Bonnie S. Niebuhr, MS, RN, CAE, ABPANC CEO Patricia Muenzen, MA, PES Director of Research

Transcription

1 ABPANC S Role Delineation Study: The Foundation for the CPAN and CAPA Certification Examinations Bonnie S. Niebuhr, MS, RN, CAE, ABPANC CEO Patricia Muenzen, MA, PES Director of Research Perianesthesia nursing certification, sponsored by ABPANC, is designed to promote and enhance the quality of care delivered to patients receiving anesthesia, sedation or analgesia. ABPANC sponsors two certification programs for qualified Registered Nurses: the CPAN program (Certified Post Anesthesia Nurse) and the CAPA program (Certified Ambulatory Perianesthesia Nurse). At the time this study was conducted there were 6,618 perianesthesia nurses holding the CPAN and/or CAPA certification credentials. This report (which serves as a White Paper for ABPANC) describes ABPANC s most recent Role Delineation Study (RDS) conducted in Included in this discussion are background information about the process leading up to the study, methods, findings, and implications. BACKGROUND Certification versus Licensure To understand the relevance of a RDS to the certification of perianesthesia nurses, it is important to distinguish between RN licensure and specialty certification. Certification, as defined by the American Board of Nursing Specialties (ABNS) and adopted by ABPANC, is the formal recognition of the specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal health outcomes. 1 Whereas state licensure provides the legal authority for an individual to practice professional nursing, private voluntary certification, as sponsored by ABPANC, reflects achievement of a standard beyond licensure for specialty nursing practice. Achievement of CPAN and/or CAPA certification status represents the knowledge and experience necessary to practice in a particular specialty in this case, perianesthesia nursing. Certification of Perianesthesia Nurses ABPANC, founded in 1985, offered the CPAN certification examination for the first time in At that time, anesthesia nursing was primarily delivered in inpatient settings. Given the changing healthcare environment and the emerging trend of outpatient surgery, ABPANC began to investigate the need for a separate certification examination related to ambulatory postanesthesia nursing in The first CAPA examination related to this emerging specialty area was given in

2 ABPANC s Mission ABPANC s activities are focused on achieving its mission of assuring a certification process for perianesthesia nurses that validates the achievement of knowledge gained through professional education and experience, ultimately promoting quality patient care. ABPANC s mission is driven by its commitment to: professional practice; advocating the value of certification to healthcare decision-makers and the public; the administration of valid, reliable, and fair certification programs; ongoing collaboration with the American Society of Perianesthesia Nursing (ASPAN), other specialty organizations, and key stakeholder groups; and evolving psychometric and technological advances in testing. Demonstrating Validity and Reliability Since their inception, the CPAN AND CAPA certification programs have been based on the results of a Role Delineation Study (RDS). Conducting a RDS, also called a job analysis or Study of Practice, is key to demonstrating the validity and reliability of specialty nursing certification examinations. Several groups have provided standards and guidance regarding the role of the job analysis in ensuring fair, valid, and reliable certification processes. The American Board of Nursing Specialties (ABNS) and the National Commission for Certifying Agencies (NCCA), both private sector groups, have established criteria for accrediting certifying agencies. Their standards are intended to assure the public that the credentials granted by certifying organizations are based on reliable and valid procedures. ABNS accreditation is the only accreditation specific to nursing. Credentialing bodies seeking accreditation by either organization are required to conduct a RDS (job analysis) to support the validity of their examinations. ABPANC achieved ABNS accreditation in 2004 and is due to submit a reaccreditation application in ABNS accreditation is granted for five years. In the Standards for Educational and Psychological Testing 3, standards are identified that address the issues of examination reliability and validity. A set of standards has also evolved under the auspices of the U.S. Equal Employment Opportunities Commission for the purpose of ensuring equitable employment practices under Title VII of the 1964 Civil Rights Act. In 1978 the EEOC published the Uniform Guidelines on Employee Selection 4 to ensure that assessment practices related to employment be job related and valid. A major RDS undertaken in led to the re-conceptualization of the model on which the CPAN and CAPA test blueprints are based. 5 In that study, the needs of perianesthesia patients were seen as the driving force for the competencies required of the certified perianesthesia nurse. The re-conceptualized model specified four domains of 2

3 perianesthesia patient needs: Physiological, Behavioral and Cognitive, Safety, and Advocacy. The new conceptual framework for the CPAN and CAPA certification examinations evolved into a model driven by the needs of perianesthesia patients, regardless of the setting in which they received perianesthesia nursing care. The needs of perianesthesia patients define the knowledge, skills, and abilities that are required of the certified perianesthesia nurse who is providing care. At the time this study was conducted, a patient s anesthetic experience was conceptualized as occurring in four phases called the Perianesthesia Continuum of Care 6 : 1. Preanesthesia Phase: a. Preanesthesia Phase - during this time the patient undergoes a presurgery interview and assessment to identify potential or actual problems b. Day of Surgery/Procedure - interview and assessment data validated and updated; patient prepared for surgery both physically and emotionally 2. Postanesthesia Phase I: Patient moves from a totally anesthetized state to one requiring less acute nursing interventions. 3. Postanesthesia Phase II: Patient is prepared for self or family care or for care in a Phase III or extended care environment 4. Postanesthesia Phase III: Patient may require extended observation/interventions after transferring or being discharged from Phase I or II. Interventions are directed toward preparing the patient for self or family care. The identified that the patient needs and perianesthesia nursing knowledge required to meet these needs is the same for both the CPAN and CAPA certification examinations. Data from that study showed that the difference between CPAN and CAPA certified nurses is the time spent meeting patient needs in the four domains. Thus, the percentage of exam content for each domain differs depending on whether the candidate takes the CPAN or CAPA certification examination. In other words, the examination candidate decides which examination is most relevant to their practice, based on what their patient needs are and the amount of time patients spend in the specific phases described in the Perianesthesia Continuum of Care. Regardless of the setting in which the candidate practices, if most of their time is spent caring for patients in Phase I, the CPAN examination is most relevant. If most of their time is spent caring for patients in the Preanesthesia phase, Phase II, and/or Phase III, the CAPA examination is most relevant. The RDS This report addresses a focused RDS update that was conducted in , the results of which led to a set of updated test blueprints (or content outlines) for the two certification examinations. The purpose of the study was to review and update the patient needs and related nursing knowledge, and to survey the profession as to the relative emphasis of each domain. 3

4 ABPANC contracted with Professional Examination Service (PES) and a planning meeting was held in July An Advisory Team was formed to oversee the study process and to serve as content experts. PES identified a timetable of activities to ensure the timely completion of the study. A description of the study goals, methods and findings follows. GOALS OF STUDY The goals of the RDS were to: Update the RDS; Delineate needs of perianesthesia patients in four domains; Delineate the knowledge base required to meet patient needs; Explore differences between CPANs and CAPAs; and Develop revised test specifications for the two certification examinations. METHODS The Advisory Team of content experts concurred that the four domains of perianesthesia patient needs were still relevant. They reviewed and updated the patient needs within each of the four domains and the associated nursing knowledge required to meet those needs based on current trends in perianesthesia practice. The patient needs were refined and one new need was identified in the area of Advocacy - Information/education regarding informed consent. The following knowledge statements were added: Evidencebased practice, Postoperative and post-discharge nausea and vomiting assessment and management; and Injury prevention. In addition, the Advisory Team reviewed the Institute of Medicine (IOM) Core Competencies 7 and determined that they were reflected within the conceptual model for the CPAN and CAPA certification examinations. The Advisory Team also reviewed the competences developed by The John A. Hartford Foundation Institute for Geriatric Nursing 8 to determine if geriatric nursing care was adequately addressed. To underscore that geriatric care is a key element of the CPAN and CAPA test blueprints, the wording All content reflects patients needs across the lifespan in a variety of settings was added as a heading to each domain of the test blueprint. Survey Development A web-based survey was developed to gather validation data from practicing CPANs and CAPAs with respect to each of the elements of the updated role delineation. In the first part of the survey, participants made two ratings with respect to each of the 51 patient needs: (1) how frequently they addressed the need in the patients to whom they provided care and (2) how much harm could result if the need was not met. In the second part of the survey, participants made two ratings for each of the 44 perianesthesia nursing knowledge elements: (1) how frequently they used the knowledge and (2) the cognitive level at which they used it. In the third part of the survey, CPAN participants were asked to estimate the percentage of the CPAN certification examination that should focus on 4

5 each domain of patient need. CAPA participants were asked the same question with respect to the CAPA certification examination. In the fourth and final section of the survey, respondents answered questions regarding their demographic and professional background. Piloting of Survey Each of the Advisory Team members was asked to nominate five CPAN or CAPA certified nurses to participate in a pilot of the RDS validation survey. Fifteen (15) CPANs and fifteen (15) CAPAs participated in the pilot survey. The only significant change made to the survey tool as a result of the feedback received from those completing the pilot survey was the use of a harm scale of None, Minimal, Moderate, and Considerable. Survey Dissemination 1160 CPAN certified nurses and 1040 CAPA certified nurses were randomly selected from the ABPANC database. Because addresses were not available for all of the selected individuals, a print invitation was mailed to each participant. The invitation included the link to the survey location and a unique password to be used by the participant to access the survey. A follow-up reminder postcard was sent one week later. The return rate for the survey was 48% (a total of 1009 of 2122 eligible, including 537 CPANs and 472 CAPAs), which is excellent for this type of study. The number eligible was calculated as the number invited minus the number that were either undeliverable or delivered to nurses who were no longer practicing. FINDINGS Characteristics of Respondents The respondent group represented all 50 states. Seventy-five percent of CPANs and 72% of CAPAs spent 80% -100% or more of their work time in direct patient care. Respondents were highly experienced, with 56% of CPANs and 47% of CAPAs having 16 or more years of experience in perianesthesia nursing. The respondent group was similar to the population of certified nurses in terms of level of education. However, in contrast to the certified population, the respondent group was more experienced, worked at larger facilities, and included more nurses in supervisory positions. The Advisory Team, reviewing these findings, believed that while the respondent group was different in some ways from the overall certificant population, the respondent group by virtue of their depth of experience was in a position to provide accurate judgments regarding the practice of the specialty. As would be expected, the majority of CPANs (81%) worked in hospital PACU settings; another 13% worked in ambulatory settings, and 6% worked in other settings. CAPAs worked primarily in the ambulatory setting: 71% percent of CAPAs worked in 5

6 ambulatory surgical units, 13% worked in PACU settings, and 17% worked in other settings. Regarding the percentage of time spent by CPANs and CAPAs caring for patients in the five phases of anesthesia, there was a dramatic difference in the time spent in Postanesthesia Phase I: CPANs spent 71% of their time caring for perianesthesia patients in this phase versus 21% for CAPAs. Relative to CPANs, CAPAs time was more evenly distributed caring for perianesthesia patients across Day of Surgery and Postanesthesia Phases I and II. Validation of Patient Needs Means, standard deviations, and frequency distributions were calculated for the two patient need rating scales (i.e., frequency and harm) and the two nurse knowledge rating scales (i.e., frequency of use and cognitive level). Subgroup analysis was conducted to compare the ratings of CPANs and CAPAs. All 51 of the perianesthesia patient needs were validated (found in Table 1) as frequently addressed by practitioners and causing harm if not addressed. Although validated for both CPANs and CAPAs, some differences emerged in the ratings of the two certificant groups. CAPAs address patient/family education and discharge planning more frequently than CPANs. This finding is consistent with the data showing that the CAPAs spent more time working in anesthesia phases where these types of needs are likely to be addressed. CPANs perceive physiological system stability needs as causing more harm if not addressed than CAPAs, consistent with their focus on the physiological needs manifest in Postanesthesia Phase I. Knowledge Required of Perianesthesia Nurses Forty of the 44 knowledge elements were used at least weekly on average and the remaining 4 (abnormal psychological/psychiatric states, special needs patient issues, multidisciplinary collaboration and referral, and conflict resolution/mediation techniques) were used at least monthly. Some differences emerged in the frequency of knowledge use by the two certificant groups. CPANs used several knowledge elements related to physiological patient needs more than CAPAs (i.e., fluid/electrolyte management, thermoregulation, post-operative and post-discharge nausea and vomiting, pre-emptive interventions, anesthetics, surgical/procedural interventions, and pharmacological interventions). CAPAs used five knowledge elements related to behavioral and psychosocial needs more than CPANs (i.e., discharge planning; diversity; teaching/learning theory; psychosocial/cognitive assessment; and impact of psychological issues on compliance, comfort, discharge and healing). The level of usage ratings indicated that the knowledge elements were used predominantly at an applied cognitive level as opposed to a recognition/recall level. A higher percentage of CPANs than CAPAs used knowledge of ACLSL/PALS, airway management, and anesthetic and reversal agents at the applied level. In contrast, a higher 6

7 percentage of CAPAs than CPANs used knowledge of discharge planning and criteria at the applied level. Because no knowledge elements were rated as never used, all 44 knowledge elements were validated. In addition, review of the 28 write-in responses to the question of whether any knowledge was missing from the delineation indicated that all 28 were already reflected in the delineation. The nursing knowledge elements validated by the study are listed in Table 2. Relationship between Patient Needs and Nursing Knowledge The goal of the CPAN and CAPA certification examinations is to assess the knowledge required of perianesthesia nurses to meet perianesthesia patient needs in the four domains of patient needs. The applicability of each knowledge element to addressing patient needs in each domain was explored. A linking task was performed in which the Advisory Team evaluated each of the 44 knowledge elements for applicability to addressing patient needs in each domain. The result of the linking task indicated that 29 knowledge elements address physiological needs, 30 address cognitive and behavioral needs, 24 address safety needs, and 16 address advocacy needs. Because a knowledge element can be drawn upon to address multiple patient needs across domains, any given knowledge element could have multiple linkages. The linkages provide the foundation for contentrelevant test questions, as item writers create questions assessing knowledge as it is applied in domain-specific contexts. DEVELOPMENT OF REVISED TEST BLUEPRINTS To develop blueprints for the two examinations, salience values were calculated for each patient need by using the frequency and harm ratings. Salience values were calculated by multiplying the respondents frequency and harm ratings. The most salient needs within each domain were identified to serve as the basis for greater testing emphasis. To create weights for the examinations, of the percentage of the relevant certification examination that should cover each domain of patient need were rounded to the nearest 5% in keeping with previous conventions. These domain weights are shown in Table 3. Although the percentage of time respondents reported spending in different phases of anesthesia were quite different for CPANs and CAPAs, their recommendations for test weights were similar. While CPANs spend 71% of their time addressing Phase 1 patient needs and CAPAs spend 21%, their recommendations regarding examination emphasis on physiological needs (which are most evident in phase 1) are similar. Table 4 compares the difference in these weightings from the previous study. The Advisory Team and the Board of Directors discussed the differences and agreed that they reflect the current practice environment where patients spend more time in Phase I and present with an increase in behavioral/cognitive needs and safety needs, than in the past. This change resulted in a slight decrease in the percentage of the CPAN test blueprint focusing on physiological needs. The factors resulting in changes to the CAPA test blueprint are due to an increase in patient needs related to safety and advocacy. The percentage weights identified in Table 3 were approved by the ABPANC Board of Directors and adopted by ABPANC for use in constructing the CPAN and CAPA 7

8 certification examinations beginning in April With these weights, the CPAN test blueprint places greater emphasis on behavioral/cognitive and safety patient needs and the CAPA test blueprint places greater emphasis on advocacy needs. IMPLICATIONS OF STUDY FINDINGS ON THE CPAN AND CAPA EXAMINATION PROGRAMS This study continued to support a model driven by patient needs. As a result of the study data, the changes to the CPAN and CAPA test blueprints were relatively minor. The data supports that patient safety needs and the role of the perianesthesia nurse in ensuring safety measures is a major public protection issue. Additional Guidance for Examination Development Salience values calculated for each patient need and knowledge area -- suggest relative testing emphasis Linkage data -- suggests focus for item development activities Usage ratings -- suggest most items should be written at an applied level Patient age and time in phase data -- useful context for items The goals of the study were achieved. While the patient needs and knowledge required to meet the needs were again validated, the need for two examinations is justified and the context of questions for the CPAN and CAPA certification examinations is different. SUMMARY Patients are at their most vulnerable when they are under the effects of anesthesia, sedation, or analgesia. Perianesthesia nurses must be proactive in ensuring patient safety and serving as patient advocate. ABPANC believes that certification of registered nurses caring for perianesthesia patients is a fundamental way of ensuring quality patient care delivery. ABPANC believes that organizing certification programs around meeting patient needs is most valuable in demonstrating the credibility and relevance of the certification program. As technology changes, so do patient needs. As patient needs change, so does nursing practice. It is key that a certifying organization, like ABPANC, maintains a test blueprint that is based on current practice. To that end, ABPANC is committed to conducting a Study of Practice or Role Delineation Study every 5 years, or more often if indicated. This study provided the opportunity for ABPANC to make very deliberate decisions about the framework on which the CPAN and CAPA examination programs are built. 8

9 References 1. ABNS, Retrieved March 10, 2005 from 2. ABPANC. Certification Handbook and Application. New York, NY, ABPANC, American Educational Research Association, American Psychological Association, National Council on Measurement in Education. Standards for Educational and Psychological Testing. Washington, DC. American Psychological Association, Inc Equal Employment Opportunity Commission, Civil Service Commission, Department of Labor, Department of Justice: Uniform guidelines on employee selection procedures. Washington, DC. Federal Register, 43:166, Niebuhr, B., and Muenzen, P. A Study of Perianesthesia Nursing Practice: The Foundation for Newly Revised CPAN and CAPA Certification Examinations, Journal of Perianesthesia Nursing, Vol 16, No. 3 (June), 2001: pp American Society of PeriAnesthesia Nurses: ASPAN Standards of Perianesthesia Nursing Practice. Cherry Hill, NJ, ASPAN, Institute of Medicine: Core Competencies from Health Professions Education: A Bridge to Quality. Washington, DC, The John A. Hartford Foundation, Institute for Geriatric Nursing and American Association of Colleges of Nursing. Older Adults: Recommended baccalaureate and curricular guidelines for geriatric nursing care. July

10 TABLE 1. Validated Perianesthesia Patient Needs Validated Patient Needs Physiological Needs Stability of respiratory system Stability of cardiovascular/ peripheral vascular systems Stability of neurological system Stability of musculoskeletal system Stability of gastrointestinal system Stability of renal system Stability of integumentary system Stability of endocrine system Maintenance of normothermia Physiological comfort (for example, relief from pain, shivering, nausea, and vomiting; temperature control and appropriate positioning) Therapeutic environment (for example, minimal interruption of normal regimen/preemptive interventions) Appropriate medication regimen (for example, minimal interruption of normal regimen/ preemptive interventions) Optimal level of physical independence Behavioral and Cognitive Needs Respect for diversity (for example, cultural, religious, physical, age-related, cognitive, and language differences) Psychosocial assistance for patient/family/significant other (for example, coping mechanisms, spiritual and emotional support) Consideration for ability to learn, learning style (for example, kinetic, auditory, visual), readiness to learn, and barriers to learning Patient/family/significant other education related to: admission procedures preparations for procedures/surgery anesthesia expectations post-anesthesia recovery settings to identifying, describing, and communicating pain perception/experience postoperative pain control measures, including pharmacological and non-pharmacological interventions discharge procedures/plans (for example, wound care, diet, ambulation, physical therapy, effects on sexuality, antibiotics, pain management, patient-controlled analgesia, dressing care, catheter care, equipment and medical devices, routine course, and/or potential complications) medications (for example, what and when to discontinue, when to restart, interactions with prescriptions, over the counter medications, herbal supplements, alcohol, and/or illegal drugs) impact of existing medical conditions (for example, diabetes, COPD, hypertension) on current surgery/procedure measures to assist healing process (for example, appropriate adjunctive therapies, consults, and/or referrals) measures to prevent complications (for example, ambulation) Interdisciplinary involvement in discharge planning (for example, case manager, dietician, and/or physical therapist) Optimal psychosocial independence 10

11 Safety Needs Delivery of care based on accepted standards of practice (for example, ASPAN Standards, Safe Medical Device Act, JCAHO, Accreditation Association for Ambulatory Health Care (AAAHC), and/or OSHA) Effective multidisciplinary discharge planning, regarding: presence of competent, responsible adult caregiver safe transport to home or discharge care site verbal and written discharge instructions ability to understand and comply with discharge instructions awareness of postoperative/postprocedural physical limitations availability of resources for care in the home preparation of safe home environment (for example, physical barriers and/or abuse assessment) Freedom from harm related to: use of protective safety devices (for example, padded side rails, safety straps, and/or restraints) immobility (for example, regional blocks) and/or positioning adverse environmental influences (for example, latex, equipment failure) exposure to infections and diseases Advocacy Needs Accurate and complete documentation and communication of information Information/education regarding: advance directives Patient Bill of Rights informed consent Access to: appropriate resources and referrals (for example, medical equipment, pharmaceutical care, pastoral care, nutritional education, physical/occupational therapy, and/or case management/social services) an environment that accommodates physical, mental, and emotional abilities/limitations an environment that provides assistance (for example, call light, personnel within hearing or at bedside, visitation) Post discharge assessment (for example, follow-up visit or telephone call) Privacy and confidentiality Care delivered legally and ethically 11

12 TABLE 2. Validated Perianesthesia Nursing Knowledge Nursing process Evidence-based practice Anatomy and physiology of body systems Growth and development Pathophysiology Normal and abnormal diagnostic values Acceptable deviations from normal physiologic states Diagnostic and therapeutic technology Physical assessment techniques ACLS/PALS Airway management Vital signs/hemodynamic monitoring Fluid and electrolyte management Thermoregulation Pain assessment and management (psychological, physiological, medical) Post-operative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV ) assessment and management (psychological, physiological, medical) Preemptive interventions (for example, analgesia, anesthesia, antiemetics, and/or fluids) Pharmacodynamics/pharmacokinetics Pharmacological interventions Anesthesia techniques (general and regional) Anesthetic and reversal agents Anesthesia recovery Surgical and procedural interventions Normal and abnormal physical response to surgery/procedure/anesthesia Environmental influences affecting patient care Alternative and adjunctive treatment modalities Discharge planning and criteria Cultural/religious/lifestyle diversity Teaching and learning theory Communication principles and techniques Psychosocial and cognitive assessment Impact of psychological issues (for example, coping styles, life situations, family issues, friendships, religious/spiritual issues) on compliance, comfort, discharge and healing Abnormal psychological/psychiatric states (for example, depression, or bipolar disorder) Special needs patient issues (for example, sign language, autism, and/or visual limitations) Multidisciplinary collaboration and referral Conflict resolution/mediation techniques Scope and standards of nursing practice (for example, ANA, ASPAN) Regulatory, legal, and ethical guidelines and standards of professional practice (for example, OSHA, patient of bill of rights, advance directives, informed consent, HIPAA) Injury prevention Infection control/standard precautions Quality assurance principles (for example, process improvement [PI] and/or CQI) Risk management concepts, principles, and techniques Data gathering: Information sources (files, charts, records) and patient/family interviews Measures to maintain privacy and confidentiality 12

13 TABLE 3. Domain Weights for New Test Blueprints for CPAN and CAPA Examinations Domain of Patient Need Percent of Examination CPAN CAPA Physiological Needs 50% 45% Behavioral & Cognitive Needs 20% 20% Safety Needs 20% 20% Advocacy Needs 10% 15% Comparison of Current and New Blueprints for CPAN and CAPA Examinations Percent of Examination Domain of Patient Need CPAN CAPA Current New Current New Physiological Needs 65% 50% 45% 45% Behavioral & Cognitive Needs 10% 20% 30% 20% Safety Needs 15% 20% 15% 20% Advocacy Needs 10% 10% 10% 15% TABLE 4. 13