care Level 3: Moderate level of participationpatient and patients family need assistance in care Level 5: Full participationpatient and patients family fully able to participate in care Participation in decision making Level 1: No participationpatient and patients family have no capacity for decision making, requires surrogacy Level 3: Moderate level of participationpatient and patients family have limited capacity, seeks input or advice from others in decision making Level 5: Full participationpatient and patients family have capacity and make decisions for selves Level 1: Not predictableuncertain, uncommon population of patients or uncommon illness, unusual or unexpected course, does not follow critical pathway or no critical pathway developed Level 3: Moderately predictablewavering, occasionally noted population of patients or occasionally occurring illness Level 5: Highly predictablecertain, common population of patients or common illness, usual and expected course, follows critical pathway
Predictability
As with the patient characteristics, each competency exists on a continuum from low (level 1) to high (level 5). The 8 competencies reect an integration of knowledge, skills, and experience of the nurse. The nurse characteristics of the Synergy Model are clinical judgment, advocacy and moral agency, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry, and facilitator of learning5,8 (Table 3). Synergy occurs and optimal outcomes may result when the competencies of the nurse complement the needs of the patient. Implicit in the interactions between patients and nurses is the notion that the patients with the greatest level of need require the nurses with the highest degree of competency.
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The Synergy Model was initially based on 5 assumptions9: 1. Each patient is a biological, social, and spiritual entity who is at a particular developmental stage. The whole patient (body, mind, and spirit) must be considered. 2. Each patient, the patients family, and the community contribute to providing a context for the nurse-patient relationship. 3. Patients can be described by a number of characteristics. All characteristics are connected and contribute to each other. Characteristics cannot be looked at in isolation. 4. Nurses can be described in a number of
Table 3 Characteristics of nurses from the American Association of Critical-Care Nurses Synergy Model for Patient Care
Characteristic Clinical judgment Denition Clinical reasoning that includes clinical decision making, critical thinking, and a global grasp of the situation, as well as nursing skills acquired through a process of integrating formal and experiential knowledge. Working on 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 concerns within or outside the clinical setting. A constellation of nursing activities that creates a compassionate, supportive, and therapeutic environment with patients and staff. The aim is to promote comfort, heal, and prevent unnecessary suffering. Working with others, including physicians, patients families, and other healthcare providers, in a way that promotes and encourages each persons contributions toward achieving optimal, realistic goals for the patient. Collaboration involves intradisciplinary and interdisciplinary work with colleagues. A body of knowledge and tools that allow nurses to manage whatever environmental and system resources exist for the patient, the patients family, and staff within or across healthcare and nonhealthcare systems. The sensitivity to recognize, appreciate, and incorporate differences into the provision of care. Differences may include, but are not limited to, individuality, cultural differences, spiritual beliefs, sex, race, ethnicity, disability, family 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 and creating practice changes through research utilization and experiential knowledge. The ability to help patients, nursing staff, physicians, and other healthcare providers learn both formally and informally.
Advocacy and moral agency Caring practices Collaboration
Systems thinking
Response to diversity
Clinical inquiry Facilitator of learning
dimensions. The interrelated dimensions paint a prole of the nurses. 5. A goal of nursing is to restore each patient to an optimal level of wellness as dened by the patient. These basic assumptions provided the guide for identication of characteristics of patients and competencies of nurses in the model.5,8 In February 2002, a practice analysis task force was created by the AACN Certication Corporation. The group consisted of advanced practice nurses from across the United States who worked in a variety of practice settings. The task force expanded the assumptions of the Synergy Model to include 4 more assumptions5,10: 1. Nurses create the environment for the care of patients. The context or environment of care also affects what a nurse can do. 2. Impact areas are interrelated, and the nature of the interrelatedness may change as a function of experience, situation, or setting changes. 3. Nurses may work to optimize outcomes for patients, patients families, healthcare providers, and the healthcare system/organization. 4. Nurses bring their background to each situation, including various levels of education/ knowledge and skills/experience.
Outcomes are considered patients conditions measured along a continuum.6 Six major quality indicators were identied: (1) satisfaction of patients and their families, (2) rate of adverse incidents, (3) complication rate, (4) adherence to the discharge plan, (5) mortality rate, and (6) each patients length of stay. The Synergy Model was congruent with outcomes derived from 3 sources: patients, nurses, and the healthcare system (see Figure). Outcomes derived from the patient include functional changes, behavioral changes, trust, satisfaction, comfort, and quality of life. Outcomes derived from nursing competencies include physiological changes, the presence or absence of complications, and the extent to which treatment goals were reached. Outcome data derived from the healthcare system include readmission rates, length of stay, and cost utilization per case.5,6,8
Advanced Practice Nursing

Advanced practice nursing is the application of an expanded range of practical, theoretical, and researchbased 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.
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Functional change, behavioral change, trust, ratings, satisfaction, comfort, quality of life Patient
Patient characteristics Physiological changes, presence or absence of complications, extent to which care or treatment objectives were attained Nurse
Nurse competencies
System Recidivism, costs/resource utilization
The American Association of Critical-Care Nurses Synergy Model for Patient Care.
These roles included direct care and independent practice, research, and consultation.12 A few years later, the published subroles and competencies of the CNS were modied to include clinical practice and direct care of patients, consultation, education, research, collaboration, and clinical leadership.7,13 Consistent with the National Association of Clinical Nurse Specialists Statement on Clinical Nurse Specialist Practice and Education,14 the roles of a CNS are currently described on the basis of 3 spheres of inuence: (1) patients and patients families, (2) nurseto-nurse, and (3) system.4,14,15 The multifaceted role of a CNS who cares for acute and critically ill patients and their families, working within an organization and with nursing staff, can also be described according to the Synergy Model. The model aligns not only the 8 characteristics of patients and the 8 competencies of nurses but also the role of the CNS in relation to the 3 spheres of influence.16
CNSs manage, support, and coordinate the care of acutely and critically ill patients with episodic illness or acute exacerbation of chronic illness7 while addressing both system and staff interaction. In Standards of Practice and Professional Performance for the Acute and Critical Care Clinical Nurse Specialist,17 AACN delineates several activities of CNSs in relation to each of the competencies inherent in the Synergy Model and the 3 spheres of 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 became evident that nurse practitioners had a scope of practice that could be maximized to meet both the medical and nursing needs of these vulnerable acutely ill patients.19,20 The American Nurses Association and the AACN formed a task force of experts to delineate the scope of practice for adult ACNPs. According to the docu-
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ment dening the scope,21 the purpose of the ACNP is to provide advanced nursing care across the continuum of acute care services to patients who are acutely and critically ill. ACNPs focus on the stabilization of acute medical problems, prevention and management of complications, comprehensive management of injury and/or illness, and restoration to maximal levels of health within an interdisciplinary and collaborative healthcare team.21 Since development of the ACNP scope and standards and the subsequent offering of a national certication examination by the American Nurses Credentialing Center (ANCC) starting in 1996, Kleinpell has surveyed those ACNPs who sought certification to determine practice habits, practice environments, and emerging roles.22-26 Since 1997, Kleinpells reporting of longitudinal survey results has served as a means of keeping practitioners, educators, administrators, and colleagues informed of changes in the role. At the inception of the role, it was thought that ACNPs would work primarily in intensive care units (ICUs). Results of Kleinpells most recent survey26 indicate that most ACNPs do work in ICUs; however, nearly 50% of the respondents reported a practice environment other than the traditional ICU or urgent/acute care practice setting. Although the practice setting may vary among ACNPs, the main focus of their practice remains direct management of patients care, with 85% to 88% of time reportedly spent on this responsibility.26 Recognizing the need for consensus on the core competencies of ACNPs, the National Organization of Nurse Practitioner Faculties convened a national panel of ACNPs to identify ACNP competencies. The panel described entry-level competencies for graduates of masters and post-masters ACNP programs. 27 The panels report describes for educators, practitioners, and the public the unique philosophy of ACNPs and the needs of the populations served. Further, the descriptions of the competencies include the role components of ACNPs within the 7 core domains outlined in the section on domains and core competencies of nurse practitioner practice of the same document.27
of the study we report here were to dene the unique activities performed by ACNPs and to conrm that CNS activities have not changed. Specic aims of the study were to obtain criticality and frequency ratings for each of 65 advanced practice activities, as determined by the practice analysis task force; compare the spheres of inuence of the individual activities when performed by either the CNS or ACNP; compare the percentage of time that CNSs and ACNPs devote to specic problems related to patients care; and obtain frequency ratings for the items on the experience inventory that are unique to critical care.
Development of a Comprehensive Description of Critical Care Nursing Practice

Subject Matter Expert Committee
Research Design and Method

The practice analysis task force of the AACN Certification Corporation was conducting the study reported in this article at the same time as the competencies were being developed by the National Organization of Nurse Practitioner Faculties. Advanced practice nursing in acute and critical care has existed for more than 20 years. However, no study had been conducted on a national level to dene the activities of both CNSs and ACNPs for the purposes of certication. The goals
The standard approach to job analysis used by licensure 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 persons doing the job. In the following section, we describe this process as it was undertaken by AACN.28 A task force of subject matter experts was appointed to create a comprehensive delineation of the work of critical care nurses. Examination of advanced practice nursing was part of a larger study of the continuum of critical care practice (new-to-critical care competencies, updated levels 1, 3, and 5 of the Synergy Model as described earlier); only the results related to advance practice nurses are reported in this article. The task force comprised 15 experts representing practitioners and educators, and it included CCRNs, CCNSs, and ACNPs who served neonatal, pediatric, and adult patients. Committee members were drawn from rural, suburban, and urban practice settings across the United States. The task force met 4 times during the course of the project. The focus was on developing a comprehensive delineation of practice in acute and critical care. At each meeting, time was spent both in full-group discussions and in small-group work. Two nurse staff members from the AACN Certication Corporation attended all meetings of the task force. Staff from Professional Examination Service, the corporations testing company at the time, facilitated all of the meetings.
Sampling Plan
A sampling plan was designed to permit comparison of the populations of patients and the techniques and tools of advanced practice nurses and to allow validation of the competencies required for advanced level practice in acute and critical care nursing. The CNS sample consisted of all holders of the CCNS credential (N = 332)
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plus 168 holders of the CCRN credential who indicated that they were working as CNSs. The ACNP sample consisted of 500 ACNPs selected randomly from the population of currently certied ACNPs. A total of 75% of this combined CNS/ACNP pool received the Survey of Advanced Practice in Acute and Critical Care Nursing, and 25% of the pool received the Survey of Patient Care Problems in Acute and Critical Care.
Measures
The Survey of Advanced Practice in Acute and Critical Care Nursing was designed to collect data that would validate advanced practice activities, the 8 competencies of nurses, and the experience inventory. For each of the 65 advanced practice activities (Table 4), organized according to the 8 competencies of nurses of the Synergy Model, 3 rating scales were used: Criticality: How critical is the activity to optimizing outcomes for acutely and critically ill patients? 1 = Not critical 2 = Minimally critical 3 = Moderately critical 4 = Highly critical Frequency: How frequently did you perform the activity during the past year in your role as an advanced practitioner? 1 = Never 2 = Less than once a month 3 = At least once a month, but less than every week 4 = At least once a week, but less than 3 times a week 5 = At least 3 times a week Sphere(s) of inuence: Toward which sphere(s) of influence did you direct the activity during the past year? (Respondents were able to select all that apply.) 1 = Individual patients 2 = Populations of patients 3 = Nursing staff 4 = Other disciplines, organizations, or systems
Complementary Data Collection Initiatives
each group was asked to review materials developed by the task force. The primary task of the CNS and ACNP groups was to define the competencies required of advanced practice nurses in acute and critical care. Critical Incident Telephone Interviews. Each member of the task force was asked to nominate ACNPs and CNSs who would be willing to participate in a telephone interview. Nomination parameters included emphasis on creating a diverse pool of interviewees with experience working with different populations of patients (neonatal, pediatric, and adult) and nurses working in diverse geographical areas. Interviewees were contacted by e-mail and telephone to establish a time for the interview and were sent materials to review. All interviewees received the list of problems related to patients care that was used in the CCNS examination program and were asked to review the list appropriate to the age of the patients with whom they worked. CNSs and ACNPs received the advanced practice competencies. A total of 21 interviews were conducted in June 2002. Each interviews was conducted by telephone and lasted from 25 to 50 minutes. A protocol was created to guide the interviews. Independent Reviews. Subject matter experts independently reviewed the various aspects of the practice delineation. In September 2002, materials for independent review were mailed. The advanced practice competency list was disseminated to 9 CNSs and 8 ACNPs. The advanced practice competencies were returned by 3 CNSs and 4 ACNPs.
Results
Survey of Advanced Practice in Acute and Critical Care Nursing
Three additional data collection initiatives were conducted to complement and extend the work of the practice analysis task force: focus panels, critical incident 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 was facilitated by a moderator from Professional Examination Service. All panels consisted of a mix of guided discussion and document reviews. In addition to responding to and discussing open-ended questions,
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The Survey of Advanced Practice in Acute and Critical Care Nursing was distributed to 750 advanced practice nurses (375 CNSs and 375 ACNPs) and was completed and returned by 261 respondents, for a 35% response rate. The group of respondents comprised 158 CNSs (42% response rate), 77 ACNPs (21% response rate), and 26 individuals who worked in either a blended CNS/ACNP role or in an other role. Because the primary goal of data analyses was to compare and contrast the practice of CNSs and ACNPs, the 26 respondents who could not be assigned unambiguously to either group were eliminated from subsequent quantitative analysis. Thus, the results reported in the remainder of this section are for the 158 CNSs and 77 ACNPs who responded to the survey.
Characteristics of the Sample
Nearly all ACNP respondents (95%) indicated that they worked in the role of a nurse practitioner;
Table 4 Activities of advanced practice nurses organized by the 8 characteristics of nurses of the American Association of CriticalCare Nurses Synergy Model for Patient Care
Characteristic Clinical judgment Activities of advanced practice nurses Synthesizes, interprets, makes decisions and recommendations, and evaluates responses on the basis of complex, 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 cohorts Prescribes medications, therapeutics, and monitoring modalities in collaboration with physicians and other members of the healthcare team as necessary Develops, implements, and evaluates research-based algorithms, clinical guidelines, protocols, and pathways 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 broad perspective (ie, the big picture) 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 on physical examination Orders appropriate diagnostic studies and interprets ndings to manage patients care in collaboration with physicians and other members of the healthcare team as necessary Initiates appropriate referrals and performs consultations Performs invasive procedures (eg, placement of pulmonary artery catheters, central venous catheters, arterial catheters; thoracentesis; lumbar punctures) Advocacy and moral agency Uses internal resources (eg, ethics committee, risk management, legal department) and external resources (eg, professional organizations, government ofcials, community agencies) to facilitate resolution of issues of advocacy or moral agency Participates in problem solving to anticipate and prevent recurrences of dissatisfaction or concern among patients or patients families Facilitates resolution of ethical and clinical conicts between patients or patients families and other healthcare 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 incorporated 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 other healthcare team members, administrators, and payors into the patients plan of care Caring practices Promotes a caring and supportive environment Supports 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 continuum (ie, facilitates safe passage) Interprets and communicates needs of complex patients and their families and administrative needs to other caregivers
continued
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Table 4 continued
Characteristic Collaboration Activities of advanced practice nurses Leads and facilitates coordination of intradisciplinary and interdisciplinary teams to develop or revise programs focused on group or systems issues Leads and facilitates coordination of intradisciplinary and interdisciplinary teams to develop or revise plans of care focused on issues related to patients and/or patients families Initiates and facilitates active involvement with external agencies (eg, industry, payors, community groups, political agencies) Serves as a role model, teaches, coaches, and mentors healthcare team to understand and use resources and expertise of others Serves as a role model, teacher, coach, and mentor for both professional leadership and accountability for 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 and interdisciplinary education to improve patients outcomes and quality of care Systems thinking Interprets and facilitates integration of organizational mission, goals, and systems into practices related to patients care Assesses and facilitates understanding of the impact of social, political, regulatory, and economic (eg, payors, products) forces on the delivery of care Using knowledge of the system, works with internal clients (eg, nursing staff, medical staff, other healthcare providers, administrators) and external clients (eg, institutions, sales representatives) to optimize delivery of care Identies and communicates resources, both internal and external (eg, consultants, referrals, community programs, and other healthcare systems) to optimize outcomes for patients and patients families Develops, implements, and evaluates strategies to optimize outcomes for patients , patients families, and payors Develops strategies to facilitate transitional movement of patients through the healthcare system Continually evaluates the care delivery model and recommends 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 Response to diversity Identies diversity issues and facilitates awareness of these issues Recognizes and assists the healthcare team to integrate individual differences in tailoring the delivery of care to meet the diverse needs and strengths of patients Serves as a role model, teacher, coach, and/or mentor for acceptance of and responsiveness to diversity Promotes and incorporates research and experiential knowledge into plans of care related to diverse populations Clinical inquiry Identies clinical problems amenable to research Serves as a role model, teacher, coach, and/or mentor of staff on the use, implementation, and evaluation of research ndings Evaluates current and innovative practices in patients care on the basis of evidence-based practice, research, and experiential knowledge Develops processes to evaluate outcomes data Incorporates evidence-based practice guidelines, research, and experiential knowledge to formulate, evaluate, and/or revise policies, procedures, and protocols Critiques research 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
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Table 4 continued
Characteristic Facilitator of learning Activities of advanced practice nurses Conducts needs assessment before developing educational plans and programs Develops, implements, and evaluates programs on the basis of the needs of learners Adapts teaching strategies to the unique needs and strengths of patients and their families to facilitate the teaching and learning process Contributes to and advances the knowledge base of the healthcare community through research, presentations, publications, and involvement in professional organizations Facilitates and/or mentors professional advancement of nursing staff Deliver formal and informal intradisciplinary and interdisciplinary education to improve patients outcomes and quality of care Promotes value of lifelong learning and evidence-based practice while continually acquiring knowledge and skills needed to address questions arising in practice to improve patients care
85% of these respondents reported that their primary position was as an ACNP. The CNS respondents held more varied positions. Although 72% of the CNS respondents worked as a CNS, another 9% worked as nurse educators, and 3% to 4% each worked as rst-line managers, middle managers, and nurse researchers. Of the CNS respondents, 68% said that the CNS role was their primary position; another 11% reported that their primary role was as a staff nurse. The most typical employment setting for both CNS respondents and ACNP respondents was community nonprot hospitals; 50% of CNS respondents and 26% of ACNP respondents worked in that setting. About one fourth of both groups worked at a university medical center. Ten percent of the ACNP respondents worked in private industry, whereas no CNS respondents worked in that setting. Finally, ACNP respondents were more likely than CNS respondents to work in a for-profit community hospital and in other settings. The type of unit(s) worked in as the primary employment setting of CNS respondents and ACNP respondents was obtained. CNS respondents were more than twice as likely as ACNP respondents to work in a medical ICU, neuro/neurosurgical ICU, progressive care unit, surgical ICU, or trauma unit. ACNP respondents were more than twice as likely as CNS respondents to work in catheterization laboratories, burn units, medical cardiology unit, outpatient clinics, private practice, subacute care and other units (Table 5). In addition, ACNPs primarily cared for patients who were adults (60%) and geriatric (22%). For CNS respondents, 72% of the patients cared for were adults and 15% were geriatric. The demographic characteristics of the advanced practice survey respondents were compiled. A total of 98% of the CNS respondents and 92% of the ACNP
respondents were women. The CNS respondents were more experienced than the ACNP respondents. CNS respondents had a mean of 22 years of experience, 19 years working in acute/critical care, and 9 years as a CNS. ACNPs had a mean of 16 years of experience, 13 years in acute/critical care, and 5 years as an ACNP. A total of 86% of the CNS respondents and 76% of the ACNP respondents indicated that they were 35 to 54 years old. However, the ACNP respondents were 4 times as likely to indicate they were 25 to 34 years old (24% of ACNPs and 6% of CNSs). No respondents from either cohort were less than 25 years old or more than 65 years old. The CNS sample was slightly older than the ACNP sample, consistent with the data on years of experience. For the highest degree earned by respondents, 74% of the CNS respondents indicated they had earned a masters degree as a CNS; 8%, an unspecied masters degree; and 7%, a doctorate. No more than 3% indicated any other advanced degree earned. Of the ACNP respondents, 65% indicated that they had earned a masters as an ACNP; 14% earned 2 masters 1 as a CNS and 1 as an ACNP, and 14% were educated as ACNPs in 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 respondents worked in 33 different jurisdictions. California contributed the largest percentage of CNS respondents (12%). Another 5 states (Illinois, Minnesota, Missouri, New Jersey, and Texas), contributed 6% each, and Ohio contributed 5%. The ACNP respondents worked in 27 different jurisdictions. A total of 8% each worked in Illinois and Texas, 6% worked in Maryland, and 5% each worked in Arkansas, New York, Pennsylvania, South
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Table 5 Type of unit(s) reported as primary employment setting by clinical nurse specialists (CNSs) and acute care nurse practitioners (ACNPs)*
CNS (n = 158) ACNP (n = 77) Unit Acute hemodialysis Burn Cardiac rehabilitation Cardiac surgery/operating room Cardiovascular/surgical ICU Catheterization laboratory CCU Combined adult/pediatric ICU Combined ICU/CCU Corporate industry Critical care transport/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 No. 3 2 8 9 42 12 36 7 38 0 2 22 21 0 15 1 17 42 9 19 3 0 4 10 1 23 12 8 33 2 48 49 21 24 % 2 1 5 6 27 8 23 4 24 0 1 14 13 0 9 1 11 27 6 12 2 0 3 6 1 15 8 5 21 1 30 31 13 15 No. 1 3 2 6 21 15 20 1 11 0 0 15 9 0 9 4 20 12 0 6 4 2 13 1 11 5 4 0 20 8 12 21 3 23 % 1 4 3 8 27 19 26 1 14 0 0 19 12 0 12 5 26 16 0 8 5 3 17 1 14 6 5 0 26 10 16 27 4 30
Table 6 State or territory of primary employment setting for clinical nurse specialists (CNSs) and acute care nurse practitioners (ACNPs) responding to advanced practice survey
CNS (n = 158) State/territory Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming No. 3 0 1 0 19 5 1 1 0 6 7 0 0 9 1 0 1 1 2 0 5 6 5 9 1 9 0 0 0 0 9 2 6 5 0 8 1 3 6 0 0 0 0 3 10 0 0 2 5 0 5 1 % 2 0 1 0 12 3 1 1 0 4 4 0 0 6 1 0 1 1 1 0 3 4 3 6 1 6 0 0 0 0 6 1 4 3 0 5 1 2 4 0 0 0 0 2 6 0 0 1 3 0 3 1
ACNP (n = 77) No. 2 0 0 4 1 1 2 0 0 3 2 0 0 6 0 0 0 0 3 0 5 2 3 1 2 2 0 0 0 0 3 0 4 3 0 3 1 0 4 0 0 4 0 4 6 0 1 4 0 0 1 0 % 3 0 0 5 1 1 3 0 0 4 3 0 0 8 0 0 0 0 4 0 6 3 4 1 3 3 0 0 0 0 4 0 5 4 0 4 1 0 5 0 0 5 0 5 8 0 1 5 0 0 1 0
*Responses do not total 100% because multiple responses were permitted. Abbreviations: CCU, coronary care unit; ICU, intensive care unit; PACU, postanesthesia care unit.
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Table 7 Activities rated most critical by clinical nurse specialists (mean score on the criticality scale = 3.5)
Activity Clinical judgment Synthesizes, interprets, makes decisions and recommendations, and evaluates responses on the basis of complex, sometimes conicting, 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 healthcare providers) through serving as a role model, teaching, coaching, and/or mentoring Caring practices Promotes a caring and supportive environment Facilitator of learning Promotes value of lifelong learning and evidence-based practice while continually acquiring knowledge and skills needed to address questions arising in practice to improve patients care Clinical inquiry Evaluates current and innovative practices in patients care on the basis of evidence-based practice, research, and experiential knowledge Incorporates evidence-based practice guidelines, research and experiential knowledge to formulate, evaluate, and/or revise policies, procedures, and protocols
Table 8 Activities rated most critical by acute care nurse practitioners (mean score on the criticality scale = 3.5)
Activity Clinical judgment Orders appropriate diagnostic studies and interprets ndings to manage patients care in collaboration with physicians and other members of the healthcare team as necessary Prescribes medications, therapeutics, and monitoring modalities in collaboration with physicians and other members of the healthcare team as necessary Elicits comprehensive history and performs physical examinations on the basis of each patients initial signs and symptoms Develops a list of differential diagnoses on the basis of ndings obtained from each patients medical history and ndings on physical examination Synthesizes, interprets, makes decisions and recommendations, and evaluates responses on the basis of complex, sometimes conicting, sources of data Initiates appropriate referrals and performs consultations Advocacy and moral agency Empowers patients and patients families to act as their own advocates
Carolina, Tennessee, and Virginia. Sixteen jurisdictions were not represented by either cohort.
Criticality and Frequency
The list of 65 advanced practice nursing activities performed in the care of acutely and critically ill patients is organized within the 8 characteristics of nurses of the Synergy Model as shown in Table 4. Respondents were asked to rate the criticality and frequency of each activity. Criticality describes how critical the activity is to optimizing the outcomes for acute and critically ill patients. The mean criticality rating for each nurse characteristic for CNS and ACNP respondents was obtained. The criticality ratings for the CNS respondents indicated that the 8 characteristics of nurses are
generally moderately to highly critical to optimizing outcomes for acute and critically ill patients. With only a single exception, the criticality ratings of the ACNP respondents were slightly lower than those of the CNS respondents. For collaboration, both the CNS and the ACNP respondents rated the characteristic as moderately to highly critical. The advanced practice activities that the CNS respondents rated highest on the criticality scale were associated with the characteristics of clinical judgment and clinical inquiry. The advanced practice activities that ACNP respondents rated highest on the criticality rating scale were associated with clinical judgment and reected the primary role of ACNPs in directly providing care to patients (Tables 7 and 8).
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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
Mean frequency score Activity Clinical judgment Develops, implements, evaluates, and modies plans of care for individual patients and patients families and cohorts Prescribes medications, therapeutics, and monitoring modalities in collaboration with physicians and other members of the healthcare team as necessary Elicits comprehensive history and performs physical examinations on the basis of each patients initial signs and symptoms Develops a list of differential diagnoses on the basis of ndings obtained from each patients medical history and ndings on physical examination Orders appropriate diagnostic studies and interprets ndings to manage patients care in collaboration with physician and other members of the healthcare team as necessary Initiates appropriate referrals and performs consultations Performs invasive procedures (eg, placement of pulmonary artery catheters, central venous catheters, arterial catheters; thoracentesis; lumbar punctures) Advocacy and moral agency Empowers patients and patients families to act as their own advocates CNS 3.9 2.7 2.8 2.5 2.4 3.1 1.2 ACNP 4.9 4.9 4.7 4.8 4.9 4.7 2.2
3.3
4.3
Frequency ratings of the CNS and ACNP respondents were generally similar for the advanced practice activities. However, for 8 of the activities, the frequency ratings of CNS and ACNP respondents differed by 1 level or more (Table 9). Of the 8 activities, 7 are in the area of clinical judgment. Of the 65 activities, both the CNS and ACNP respondents performed all but 1 activity at least once a month. The remaining activity, Performs invasive procedures (eg, placement of pulmonary artery catheters, central venous catheters, arterial catheters; thoracentesis; lumbar punctures), was performed less than once a month by the CNS respondents. However, 2% of the CNSs who responded reported performing invasive procedures, although much less often then the ACNP respondents (Table 9).
Spheres of Inuence
the activities were directed toward more than a single sphere of inuence. The largest difference in responses from the CNS and ACNP respondents was the difference in the time each spent with individual patients. Consistent with the diversity of roles of CNSs, these respondents were more likely to direct their time to nursing personnel (36%), populations of patients (21%), and other disciplines, organizations, or systems (17%). As expected, and reflecting the direct care role of ACNPs, these respondents direct 74% of their practice toward individual patients, whereas the CNS respondents directed only 26% of their practice time to individual patients. ACNP respondents directed relatively equal amounts of time to the other spheres of inuence.
Ratings of Problems Related to Patients Care by CNSs and ACNPs
The Survey of Patient Care Problems in Acute and Critical Care Nursing Practice was conducted to collect data that would validate the 65 advanced clinical activities identied by the practice analysis task force. Each respondent was asked to assign a sphere of inuence (individual patient, populations of patients, nursing staff, or others) to each of the activities as it related to the respondents practice. The mean percentage of practice time that respondents directed toward the spheres of inuence was determined (Table 10). For both CNSs and ACNPs, many of
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The Survey of Patient Care Problems in Acute and Critical Care Nursing Practice was disseminated to 125 CNSs and 125 ACNPs. Of the 250 surveys sent, 143 were completed and returned, resulting in a 62% return rate for CNSs and a 43% return rate for ACNPs. A total of 54% of CNS respondents reported working primarily in a community hospital (nonprofit) setting, and 20% reporting working in a university medical center. In contrast, ACNP respondents were most likely to work in a university medical center (29%), and then either a nonprot (19%) or a for-prot (16%) community hospital.
Table 10 Mean percentage of practice directed toward each sphere of inuence by clinical nurse specialists (CNSs) and acute care nurse practitioners (ACNPs) responding to the advanced practice survey
Percentage Sphere of inuence Individual patients Populations of patients Nursing personnel Other disciplines, organizations, or systems CNS Mean SD 25.8 21.4 36.2 16.7 20.8 13.5 21.2 14.6 ACNP Mean SD 73.9 9.4 9.6 7.3 20.5 12.4 7.9 10.5
At least 20% of the CNS cohort indicated each of 6 primary employment settings: combined ICU/coronary care unit (29%), medical ICU (28%), telemetry unit (23%), cardiovascular/surgical ICU (23%), step-down unit (20%), and surgical ICU (20%). Three employment settings were indicated by more than 20% of ACNP respondents: step-down unit (27%), medical cardiology unit (22%), and telemetry unit (22%). CNS respondents reported that the acuity levels of the majority of their patients were critical; however, about one fourth of their patients require acute care, and about 6% require subacute care. Conversely, for the ACNP respondents, the acuity levels of their patients were almost equally distributed among the 3 acuity levels. Table 11 lists the problems related to patients care organized by systems. The percentages of time that CNS and ACNP respondents devoted to such problems in each system was calculated. Table 12 lists those problems for which the percentages of time allocated to the problem differed by 5% or more between ACNPs and CNSs. CNSs most often provided care for patients with life-threatening coagulopathies, acute renal failure, diabetic ketoacidosis, chronic renal failure, and septic shock. ACNP respondents reported caring most often for patients with acute hypoglycemia, life-threatening coagulopathies, stroke, chronic lung disease, gastroesophageal reux, acute renal failure, chronic renal failure, and septic shock. Four problems required large amounts of time for both CNSs and ACNPs: acute and chronic renal failure, life-threatening coagulopathies, and septic shock.
Experience Inventory
and/or monitoring device? The following scale was used: 0 = Never 1 = Less than once a month 2 = At least once a month, but less than every week 3 = At least once a week, but less than 3 times a week 4 = At least 3 times a week. Mean frequency ratings for the CNS and ACNP survey participants were calculated and compared. Generally, the frequency ratings of CNS and ACNP respondents were similar for the advanced practice activities. The percentage of respondents who rated each item as unique to critical care was also included. Six items were rated by more than 90% of the participants as unique to critical care: hemodynamic monitoring and/or pulmonary artery monitoring (92%); cardiac assist devices (92%); pulmonary artery monitoring (96%); invasive determination of cardiac output and cardiac input (93%); direct monitoring of the right atrium, left atrium, or pulmonary artery (94%); and monitoring of intracranial pressure (93%). Respondents conrmed that all of the items on the inventory were experienced by both the ACNPs and CNSs caring for patients with critical and acute illness.
Discussion
In order for the AACN Certication Corporation to support its current and future certication initiatives, a study of practice of acute and critical care nursing was conducted between 2001 and 2003. Only that part of the study relative to advanced practice nurses is presented here. A practice analysis task force set out to dene the activities performed by ACNPs and to conrm that the activities performed by CNSs remained as previously dened. In addition, frequency ratings for the activities of advanced practice nurses, an experience inventory, and problems related to patients care were obtained from the study respondents. As the term ACNP denotes, care provided by these practitioners occurs in areas where acute or critical care is provided. Indeed, respondents reported that the care provided by these practitioners occurred in areas outside of traditional critical care units, such as cardiac catheterization laboratories, burn units, private practice, outpatient clinics, and medical cardiology areas. In Kleinpells most recent study,26 similar practice areas were identied; however, the ndings are in contrast to the care provided by CNSs in our study, which was provided primarily in ICUs and reflected the study sample.
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For comparison purposes, respondents were asked to provide a frequency rating for each item on the experience inventory (Table 13). Respondents were asked this question: During the past year, how frequently did you provide direct bedside care to patients receiving this intervention, test, procedure, medication,
Table 11 Problems related to patients care, organized by system

Cardiovascular Myocardial conduction system defects Acute congestive heart failure/pulmonary edema Cardiogenic shock Congenital heart defect/disease Hypovolemic shock Dysrhythmias Acute myocardial infarction/ischemia Acute inammatory disease Cardiomyopathies Cardiac trauma Acute coronary syndromes Conduction defects Heart failure Pulmonary edema Hypertensive crisis Shock states Structural heart defects Ruptured or dissecting aneurysm Acute peripheral vascular insufciency Cardiac tamponade Cardiac surgery Pulmonary hypertension Pulmonary Acute respiratory infections Respiratory distress syndrome Transient tachypnea of the newborn Pulmonary hypertension Pulmonary trauma Pulmonary aspirations Air-leak syndromes Chronic lung disease Apnea of prematurity Congenital anomalies Acute respiratory failure Thoracic trauma Acute respiratory distress syndrome Respiratory distress Status asthmaticus, exacerbation of chronic obstructive pulmonary disease, emphysema, bronchitis Acute pulmonary embolus Thoracic surgery Aspirations Bronchopulmonary dysplasia Endocrine Inborn errors of metabolism Infant of diabetic mother Acute hypoglycemia Syndrome of inappropriate secretion of antidiuretic hormone Diabetes insipidus Diabetic ketoacidosis Adrenal disorders Syndrome of inappropriate diuresis Hyperglycemic hyperosmolar nonketotic coma Hematology Life-threatening coagulopathies Immunosuppression Hyperbilirubinemia Anemia of prematurity Organ transplantation Sickle cell crisis HELLP syndrome Neurology Hydrocephalus Neurological infectious diseases Seizure disorders Encephalopathy Spinal fusion Acute spinal cord injury Congenital neurological abnormalities Neuromuscular disorders Aneurysm Space-occupying lesions Stroke (embolic events, hemorrhagic) Intracranial hemorrhage/intraventricular hemorrhage Neurosurgery Neuromuscular disorders Gastrointestinal Gastrointestinal abnormalities Bowel infarction/obstruction/perforation Gastroesophageal reux Hepatic failure/coma Acute abdominal trauma Acute hemorrhage Pancreatitis Gastrointestinal surgeries Renal Acute renal failure Congenital renal-genitourinary abnormalities Renal trauma Acute and chronic renal failure Life-threatening electrolyte imbalances Near-drowning Multisystem Septic shock/infectious diseases Exposure to toxic agents Asphyxia Low birth weight/prematurity Life-threatening maternal-fetal complications Ingestions and inhalations of toxic agents Burns Hemolytic uremic syndrome Multisystem trauma Systemic inammatory response syndrome, sepsis, multiorgan dysfunction syndrome
A debate about combining the CNS and ACNP role has ensued since 1986. Analysis of masters degree programs to prepare advanced practice nurses has shown the same basic core curriculum for ACNPs and CNSs,
with the exception that ACNP curricula emphasize history taking, physical assessment, and pharmacology.29 Moloney-Harmon4 described the practice of the CNS by using the 8 competencies of nurses of the
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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
Percentage of time Problem Cardiovascular Acute congestive heart failure/pulmonary edema Pulmonary Acute respiratory distress syndrome Chronic lung disease Pulmonary hypertension (eg, persistent pulmonary hypertension of the newborn) Respiratory distress (eg, emphysema, bronchitis) Endocrine Acute hypoglycemia Adrenal disorders (eg, adrenal insufciency) Diabetic ketoacidosis Syndrome of inappropriate diuresis Hematology/immunology Immunosuppression (eg, Rh incompatibilities, blood group incompatibilities, hydrops fetalis, congenital, acquired [HIV infection, AIDS, neoplasms]) Life-threatening coagulopathies (eg, idiopathic thrombocytopenia purpura, disseminated intravascular coagulation, hemophilia, heparin-induced thrombocytopenia, ReoPro-induced) Organ transplantation (eg, liver, bone marrow, kidney, heart, pancreas, lung) Neurology Head trauma (blunt, penetrating) Neurosurgery (eg, evacuation of hematoma, tumor resection) Stroke (embolic events, hemorrhagic) Gastrointestinal Gastroesophageal reux Gastrointestinal surgeries (eg, Whipple procedure, esophagogastrectomy, gastric bypass) Renal Acute renal failure (eg, acute tubular necrosis, hypoxia, dialysis) Chronic renal failure Multisystem Septic shock/infectious diseases (eg, congenital viral, bacterial, catheter sepsis, nosocomial infections, immunosuppression) Systemic inammatory response syndrome, sepsis, multiorgan dysfunction syndrome Ingestions and inhalations of toxic agents (eg, drug/alcohol overdose, poisoning) CNS 11.9 12.7 9.3 1.0 5.4 14.4 6.3 46.3 2.8 23.8 54.3 8.8 13.7 10.1 19.9 5.9 15.7 43.3 31.0 31.0 23.2 10.5 ACNP 4.5 4.1 18.9 6.6 10.7 36.2 12.2 9.2 7.9 9.5 63.1 16.8 5.1 3.7 40.9 32.9 9.1 31.7 42.2 53.6 12.9 3.9
Synergy Model. Interventions were delineated on the basis of the 3 spheres of inuence: patients and patients families, nurse-nurse, and system. As noted, CNS practice had historically been delineated on the basis of roles, including clinician, educator, researcher, and consultant.12 Nurse practitioner practice has also been defined by using the same roles.30 However, in the study we report here, the majority of ACNP time was spent in the role of clinician, directing practice toward the individual patient sphere of inuence. This nding is 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 inuence asked about in the survey. In 2003, the ANCC conducted a role delineation study31 of nurse practitioners in 7 different specialties:
acute care, adult, family, gerontology, pediatric, adult psychiatric, and mental health. In that study,31 data were collected on the roles and responsibilities of nurse practitioners working in each of these specialties. Response rates ranged among specialties from 17% to 51.4%. Similar to the ndings in our study, the majority of the respondents in the ANCC study were women (93%). A total of 43% of the respondents were between the ages 41 and 50 years, a nding that parallels the ACNP respondents in our study, 76% of whom indicated that they were 35 to 54 years old. The ANCC assessed frequency (how often an activity was performed, ranging from never to daily or approximately every other day), performance expectation (when the ACNP was expected to perform this activity on the job, ranging from never to within the rst 6 months as an ACNP), and consequence (what
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Table 13 Experience inventory items

Cardiovascular Electrocardiographic monitoring 12-Lead electrocardiogram Hemodynamic and/or pulmonary monitoring Percutaneous transluminal coronary angioplasty Transcutaneous (external) pacemakers External pacemakers (eg, transesophageal) Temporary pacemakers Programmable pacemakers Internal pacemakers Automatic implantable cardioverter debrillators Phosphodiesterase inhibitors (eg, amrinone, milrinone) Cardiac assist devices (eg, intra-aortic balloon pump, right ventricular assistive device, biventricular assistive device, left ventricular assistive device) Pericardiocentesis Neonatal resuscitation Arterial pressure monitoring Central venous pressure monitoring Pulmonary artery pressure monitoring Invasive cardiac output/index determination Direct right atrial, left atrial, pulmonary artery pressure monitoring Umbilical arterial and venous pressure monitoring Hematology/immunology Blood product administration Blood screening and typing Immunizations Exchange transfusions Modes of phototherapy (eg, ber-optic blanket, halogen lights) Plasmapheresis Renal Ultraltration Renal replacement therapies Pulmonary Pulse oximeter Pulmonary monitor Continuous respiratory monitors End-tidal carbon dioxide monitor Nasal/facial continuous positive airway pressure, bilevel positive airway pressure Conventional mechanical ventilation Heliox Pressure control/support ventilation Nonconventional mechanical ventilation (eg, high frequency, jet/oscillating) Survanta Surfactant replacement therapy Rapid ventilation systems, pediatric high frequency Oscillating ventilators, pediatric jet oscillating High-frequency ventilation Synchronized ventilation Train-of-four (peripheral nerve stimulator) Nitric oxide Extracorporeal membrane oxygenation Airway management (eg, new tracheostomy, endotracheal tube) Chest tubes Neurology Intracranial pressure monitoring devices Ventriculostomy Extraventricular drain Brain resuscitation Ventricular reservoirs/shunt Gastrointestinal Sclerosing therapies Trophic feedings Parenteral and enteral feeding systems Multisystem Immunoglobulin therapy
degree of harm would come to a patient if the activity were performed incorrectly, ranging from little to severe harm). Criticality data were calculated on the basis of these 3 variables, a different method than was used in our study. The respondents in our study were asked to rate the 65 advanced practice activities on how critical each activity is to optimizing the outcomes of acute and critically ill patients. The CNSs rated 8 activities in the nurse characteristics of clinical judgment and clinical inquiry as most critical, and the ACNPs rated 8 activities in the nurse characteristic of clinical judgment as most critical. Again, this focus on clinical judgment corresponds to the main focus of patients care. The 8 activities rated highest in frequency by the ACNPs (Table 8) were also reported to be performed by the ACNPs in the Kleinpell study.26 Only a single activity was performed less than once a month by both ACNPs and CNSs: performing
invasive procedures (eg, placement of pulmonary artery catheters, central venous catheters, arterial catheters; thoracentesis; lumbar punctures). Although CNSs are generally not thought of as performing invasive procedures, 2% of the CNS respondents reported performing an invasive activity less than once a month. ACNPs are often thought of as spending a majority of their time performing invasive procedures; however, we found this idea to be untrue. Kleinpell 26 also found that ACNPs do not spend most of their time performing invasive procedures. Nurse practitioner respondents in the ANCC study who worked as ACNPs or adult nurse practitioners reported spending 73% and 76%, respectively, of the time with direct care of patients. This nding is consistent with the ndings of our study, in which ACNPs reported spending most of their time with activities associated with clinical judgment. ACNPs and adult nurse practitioners in the ANCC study spent 12% and
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13% of their time, respectively, with management, supervision, and administrative issues, and they spent 10% and 11%, respectively, teaching. Both groups spent 7% of their time with research activities and 11% performing consultation with staff. However, in the ANCC study, 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 by the participants in the current study reect the settings in which care is provided by advanced practice nurses in acute and critical care. Both CNSs and ACNPs reported focusing much of their attention on problems such as life-threatening coagulopathies, acute and chronic renal failure, and sepsis or problems stemming from infectious diseases. CNSs focus more of their time than their ACNP counterparts do on diabetic ketoacidosis, immunosuppression, and ingestions of toxic agents. ACNPs focus more of their time on problems such as stroke, acute hypoglycemia, and gastroesophageal reux disease. Interestingly, the last 3 problems have a component of chronicity, a characteristic that either may indicate that the care provided by ACNPs goes beyond the acute episode or may reect the recidivism of acute care patients. No comparison data are available. Study respondents were asked to rate how frequently each item was performed in their practice. Six items were rated at greater than 90% by the participants as unique to critical care. Of the 6 items, 4 involved hemodynamic monitoring. All of the items on the inventory were reported to be unique to critical care by the respondents. Many of these items were also reported to be performed by ACNPs in the Kleinpell study.26
the CCNS certication examination program certies clinical nurse specialists in acute and critical care. Study participants were asked where they were employed, but more importantly, the study concentrated on the types of patients being cared for by CNSs and ACNPs, and the competencies needed by those advanced practice nurses to provide that care, regardless of the clinical setting in which the nurses practiced.
Summary
The activities performed by advanced practice nurses who work with acute and critically ill patients have been described and discussed on the basis of the nurse competencies of the Synergy Model. Definite differences in the roles and practices of the ACNPs and CNSs were found. Findings from this study have been and will be incorporated into the AACN Certication 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. Moseley, 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.
REFERENCES 1. Niebuhr B. Credentialing of critical care nurses. AACN Clin Issues. 1993; 4:611-616. 2. Benner, P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, Calif: Addison Wesley; 1984. 3. Professional Examination Service. Final Report for Phase 1 in the Development of a Certication Examination Program for Clinical Nurse Specialists (CNSs): Role Delineation Study for CNSs Caring for Acutely and Critically Ill Patients. New York, NY: Professional Examination Service; 1998. 4. Moloney-Harmon PA. The Synergy Model: contemporary practice of the clinical nurse specialist. Crit Care Nurse. April 1999;19:101-104. 5. Hardin S. Introduction. In: Hardin SR, Kaplow R, eds. Synergy for Clinical Excellence. Boston, Mass: Jones & Bartlett; 2005. 6. Curley MAQ. Patient-nurse synergy: optimizing patients outcomes. Am J Crit Care. 1998;7:64-72. 7. The AACN Synergy Model for Patient Care: Assumptions guiding the Synergy Model. Available at: http://www.certcorp.org/certcorp/certcorp.nsf /vwdoc/SynModel?opendocument#Assumptions%20Gu. Accessed January 10, 2006. 8. Kaplow R. Synergy Model: guiding the practice of the CNS in acute and critical care. In McKinley M, ed. AACN: Acute and Critical Care Clinical Nurse Specialists: Sharing Best Practices. New York, NY: Elsevier, in press. 9. American Association of Critical-Care Nurses. Standards for Acute and Critical Care Nursing Practice. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 2000. 10. Practice Analysis Task Force. Assumptions Guiding the Synergy Model. Aliso Viejo, Calif: AACN Certication Corporation; 2002. Work Product from February 8, 2002. 11. Hamric AB. A definition of advanced nursing practice. In: Hamric AB, Spross JA, Hanson CM, eds. Advanced Nursing Practice: An Integrative Approach. Philadelphia, Pa: WB Saunders Co; 1996. 12. Hamric AB, Spross JA, eds. The Clinical Nurse Specialist in Theory and Practice. Orlando, Fla: Grune & Stratton Inc; 1983. 13. Hamric AB, Spross JA, eds. The Clinical Nurse Specialist in Theory and Practice. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1989. 14. National Association of Clinical Nurse Specialists. Statement on Clinical Nurse Specialist Practice and Education. Harrisburg, Pa: National Association of Clinical Nurse Specialists; 2004. 15. Zuzelo PR. Clinical nurse specialist practice: spheres of inuence. AORN J. 2003;77:361-372.
Limitations
The most signicant limitation of our study is the limited number of ACNP respondents. Therefore, the results of this study specically related to the roles of ACNPs reect the subset of certied ACNPs who participated in the study. However, despite the number of participants, the results of our study are consistent with the results of both the ANCC study31 and Kleinpells most recently reported study.26 AACN Certification Corporation recognizes the effect of the dynamic healthcare environment on critical care nursing practice. Although high-acuity patients are still cared for in intensive care settings, many patients traditionally cared for in those areas may now be admitted to or cared for in other units. The corporation acknowledges that critical care nursing is not limited to the walls of traditional intensive care settings, and so
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16. Cohen SS, Crego N, Cuming RG, Smyth M. The Synergy Model and the role of clinical nurse specialists in a multihospital system. Am J Crit Care. 2002;11:436-446. 17. American Association of Critical-Care Nurses. Standards of practice and professional performance for the acute and critical care clinical nurse specialist. Available at: http://www.aacn.org/AACN/pubpolcy.nsf/vwdoc/pmp. Accessed January 10, 2006. 18. Becker DE, Richmond TS. Advanced practice nurses on acute care services. In: Mezey MD, McGivern DO, Sullivan-Marx EM, eds. Nurse Practitioners: Evolution of Advanced Practice. 4th ed. New York, NY: Springer; 2003. 19. Miller SK. Dening the acute in acute care nurse practitioner. Clin Excell Nurse Pract. 1998;2:52-55. 20. American College of Physicians. Physician assistants and nurse practitioners. Ann Intern Med. 1994;121:714-716. 21. American Nurses Association and American Association of Critical-Care Nurses. Standards of Clinical Practice and Scope of Practice for the Acute Care Nurse Practitioner. Washington, DC: American Nurses Publishing; 1995. 22. Kleinpell RM. Acute-care nurse practitioners: roles and practice proles. AACN Clin Issues. 1997;8:156-162. 23. Kleinpell RM. Reports of role descriptions of acute care nurse practitioners. AACN Clin Issues. 1998;9:290-295. 24. Kleinpell-Nowell R. Longitudinal survey of acute care nurse practitioner practice: year 1. AACN Clin Issues. 1999;10:515-520. 25. Kleinpell-Nowell R. Longitudinal survey of acute care nurse practitioner practice: year 2. AACN Clin Issues. 2001;12:447-452. 26. Kleinpell RM. Acute care nurse practitioner practice: results of a 5-year longitudinal study. Am J Crit Care. 2005;14:211-219. 27. National Panel for Acute Care Nurse Practitioner Competencies. Acute Care Nurse Practitioner Competencies. Washington, DC: National Organization of Nurse Practitioner Faculties; 2004. 28. Browning AH, Bugbee AC, Mullins MA, eds. Certification: A NOCA Handbook. Washington, DC: National Organization for Competency Assurance; 1996. 29. Forbes KE, Rafson J, Spross J, Kozlowski D. The clinical nurse specialist and nurse practitioner: core curriculum survey results. Clin Nurse Spec. 1990;4:63-66. 30. Hanson C, Martin LL. The nurse practitioner and clinical nurse specialist: should the roles be merged? J Am Acad Nurse Pract. 1990;2:2-9. 31. American Nurses Credentialing Center. A Role Delineation Study of Seven Nurse Practitioner Specialties. Silver Spring, Md: American Nurses Credentialing Center; 2004.
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Activities Performed by Acute and Critical Care Advanced Practice

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Activities Performed by Acute and Critical Care Advanced Practice Nurses: American Association of Critical-Care Nurses Study of Practice

Deborah Becker, Roberta Kaplow, Patricia M. Muenzen and Carol Hartigan

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

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Participation in care Participation in decision making Predictability

The AACN Synergy Model for Patient Care

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

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

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Advocacy and moral agency Caring practices Collaboration

Clinical inquiry Facilitator of learning

Advanced Practice Nursing

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

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System Recidivism, costs/resource utilization

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

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Development of a Comprehensive Description of Critical Care Nursing Practice

Research Design and Method

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

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

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

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

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

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ACNP (n = 77) No. 2 0 0 4 1 1 2 0 0 3 2 0 0 6 0 0 0 0 3 0 5 2 3 1 2 2 0 0 0 0 3 0 4 3 0 3 1 0 4 0 0 4 0 4 6 0 1 4 0 0 1 0 % 3 0 0 5 1 1 3 0 0 4 3 0 0 8 0 0 0 0 4 0 6 3 4 1 3 3 0 0 0 0 4 0 5 4 0 4 1 0 5 0 0 5 0 5 8 0 1 5 0 0 1 0

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

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

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

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

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Table 11 Problems related to patients care, organized by system

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

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

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Table 13 Experience inventory items

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

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

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

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