Family Nurse Practitioner Role Delineation Study National Survey Results

Transcription

1 2011 Family Nurse Practitioner Role Delineation Study National Survey Results MARCH 2012

2 About this Report This report pertaining to the practice of family nurse practitioners was based on the results of a national study of practice of adult-gerontology, family, and pediatric primary care nurse practitioners.

3 Table of Contents ACKNOWLEDGEMENTS... 3 BACKGROUND... 5 ROLE DELINEATION STUDY OVERVIEW... 5 UPDATED TEST CONTENT OUTLINES... 5 ROLE OF THE CONTENT EXPERT PANELS... 5 SURVEY METHODOLOGY... 6 SURVEY CHRONOLOGY... 6 SAMPLE SELECTION... 6 SURVEY DEVELOPMENT AND MEASURES... 7 DATA COLLECTION... 8 DATA ANALYSIS... 9 SURVEY RESULTS DEMOGRAPHIC INFORMATION PRACTICE DESCRIPTIONS APPENDICIES WORK ACTITIVIES STATEMENTS... APPENDIX A DEMOGRAPHIC DATA SUMMARY... APPENDIX B WORK ACTIVITIES DESCRIPTIVE STATISTICS... APPENDIX C WORK ACTIVITIES MEAN OVERALL CRITICALITY -- RANK ORDER... APPENDIX D 2

4 Acknowledgements The American Nurses Credentialing Center (ANCC) wishes to thank a number of content experts who served on the 2011 ANCC Primary Care Nurse Practitioner (Adult- Gerontology, Family, and Pediatric) Role Delineation Study panels for sustaining this effort and producing a role delineation study of such high caliber. Without their numerous hours of input and feedback, the study would not be possible. Adult-Gerontology Primary Care Nurse Practitioner Sharon L. Verney, MSN, ANP-BC, GNP-BC Marianne Shaughnessy, MSN, ANP-BC Elizabeth B. Esstman, MSN, GNP-BC Deborah S. Croy, MSN, ANP-BC Denise Brown, MSN, GNP-BC April D. Bigelow, PhD, ANP-BC Kellie L Kahveci, MSN, ANP-BC, GNP-BC Ronda M. Thompson, MSN, ANP-BC, GNP-BC Viet H. Nguyen, MN, ANP-BC, GNP-BC Christine Marie Sabatino, MSN, ANP-BC, GNP-BC Family Nurse Practitioner Tammy K. Norman, MSN, FNP-BC Katharine Arce, MSN, MPH, FNP-BC Mary Janette A. Betita, MSN, FNP-BC Mollie E. Aleshire, DNP, FNP-BC, PNP-BC Melissa M. Ilg, MSN, ANP-BC, FNP-BC Cheryl A. O'Donnell, Ph.D, FNP, GNP-BC Diana Kay Fauss, MSN, FNP-BC,GNP-BC Regina M. Nickelson, MSN, FNP-BC Carol F. Braungart MS, ACNP-BC, FNP-BC Carol M. Patton, Ph.D, FNP-BC Pediatric Primary Care Nurse Practitioner Mary M. Aruda, PhD, PNP-BC, FNP-BC Melissa Geist, Ed.D, FNP-BC, PNP-BC Patricia C. Chatfield, MSN, PNP-BC Martha Driessnack, Ph.D, PNP-BC Christine A. Honnick, MSN, PNP-BC Ann L. Parsons, MN, PNP-BC Valerie J. Griffin, MSN, FNP-BC, PNP-BC Rachel L. Anger, MSN, PNP-BC Bonnie E. Kitchen, MNSc, PNP-BC Kathryn S. Schartz, MSN, PNP-BC 3

5 We also would like to thank the ANCC staff who also spent numerous hours working to make this study possible: Christine DePascale, MS (Project Manager) David Paulson, PhD, CAE Chie Ohba, PhD Cheray Jones Finally, we would like to thank the ANCC-certified nurse practitioners who supported this study by donating their time completing the survey questionnaire. The contributions that all of these people made to the study were essential to its success. 4

6 Background The American Nurses Credentialing Center (ANCC), which was incorporated in 1991 as a subsidiary of the American Nurses Association, is the largest nursing credentialing organization in the United States. Its vision is to be a transformational force for global quality healthcare through excellence in credentialing. Currently, ANCC offers 25 examinations at various levels including diploma and associate degree, baccalaureate, and advanced practice for nurse practitioners, clinical nurse specialists, and other disciplines. More than 14,000 candidates take an ANCC certification examination each year. In addition to certification, ANCC provides services such as the Magnet and Pathways to Excellence recognition programs for hospitals and other facilities that demonstrate excellence in nursing services, accreditation of continuing education programs, education and consultation services, and outreach to nursing organizations around the globe. Role Delineation Study Overview Role delineation or job analysis studies are typically carried out at the national level with the goal of describing current practice expectations, performance requirements, and environments. ANCC has a current goal of conducting a study of nurse practitioners approximately every three years in order to capture changes in work activities and the knowledge and skill areas required to perform those activities. The findings are used to update the content of its respective certification examinations. The 2011 Primary Care Nurse Practitioner (Adult-Gerontology, Family, and Pediatric) Role Delineation Study involved two sets of processes or activities that ran more or less concurrently: a national web-based survey and a linking activity. The national survey was designed to collect information on the work activities nurse practitioners actually perform in practice, while the linking activity identifies the major knowledge and skill areas required to perform the work activities listed in the survey. The results of both of these processes were used in the updating of the test content outlines for each examination contained within the study. Updated Test Content Outlines The results of this role delineation study were used in the updating of the test content outlines for each examination contained within the study. Examination forms produced based on the family nurse practitioner test content outline updated through this study are scheduled to go into effect August 6, A copy of the test content outline is available on the American Nurses Credentialing Center website. Role of the Content Expert Panels Throughout the study, ANCC invited professionals in practice and educators who teach courses relevant to nurse practitioners to serve on content expert panels for this study. They developed the work activities and demographic items for the survey, linked knowledge and skill areas to the work activities list, and finalized the test content outlines for the respective certification examinations. All of the content experts serving on the panels were certified by ANCC in the nurse practitioner population they represented and were invited to serve on the panels based upon expertise in their specialties. 5

7 Survey Methodology The purpose of the development and administration of the national survey was to collect information on the work activities nurse practitioners actually perform in practice. Since the survey instrument that was used for the purposes of this study would be used across the three primary care nurse practitioner populations, representatives from each of these three population-based role delineation study panels were also asked to serve as members of a nine member initial study workgroup that acted as a sort of steering committee for the panels. This initial workgroup met for three days May 16-18, 2011 to draft a single pilot version of the survey and to construct the initial map of knowledge and skill areas relevant to the work activities included in the survey. Survey Chronology The survey development and administration timeline was as follows: May - June 2011 The initial study workgroup along with staff from ANCC drafted the survey The survey was pilot tested and revised. July - August 2011 The final survey was administered on the web. September - November 2011 The survey activity results were analyzed, and activity weights were determined. Each panel met to review the survey results and activity weights. Sample Selection On May 10, 2011, there were a total 46,065 actively certified ANCC family nurse practitioners. A random sample of 1,498 family nurse practitioners stratified by region was selected from the ANCC certification database. Table 1 presents the numbers of ANCC certified family nurse practitioners that were selected from each region. Table 1. Number of Surveys Mailed Out per Geographic Region Geographic Region Number of ANCC Certified Family Nurse Practitioner Selected (percent of total pop.) Northeast NY, CT, MA, NJ, ME, PA, NH, VT, RI 260 (17.4%) South TN, MS, TX, FL, LA, AL, GA, AR, OK, VA, MD, SC, DC, NC, WV, DE, KY 642 (42.9%) Midwest IA, NE, KS, OH, MO, MN, SD, ND, MI, IL, IN, WI 326 (21.8%) West WA, AZ, CA, OR, CO, AK, ID, NM, UT, HI, NV, WY, MT 267 (17.8%) Other AE, AP, APO 3 (0.2%) Total 1,498 (100%) 6

8 Survey Development and Measures On May 16-18, 2011, the initial study workgroup met in Silver Spring, MD in order to draft the national Primary Care Nurse Practitioner (Adult-Gerontology, Family, and Pediatric) Role Delineation Study survey for the 2011 role delineation study. The panel members reviewed the work activities which had been used in the ANCC's 2008 Role Delineation Survey of Nurse Practitioners as well as the following documents: Consensus Model for APRN Regulation (APRN Consensus Workgroup and NCSBN APRN Advisory Council, 2008) Nurse Practitioner Core Competencies (NONPF, 2011) Nurse Practitioner Primary Care Competencies in Specialty Area: Family (NONPF, 2002) Nurse Practitioner Primary Care Competencies in Specialty Area: Pediatrics (NONPF, 2002) Adult-Gerontology Primary Care Nurse Practitioner Competencies (NONPF, 2010) The Essentials of Master s Education in Nursing (AACN, 2011) Appendix A from The Essentials of Doctorate of Nursing Practice Education for Advanced Practice Nurses (AACN, 2006) During the meeting, they discussed any additions, deletions, and changes they would make to update the 2008 work activity list to reflect current practice of primary care nurse practitioners working within any of the three population areas. The goal of this process was to create a comprehensive list of relevant work activities that were potentially performed by nurse practitioners in any one of the population areas, regardless of whether it was performed in the others. As a result of this meeting, the panel reached consensus on a list of 100 work activities to be used in the 2011 survey. These work activities were divided into four domains: Assessment, Diagnosis, Clinical Management, and Role. The complete text of the work activities list is presented in Appendix A. The workgroup also identified and finalized a set of 18 demographic questions. (See Appendix B). During the same meeting, the workgroup reviewed and approved three scales that respondents would use to rate the work activities listed in the survey Frequency (the frequency with which a work activity is performed), Performance Expectation (how soon on the job the performance of an activity is expected), and Consequence (the consequence of performing an activity incorrectly). The performance expectation scale was specifically designed to distinguish entry-level skills. These three questions and the instructions for answering them are presented in Table 2. 7

9 Table 2. Survey Questions for Rating Work Activity Statements Please respond to each activity with three separate responses, one response in each category. When considering a response for one category, do not consider the other categories. For example: When considering the consequences of incorrect performance of an activity, do not worry about whether the nurse practitioner performs or is expected to perform the activity; the possibility exists that an activity has severe consequences, even if it is never performed. Performance Expectation: When is a newly certified primary care nurse practitioner with a population focus of <<population>> first expected to perform this activity? -- Within the first 6 months of working within the role and population. -- After the first 6 months of working within the role and population. -- Never expected to perform this activity within the role and population Frequency: How often does a newly certified primary care nurse practitioner with a population focus of <<population>> perform this activity (consider within a one year period)? -- Frequently -- Often -- Occasionally -- Seldom -- Never Consequences: Does incorrect performance of this activity cause: -- No negative consequences -- Minimal negative consequences -- Moderate negative consequences -- Significant negative consequences The study design included combining each respondent s responses to each of the three rating scales in a hierarchical manner into one overall ranking of criticality. To select a procedure for combining the three scales, importance of each scale to the performance of the work activity was considered. Performance expectation scale was determined to be regarded as more critical than the other two scales for representing entry-level practice. The consequence scale was then regarded as more critical than the frequency scale. Therefore, the scales were combined so that a particular value on the performance expectation scale would outweigh or outrank all values on the consequence and frequency scales. This hierarchical scheme emphasized the work activities that are required of new practitioners immediately on the job and have the greatest impact on public health or safety. Thus this scheme was selected as the organizing mechanism for combining the responses from the three survey scales into an overall measure of criticality. Data Collection Pilot Testing. Using the same procedures intended for administering the national data collection, the survey was piloted in June Twenty-five ANCC certified family nurse practitioners randomly selected from across the nation were included in the sample of 100 ANCC certified nurse practitioners invited to take the pilot survey. Overall, 34 (34 percent) of the nurse practitioners invited to take the pilot survey responded; 11 respondents were family nurse practitioners. The respondents of the pilot test in general indicated that the work activities were appropriate and reflective of the job of the nurse practitioner. National Survey. In July and August 2011, the 1,498 family nurse practitioners selected to take the national web-based survey were sent three notifications via the United States Postal Service: an alert letter, and two follow-up reminders. The alert letter explained the purpose and importance of the study, the eligibility criteria of the study, and stated how to access the survey via the internet. The letter indicated that the participant s responses would be kept confidential. The letter also notified that respondents completing the survey receive a 5 hour reduction of their continuing education requirement for their ANCC recertification. 8

10 The first follow-up reminder letter was sent approximately two-weeks after the alert letter. It thanked recipients if they had already submitted their completed survey and encouraged them to do so if they had not already. The final follow-up reminder letter was sent out only to those who had not yet responded to the survey and was sent out approximately two-weeks prior to the end of the survey. Data Analysis The three rating scales were combined into a single measure of overall criticality using a hierarchical method. As agreed by the initial study workgroup, the three rating scales were combined into a single measure in such a manner that a particular value on the performance expectation scale would outweigh or outrank all values on the consequence and frequency scales, and that a particular value on the consequence scale would outweigh or outrank all values on the frequency scale. Table 3 displays how the values of the overall criticality rating were constructed according to all the possible survey response patterns that might be given to rate an individual work activity by its frequency, performance expectation, and consequence. For example, if a respondent indicated that a particular work activity was expected to be performed within the first six months of assuming the role of a nurse practitioner, could cause severe harm to the patient if it was performed incorrectly, and is performed occasionally, the overall criticality rating for that response pattern would be 39. A score of 32 suggests that a work activity is generally expected to be performed within the first six months of assuming the role of a nurse practitioner and have moderate consequences if incorrectly performed. Therefore, work activities with scores of 32 or higher on the overall criticality variable may be considered as highly critical. When a work activity was rated as never expected on the performance expectation scale, it would receive an overall criticality score of 1 as the bottom row in Table 3 indicates. Table 3. Construction of the Overall Criticality Variable Survey Response Options Performance Expectation Consequence Frequency Within first 6 months Significant Negative Consequences Moderate Negative Consequences Minimal Negative Consequences No Negative Consequences Overall Criticality Score Frequently 41 Often 40 Occasionally 39 Seldom 38 Never 37 Frequently 36 Often 35 Occasionally 34 Seldom 33 Never 32 Frequently 31 Often 30 Occasionally 29 Seldom 28 Never 27 Frequently 26 Often 25 Occasionally 24 Seldom 23 Never 22 9

11 Table 3. Construction of the Overall Criticality Variable (Continued) Survey Response Options Performance Expectation Consequence Frequency After first 6 months Significant Negative Consequences Moderate Negative Consequences Minimal Negative Consequences No Negative Consequences Overall Criticality Score Frequently 21 Often 20 Occasionally 19 Seldom 18 Never 17 Frequently 16 Often 15 Occasionally 14 Seldom 13 Never 12 Frequently 11 Often 10 Occasionally 9 Seldom 8 Never 7 Frequently 6 Often 5 Occasionally 4 Seldom 3 Never 2 Never expected All options All options 1 10

12 Survey Results The total sample size of the national survey included 1,498 ANCC certified family nurse practitioners. A total of 390 valid family nurse practitioner surveys were returned for an overall response rate of 31.8 percent and a total usable response rate of 25.5 percent. Table 4 shows the percent of surveys per population returned in each geographic region compared to the number of ANCC certified family nurse practitioners selected within the region. Table 4. Number of Surveys Returned per Geographic Region for Family Nurse Practitioner Family Nurse Practitioner Geographic Region Number Selected (percent Number Return (percent of of total pop.) total pop.) Northeast NY, CT, MA, NJ, ME, PA, NH, VT, RI 260 (17.4%) 70 (18.0%) South TN, MS, TX, FL, LA, AL, GA, AR, OK, VA, MD, SC, DC, NC, WV, DE, KY 642 (42.9%) 186 (47.7%) Midwest IA, NE, KS, OH, MO, MN, SD, ND, MI, IL, IN, WI 326 (21.8%) 76 (19.5%) West WA, AZ, CA, OR, CO, AK, ID, NM, UT, HI, NV, WY, MT 267 (17.8%) 58 (14.9%) Other AE, AP, APO 3 (0.2%) 0 (0.0%) Total 1,498 (100%) 390 (100%) Demographic Information Appendix B details the family nurse practitioners survey respondents responses to the survey s eighteen demographic questions which included inquiry on the practitioner s background and practice setting. Demographic Background Approximately 90 percent of the respondents were female and 87 percent reported to be white. Approximately 60 percent of the overall sample fell into the age group of years of age. Approximately 84 percent of family nurse practitioners indicated that they held a Masters in Nursing as one of their highest degree. Eleven percent indicated they held a Post-Masters Certificate. Two percent of the respondents had doctorate degrees in Nursing Research (Ph.D., DNS, DNS) and three percent indicated they held a Doctorate of Nursing Practice. Four percent of the respondents indicated they held a degree other than what was listed as their highest level of education. The average number of years of experience the family nurse practitioner respondents had as a RN was 21 years. The respondents also reported on average 11 years of experience as a nurse practitioner. 11

13 Practice Settings Approximately 40 percent of the family nurse practitioner respondents indicated that they practiced in cities with populations between 50,000 and 249,999. Towns with a population between 2,500 and 49,999 had the second highest percent of respondents (31 percent). Thirteen percent of the respondents indicated working in a rural (population less than 2,500) practice location. In terms of practice setting, the highest percentage of family nurse practitioner respondents indicating they practice in a private group practice (38 percent). Hospital, outpatient and Community/Public Health came in either second or third (20 percent and 14 percent respectively). Family nurse practitioners also reported on average 79 percent of their time was spent providing direct patient care with approximately 21 percent of their time providing health maintenance, 37 percent providing care for acute illnesses, and 28 percent providing care for chronic illnesses. The family nurse practitioners also indicated spending on average approximately 15 percent of their time providing care for children 12 years old and under, 10 percents of their time for adolescents ages 13 to 17, 44 percent of their time for Adults ages 18 to 64 years old, and 30 percent of their time providing care to older adults 65 years old and older. When asked how many hours per week on average they spent in direct patient care, 87 percent of the family nurse practitioners reported spending between 20 and 39 hours per week. Finally, overall 98 percent of the family nurse practitioners indicated that they have privileges to prescribe medication in their current practice. 87 percent indicated that they are required to have a physician collaborator or supervisor in their practice setting, and 31 percent reported having hospital privileges. Practice Descriptions Descriptive statistics (means, standard deviations, and medians) for the three ratings of all 100 work activities performance expectation, consequence, and frequency and mean overall criticality are listed in Appendix C. The scales were highly reliable. Cronbach s coefficient alpha estimates for the performance expectation, consequence, and frequency scales when applied to all the data were , , and , respectively. (Cronbach's coefficient alpha, a measure of internal stability, ranges in value between 0 and 1.) In Appendix D, the overall criticality statistics are presented in rank order of criticality. As indicated in Table 5, 47 work activity statements were rated by the family nurse practitioner respondents as highly critical (with a mean overall criticality rank of 32 or above). These work activities included a high proportion of items from the Assessment (11 out 25 work activities percent), Diagnosis (9 out of 10 work activities 90 percent), and Clinical Management (20 out of 38 work activities 53 percent) domains. Seven out the 27 (26 percent) of the work activities listed under the Role domain had a mean overall criticality ranking of 32 or higher. Table 5. Number of Work Activities by Mean Overall Criticality Range and Population for Family Nurse Practitioners Mean Overall Criticality Score 37.0 and above Between 32.0 and 36.9 Between 27.0 and 31.9 Between 22.0 and 26.9 Between 17.0 and 21.9 Between 12.0 and 16.9 Between 7.0 and and under Total number above 32.0 Number of Work Activities

14 Table 6 and 7 displays the 20 highest-ranking and the 20 lowest-ranking work activities by mean overall criticality respectively. The grey shading in Table 10 indicates the four work activities that received criticality ratings of 37 and above. All except one of these task statements fell into the domain Clinical Management. The highest ranking task fell into the domain Role. The two lowest ranked work activities that received criticality rankings of 11 or less are highlighted in Table 11. Both of these work activities fell within the Role domain. The focus of these work activities centered on policy making and scholarly writing. Table 6. Top 20 Work Activities Ranked by Mean Overall Criticality for Family Nurse Practitioners Mean Overall Work Activity Number and Name Criticality 96 Maintains confidentiality and privacy according to regulatory standards (e.g., HIPAA) Prescribes medications Monitors the safety and effectiveness of interventions Reports suspected abuse, exploitation and/or neglect Performs a focused physical exam Formulates diagnoses Evaluates effectiveness of pharmacologic regimen Identifies and refers patient with conditions beyond scope of practice Assesses patient for acute pain Obtains a focused health history Differentiates between normal physiologic changes and abnormal/atypical findings Performs a comprehensive physical exam Develops differential diagnoses Orders diagnostic tests Documents in accordance with regulatory process and payor source Obtains a comprehensive health history Interprets results from diagnostic tests Evaluates patient responses to interventions Manages episodic disease Prioritizes diagnoses 35.1 Table 6. Bottom 20 Work Activities Ranked by Mean Overall Criticality for Family Nurse Practitioners Mean Overall Work Activity Number and Name Criticality 77 Advocates for improved access, quality, and cost-effective health care Facilitates the development of advance care planning/advance directives Identifies opportunities for quality improvement Plans for potential crisis and/or disaster situations Implements patient and provider safety and quality improvement initiatives Provides palliative care Serves as an interprofessional resource for patient care Provides end of life care Evaluates the impact of health care delivery on providers, stakeholders and the environment Performs a community risk assessment Fosters collaboration with multiple stakeholders (e.g. patients, community, integrated health 18.8 care teams, and policy makers) to improve health care 41 Develops population-focused plan of care based on epidemiologic data Performs a genetic assessment Conducts peer review to promote a culture of excellence Performs a population risk assessment Engages in policy-making internal to the organization Analyzes the impact of globalization on health Precepts students, novice nurse practitioners, and/or other health professionals

15 Mean Overall Work Activity Number and Name Criticality 84 Engages in scholarly activities (e.g., give presentations, publish professional article, engage 11.6 in research activities) 87 Engages in policy-making external to the organization

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17 Appendix A Work Activities Statements

18 Task List for Final Survey I. Assessment 1. Obtains a comprehensive health history 2. Obtains a focused health history 3. Obtains a history regarding sexual and reproductive health and behaviors 4. Performs age-appropriate screenings (e.g., developmental, hearing, vision, oral health, genetics) 5. Determines health status of patient using primary and secondary sources of data (e.g., epidemiological, social, environmental) 6. Performs a psychosocial evaluation 7. Performs a lifestyle assessment (e.g., sleep, exercise, BMI) 8. Performs a nutritional assessment 9. Performs a cultural assessment 10. Performs a spiritual assessment 11. Performs an individual risk assessment, including safety 12. Performs a genetic assessment 13. Performs a mental health assessment 14. Performs a family/caregiver risk assessment 15. Performs a community risk assessment 16. Performs a population risk assessment 17. Performs a functional assessment, including mobility and cognition 18. Assesses patient s capacity for decision-making 19. Assesses patient for development delays/impairment, learning disabilities 20. Assesses patient for acute pain 21. Assesses patient for chronic pain 22. Assesses for advance care planning/advanced directives 23. Assesses family dynamics and communication patterns 24. Performs a comprehensive physical exam 25. Performs a focused physical exam II. Diagnosis 26. Differentiates between normal physiologic changes and abnormal/atypical findings 27. Orders diagnostic tests 28. Performs diagnostic tests 29. Interprets results from diagnostic tests 30. Synthesizes data to inform clinical reasoning 31. Develops differential diagnoses 32. Prioritizes differential diagnoses 33. Formulates diagnoses 34. Prioritizes diagnoses 35. Develops a comprehensive problem list III. Clinical Management 36. Develops a mutually agreeable individualized plan of care 37. Evaluates patient, family and/or caregiver s knowledge of plan of care 38. Educates patient, family and/or caregiver regarding plan of care include testing, diagnosis, treatments and/or implications. 39. Facilitates the development of advance care planning/advance directives 40. Prioritizes plan of care considering safety, risk reduction, and comorbidities 41. Develops population-focused plan of care based on epidemiologic data 42. Implements plan of care that incorporates cultural, spiritual, psychosocial considerations 43. Prescribes medications 44. Monitors the safety and effectiveness of interventions 45. Prescribes non-pharmacologic interventions 46. Manages health maintenance status and health promotion interventions Appendix A Work Activities Statements A-2 Copyright 2011 American Nurses Credentialing Center, All Rights Reserved

19 Task List for Final Survey 47. Immunizes based on current recommendations 48. Counsels regarding nutrition and weight status 49. Reports suspected abuse, exploitation and/or neglect 50. Facilitates transitions in levels of care 51. Facilitates transitions of care between health care providers 52. Plans follow-up care 53. Manages episodic disease 54. Manages chronic disease 55. Selects evidence-based technological interventions 56. Provides palliative care 57. Provides end of life care 58. Performs primary care procedures (e.g., wart removal, suturing, cerumen) 59. Coaches patient, family, and/or caregiver regarding lifestyle and behavioral changes 60. Counsels on family planning, sexuality, and/or reproductive health 61. Counsels patient and/or family through grief, dying, and death 62. Evaluates patient responses to interventions 63. Evaluates effectiveness of pharmacologic regimen 64. Evaluates effectiveness of nonpharmacologic interventions 65. Evaluates adherence to treatment plan 66. Evaluates the impact of diagnosis and treatment on patient, family, and caregiver 67. Evaluates treatment outcomes related to acute pain 68. Evaluates treatment and educational outcomes related to chronic pain 69. Evaluates treatment and educational outcomes related to nutrition 70. Evaluates plan of care considering safety, risk reduction and comorbidities 71. Modifies plan of care to meet the needs of patient, families, and/or caregivers 72. Modifies plan of care based on patient response to interventions 73. Maintains a comprehensive problem list IV. Role 74. Fosters collaboration with multiple stakeholders (e.g. patients, community, integrated health care teams, and policy makers) to improve health care 75. Collaborates with other professionals 76. Advocates for individual patient needs 77. Advocates for improved access, quality, and cost-effective health care 78. Conducts peer review to promote a culture of excellence 79. Serves as an inter-professional resource for patient care 80. Creates a climate of patient-centered care (definition of patient-centered care -- care based on a partnership between the patient and the healthcare provider that is focus on the patient s values, preferences and needs) 81. Identifies opportunities for quality improvement 82. Implements patient and provider safety and quality improvement initiatives 83. Engages in professional development activities 84. Engages in scholarly activities (e.g., give presentations, publish professional article, engage in research activities) 85. Identifies and refers patient with conditions beyond scope of practice 86. Engages in policy-making internal to the organization 87. Engages in policy-making external to the organization 88. Identifies ethical dilemmas and seek resources for resolution 89. Identifies legal dilemmas and seek resources for resolution 90. Promotes the role of the nurse practitioner 91. Integrates theory, current evidence, professional standards, and clinical guidelines to improve practice 92. Documents daily patient related activities 93. Documents in accordance with regulatory process and payor source 94. Bills for services according to level of care 95. Precepts students, novice nurse practitioners, and/or other health professionals Appendix A Work Activities Statements A-3 Copyright 2011 American Nurses Credentialing Center, All Rights Reserved

20 Task List for Final Survey 96. Maintains confidentiality and privacy according to regulatory standards (e.g., HIPAA) 97. Evaluates the impact of health care delivery on providers, stakeholders and the environment 98. Analyzes the impact of globalization on health 99. Plans for potential crisis and/or disaster situations 100. Integrates informatics and/or health care technology into practice Appendix A Work Activities Statements A-4 Copyright 2011 American Nurses Credentialing Center, All Rights Reserved

21 Appendix B Demographic Data Summary

22 1. Primary place of work Primary Place of Work: Recruitment Pool West N = 267, 17.82% Primary Place of Work: Respondents (N = 390) (N = 1498) West Northeast N = 58, N = 70, 14.87% 17.95% Northeast N = 260, 17.36% Midwest N = 326, 21.76% Other N =3, 0.20% South N = 642, 42.86% Midwest N = 76, 19.49% Other N = 0, 0.00% South N = 186, 47.69% 2. What is your gender? Count Percent Female % Male % Total % (Missing 1) 3. What is your age? Count Percent Under 25 years old 0 0.0% years old % years old % years old % years old % 65 and older % Total % Appendix B Demographic Data Summary B-2

23 4. What is your race/ethnic background? Count Percent White % Black or African American % American Indian and Alaska Native 2 0.5% Asian % Native Hawaiian and other Pacific Islander 0 0.0% Hispanic or Latino % Middle Eastern 2 0.5% Other 3 0.8% Total % (Missing 2) 5. Indicate the highest educational level you have completed: Count Percent Masters in Nursing % Masters in field other than Nursing % Post-Masters Certificate % Doctorate in Nursing Research (e.g., Ph.D., DNS, DSN) 9 2.3% Doctorate in Nursing Practice (DNP) % Doctorate in field other than Nursing 3 0.8% Other % *The percentage is computed using "Total = 390," however, the total count is larger than 390, as this question asks the respondents to choose all that apply 6a. How many years of experience do you have as a registered nurse? Number of Years Count Percent 0 to % 10 to % 20 to % 30 to % 40 to % 50 to % Total % (Missing 2) Appendix B Demographic Data Summary B-3

24 6b. How many years of experience do you have as a nurse practitioner? Number of Years Count Percent 0 to % 10 to % 20 to % 30 to % 40 to % 50 to % Total 389 (Missing 1) 7. Which one best characterizes your current clinical practice location(s)? (Mark all that apply) Count Percent Rural (population less than 2,500) % Town (population between 2,500-49,999) % City (population between 50, ,999) % Metropolitan (population between 250, ,999) % Greater Metropolitan (population greater than 999,999) % (Missing 4) *The percentage is computed using "Total = 390," however, the total count is larger than 390, as this question asks the respondents to choose all that apply Appendix B Demographic Data Summary B-4

25 Appendix B Demographic Data Summary B-5 8. Estimate the percentage of time (during an average week) that you provide direct patient care in each of the age groups listed below. Infant Preschool School age Adolescent Adult (birth to 1 years) (2 to 4 years) (5 to 12 years) (13 to 17 years) (18 to 64 years) Percent of Time Count Percent Count Percent Count Percent Count Percent Count Percent 0% % % % % 7 1.8% 1% to 19% % % % % % 20% to 39% % % % % % 40% to 59% 0 0.0% 0 0.0% 6 1.5% % % 60% to 79% 0 0.0% 0 0.0% 1 0.3% 3 0.8% % 80% to 100% 1 0.3% 1 0.3% 0 0.0% 2 0.5% % Total % % % % % Infant Preschool School age Adolescent Adult (birth to 1 years) (2 to 4 years) (5 to 12 years) (13 to 17 years) (18 to 64 years) Mean percent spent with each age group 3.5% 4.9% 7.1% 10.2% 44.2% (Continue to the next page)

26 Appendix B Demographic Data Summary B-6 8. Estimate the percentage of time (during an average week) that you provide direct patient care in each of the age groups listed below. (Continued) Young-Old Middle-Old Oldest-Old (65 to 74 years) (75 to 84 years) (85 years and older) Percent of Time Count Percent Count Percent Count Percent 0% % % % 1% to 19% % % % 20% to 39% % % % 40% to 59% % 9 2.3% 2 0.5% 60% to 79% 0 0.0% 2 0.5% 0 0.0% 80% to 100% 0 0.0% 0 0.0% 0 0.0% Valid Responses % % % Missing Young-Old Middle-Old Oldest-Old (65 to 74 years) (75 to 84 years) (85 years and older) Mean percent spent with each age group 15.3% 10.1% 4.7%

27 Appendix B Demographic Data Summary B-7 9. Estimate the percentage of time (during an average week) spent in direct patient care. Health maintenance Maternity care Acute illness care Chronic illness care End-of-life care Percent of Time Count Percent Count Percent Count Percent Count Percent Count Percent 0% % % 8 2.1% % % 1% to 19% % % % % % 20% to 39% % 4 1.0% % % 4 1.3% 40% to 59% % 4 1.0% % % 1 0.3% 60% to 79% 8 2.1% 3 0.8% % % 1 0.3% 80% to 100% 2 0.5% 0 0.0% % 4 1.0% 0 0.0% Total % % % % % Health maintenance Maternity care Acute illness care Chronic illness care End-of-life care Mean percent spent with each type of direct care 21.3% 2.3% 37.4% 27.7% 1.9% (Continue to the next page)

28 Appendix B Demographic Data Summary B-8 9. The percentage of time (during an average week) that you provide patients with (continue) Mental health care Other Percent of Time Count Percent Count Percent 0% % % 1% to 19% % % 20% to 39% % 5 1.3% 40% to 59% 5 1.3% 2 0.5% 60% to 79% 1 0.3% 4 1.0% 80% to 100% 1 0.3% 2 0.5% Total % % Missing Mental health care Other Mean percent spent with each type of direct care 8.6% 2.8%

29 10. Which of the following best or most accurately describes your practice setting? (Mark all that apply.) Count Percent Community/Public Health (city/county/state/federal agency) % Home Health Care 5 1.3% Hospice Facility 1 0.3% Hospital, Inpatient % Hospital, Outpatient % Managed care (HMO, Blue Cross/Blue Shield) % Medical school 2 0.5% Nursing home/long-term care % Independent nurse practitioner practice % Occupational Health % Private Practice % Retail based clinic % School or College Health % School/College of nursing % VA/Armed forces % Other % Missing 4) *The percentage is computed using "Total = 390," however, the total count is larger than 390, as this question asks the respondents to choose all that apply 11. On average, how many hours per week do you spend in direct patient care? Number of Hours Count Percent 0 to % 10 to % 20 to % 30 to % 40 to % 50 or more % Total % (Missing 27) (Invalid 3) Appendix B Demographic Data Summary B-9

30 Appendix B Demographic Data Summary B Approximately what percentage of your average work week is spent in each of the following activities? Management, Direct supervision, and patient care administration Teaching Research Consultation Other Percent of Time Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent 0% 5 1.3% % % % % % 1% to 19% 9 2.3% % % % % % 20% to 39% % % % 2 0.5% 9 2.3% 4 1.0% 40% to 59% % % 5 1.3% 1 0.3% 2 0.5% 0 0.0% 60% to 79% % 6 1.5% 4 1.0% 0 0.0% 0 0.0% 0 0.0% 80% to 100% % 5 1.3% 3 0.8% 0 0.0% 2 0.5% 0 0.0% Total % % % % % % Management, Direct supervision, and patient care administration Teaching Research Consultation Other Mean percent spent with each activity 78.7% 8.4% 7.0% 1.4% 3.9% 0.6%

31 13. On average, what percentage of your patient visits are pertaining to conditions related to each of the body systems listed below. Appendix B Demographic Data Summary B-11 Head, Eyes, Ears Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Nose and Throat System System System System System Percent of Time Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent 0% % % % % % % 1% to 19% % % % % % % 20% to 39% % % % % % % 40% to 59% % % % 3 0.8% 6 1.5% 8 2.1% 60% to 79% 5 1.3% 1 0.3% 2 0.5% 1 0.3% 7 1.8% 1 0.3% 80% to 100% 0 0.0% 0 0.0% 4 1.0% 0 0.0% 7 1.8% 3 0.8% Total % % % % % % Head, Eyes, Ears Respiratory Cardiovascular Gastrointestinal Genitourinary Musculoskeletal Nose and Throat System System System System System Mean percent spent treating conditions within each body system 14.8% 14.1% 12.4% 8.8% 10.2% 11.3% (Continue to the next page)

32 Appendix B Demographic Data Summary B On average, what percentage of your patient visits are pertaining to conditions related to each of the body systems listed below. (Continued) Endocrine System Neurological (including metabolic Hematopoietic Immune Integumentary System disorders) System System System Percent of Time Count Percent Count Percent Count Percent Count Percent Count Percent 0% % % % % % 1% to 19% % % % % % 20% to 39% 9 2.3% % 4 1.0% 4 1.0% 6 1.5% 40% to 59% 2 0.5% 4 1.0% 2 0.5% 2 0.5% 1 0.3% 60% to 79% 0 0.0% 3 0.8% 1 0.3% 2 0.5% 2 0.5% 80% to 100% 4 1.0% 3 0.8% 1 0.3% 1 0.3% 3 0.8% Total % % % % % Endocrine System Neurological (including metabolic Hematopoietic Immune Integumentary System disorders) System System System Mean percent spent treating conditions within each body system 5.9% 10.2% 2.8% 3.1% 6.2%

33 14. Consider your patient visits within the past year. Estimate the percent of patients for which you prescribed/managed medications within each of these drug agent categories. Number/Percent of Respondents Who Prescribed or Managed Medications within the Drug Agent Category during one or more percent of patient visits Count Percent Antiinfective % Antiinflammatory % Autonomic Nervous System % Cancer % Cardiovascular % Emergency % Endocrine % Gastrointestinal % Herbal % Immunologic % Neurologic and Neuromuscular % Pain % Psychiatric % Reproductive and Gender-Related % Respiratory % Urologic % *The percentage is computed using "Total = 344." 15. Do you have privileges to prescribe medications in your current practice setting? Count Percent Yes % No 7 1.8% Total % 16. Are you required to have a physician collaborator/supervisor? Count Percent Yes % No % Total % Missing 3) Appendix B Demographic Data Summary B-13

34 17. Do you have hospital privileges in your current practice setting? Count Percent Yes % No % Total % 18. Do you: (Mark all that apply) Count Percent Admit patients to the hospital % Manage patients during hospitalization % Discharge patients from the hospital % Appendix B Demographic Data Summary B-14

35 Appendix C Work Activities Descriptive Statistics

36 Appendix C Work Activities Descriptive Statistics C-2 Family Nurse Practitioner Survey Order Performance Expectation Consequence Frequency Overall Rank Std Median Std Med- Std Med- Std N Mean Dev Mean Dev ian Mean Dev ian Mean Dev 1 Obtains a comprehensive health history Obtains a focused health history Obtains a history regarding sexual and reproductive health and behaviors 4 Performs age-appropriate screenings (e.g., developmental, hearing, vision, oral health, genetics) 5 Determines health status of patient using primary and secondary sources of data (e.g., epidemiological, social, environmental) Performs a psychosocial evaluation Performs a lifestyle assessment (e.g., sleep, exercise, BMI) Performs a nutritional assessment Performs a cultural assessment Performs a spiritual assessment Performs an individual risk assessment, including safety Performs a genetic assessment Performs a mental health assessment Performs a family/caregiver risk assessment Performance expectation response options: 0 = never, 1 = after first 6 months, 2 = within the first 6 months; Consequences response option: 0 = no negative consequences, 1 = minimal, 2 = moderate, 3= significant; Frequency response options: 0 = never, 1 = seldom, 2 = occasionally, 3 = often, 4 = frequently

37 Appendix C Work Activities Descriptive Statistics C-3 Family Nurse Practitioner Survey Order Performance Expectation Consequence Frequency Overall Rank Std Median Std Med- Std Med- Std N Mean Dev Mean Dev ian Mean Dev ian Mean Dev 15 Performs a community risk assessment Performs a population risk assessment Performs a functional assessment, including mobility and cognition Assesses patient s capacity for decision-making Assesses patient for development delays/impairment, learning disabilities Assesses patient for acute pain Assesses patient for chronic pain Assesses for advance care planning/advanced directives Assesses family dynamics and communication patterns Performs a comprehensive physical exam Performs a focused physical exam Differentiates between normal physiologic changes and abnormal/atypical findings Orders diagnostic tests Performs diagnostic tests Interprets results from diagnostic tests Synthesizes data to inform clinical reasoning Develops differential diagnoses Performance expectation response options: 0 = never, 1 = after first 6 months, 2 = within the first 6 months; Consequences response option: 0 = no negative consequences, 1 = minimal, 2 = moderate, 3= significant; Frequency response options: 0 = never, 1 = seldom, 2 = occasionally, 3 = often, 4 = frequently

38 Appendix C Work Activities Descriptive Statistics C-4 Family Nurse Practitioner Survey Order Performance Expectation Consequence Frequency Overall Rank Std Median Std Med- Std Med- Std N Mean Dev Mean Dev ian Mean Dev ian Mean Dev 32 Prioritizes differential diagnoses Formulates diagnoses Prioritizes diagnoses Develops a comprehensive problem list Develops a mutually agreeable individualized plan of care Evaluates patient, family and/or caregiver s knowledge of plan of care 38 Educates patient, family and/or caregiver regarding plan of care include testing, diagnosis, treatments and/or implications. 39 Facilitates the development of advance care planning/advance directives 40 Prioritizes plan of care considering safety, risk reduction, and comorbidities 41 Develops population-focused plan of care based on epidemiologic data 42 Implements plan of care that incorporates cultural, spiritual, psychosocial considerations Prescribes medications Monitors the safety and effectiveness of interventions Prescribes non-pharmacologic interventions Performance expectation response options: 0 = never, 1 = after first 6 months, 2 = within the first 6 months; Consequences response option: 0 = no negative consequences, 1 = minimal, 2 = moderate, 3= significant; Frequency response options: 0 = never, 1 = seldom, 2 = occasionally, 3 = often, 4 = frequently