Villanueva, Nancy; Blank‐Reid, Cynthia; Stewart‐Amidei, Chris; Cartwright, Cathy C.; Haymore, Joseph; Jones, Rich W.
In 2006, the American Association of Neuroscience Nurses (AANN) commissioned a task force to develop a scope of practice (SOP) document for advanced practice nurses (APNs) in neuroscience nursing. The task force comprised six members who represented diverse practice settings and geographic regions. The task force included three nurse practitioners (NPs) and three clinical nurse specialists (CNSs) whose practice settings encompassed both the inpatient and outpatient arenas. As the members began to discuss how best to proceed with the development of the document, it became clear that information regarding the current practices of neuroscience APNs was needed. This need for information led to the development of the 2006 AANN Membership Survey, results of which are described in the following sections. Information obtained from the survey will be used as a guide in the development of the SOP document.
The target participants were AANN members who had indicated in the membership database that their primary job function was either as an NP or CNS. The task force decided to use an electronic survey method provided by ZoomerangTM, an electronic survey company. This format had been used previously by AANN, and the membership was familiar with and knowledgeable regarding its use. The survey was developed using tasks compiled from a review of literature as well as input from experienced APNs (American Association of Colleges of Nursing [AACN], 2002, 2004; Bell, 2006; Yeager, Shaw, Casavant, & Burns, 2006). An open‐ended question was included to identify any other procedures or activities not included in the listing to better capture the full scope of practice. Task force members reviewed the compiled survey questions and made necessary revisions to ensure content reliability. No previous survey of its kind was available for comparison.
After the survey was designed by the task force, it was converted into an electronic document. An email was sent to the target group (N = 691), inviting them to participate in the online survey. The e‐mail also contained a message explaining the survey's purpose and a link to the survey; participation was voluntary and anonymous. The 2006 AANN Membership Survey consisted of 47 questions (See Figure 1 for questions 1‐7. The entire survey instrument can be viewed at www.AANN.org.) The initial questions elicited general information (e.g., highest degree completed, prescriptive authority). Feedback was sought on the definitions of direct supervision, indirect supervision, and remote supervision that had been developed by the task force. Members were also asked to comment if they performed various activities and procedures and with what degree of supervision. Members were strongly encouraged to provide feedback to the task force via the comment sections of the survey. Once the time frame for the survey was complete, the results were tabulated by the survey company.
Definition of Terms
The following are the definitions used in the survey:
Clinical Nurse Specialist (CNS): A licensed registered nurse (RN) with graduate preparation in nursing as a CNS. This individual is an expert clinician in a specialized area of nursing practice. The specialty may be identified in terms of a population (e.g., pediatrics), setting (e.g., critical care), disease or subspecialty (e.g., oncology), type of care, and type of problem (e.g., pain). The CNS practices in a wide variety of healthcare settings. The CNS provides patient care and influences care outcomes through expert consultation to nursing and associated team members. Clinical expertise is used to effect systemwide changes in organizations to improve programs of care (National Association of Clinical Nurse Specialists [NACNS], 2007).
Nurse Practitioners (NP): An APN with a minimum of a master's degree in nursing who practices in a variety of settings (e.g., ambulatory, acute, and long term). Programs of study are varied with a specific focus (e.g., adult, pediatric, family, geriatric), and, for some, a specific patient population (e.g., acute care, critical care, primary care). An NP provides nursing and medical services to individuals, families, and groups. He or she diagnoses and manages a range of health problems (chronic and acute illnesses). In addition, health promotion and disease prevention are emphasized in an NP's professional responsibilities. An NP may practice autonomously or in collaboration with other healthcare professionals (American Academy of Nurse Practitioners [AANP], 2002, 2007a, 2007b).
Direct Supervision: The collaborating physician is immediately available onsite when the activity or procedure is being performed.
Indirect Supervision: The collaborating physician is available, but not onsite, when the activity or procedure is being performed. The physician is available to the APN, but the time frame for assistance is not immediate, as it is for direct supervision.
Remote: The collaborating physician is available by phone for verbal consultation, but is not physically present.
Participant Pro. le
A total of 282 individuals completed the survey. Of these respondents, 58.5% (n = 165) were NPs, and 41.5% (n = 117) were CNSs. Of the CNS respondents, 39 (33%) individuals reported that they also held an NP credential. Respondents' educational backgrounds were very similar. More than 70% of the CNS and NP respondents had completed a master's of science in nursing (MSN) degree, with 4% of the NP and 3% of the CNS respondents holding a PhD or doctor of nursing practice (DNP) degree (Table 1).
Prescriptive authority and collaborative practice survey results revealed that the majority of NP respondents (87%) had prescriptive authority, compared to 23% of CNS respondents. Collaborative practice agreements were in effect for 83% of the NP and 59% of the CNS participants.
Survey respondents were asked if they performed a particular procedure or activity. If they responded positively, they further clarified the degree of supervision under which the procedure or activity was performed (direct, indirect, or remote). Not all respondents provided a response to each procedure or activity question. Table 2 illustrates the responses to the questions and the breakdown of the level of supervision under which the procedures were performed.
The majority of respondents (92%) did not insert intraventricular catheters. However, aspiration of cerebrospinal fluid and/or irrigation of the intraventricular catheters were performed by 44% of the respondents, with instillation of medication performed by 31%. Administration of medications via a ventricular reservoir was lower, being performed by 18% of respondents (Table 2). This difference may be due to the respondents' practice settings; if the majority of respondents work in an acute care setting, the incidence of instillation of medications via a reservoir device would be lower since this procedure is performed more commonly in an outpatient setting. Insertion of central venous catheters was performed by a small percentage of respondents (9.5%) and insertion of arterial catheters was performed by a slightly higher percentage of respondents (13.8%).
Lumbar Puncture and Insertion of Lumbar Drain
Lumbar punctures were performed by 21% of respondents, with a lower percentage (12.4%) inserting lumbar drains. Medication installation via a lumbar drain was reported at 19% (Table 2).
Programming and/or reprogramming shunts was performed by 36% of the respondents as compared to implanted pumps (25%) and deep brain stimulators (13.8%). Medication refills of an implanted pump were reported at 21% (Table 2).
Application of skeletal traction (e.g., Gardner‐Wells tongs) was performed by a small percentage of respondents (7.8%), with a larger number reporting that they would perform adjustments to traction (17%) and remove traction (17%). Halo traction adjustments were reported at 27% with removal of a halo device at 27% (Table 2).
Target participants were queried regarding assisting with opening and closing incisions in the scalp and cervical, thoracic, and lumbar regions. Performing an opening incision was less than 8% across all locations with the highest at 7% (scalp and lumbar) and lowest at 1% (peripheral nerve procedures). Closing incisions was higher at 13% (Table 2).
Bill for Service
Forty‐one percent of the respondents reported that they billed for their services. However, information was not obtained about whether the billing was done under the APN's billing number or physician's billing number.
The role of the advanced practice nurse has been evolving over the past four decades. Nurses practicing in the advanced role are best positioned to describe their scope of practice. This survey of neuroscience APNs is the first of its kind in the specialty. The percentage of respondents practicing in the NP or CNS role was a reflection of the national numbers of NPs and CNSs in practice. Similarly, one‐third of CNS respondents were also trained as NPs (also consistent with national norms). Among APNs, the CNS and NP roles are said to be the most similar. In fact, skill sets and roles may be interchangeable. Results from this survey support the concept that many of the procedures performed by NPs and CNSs can be performed in either role.
The differences in prescriptive authority among respondents can be explained by differing state regulations; some states allow prescriptive authority only for NPs, while others allow CNSs and NPs to prescribe medications. Further, states differ with regard to the level of prescriptive authority afforded to APNs (information that was not captured in this survey).
Collaborative practice agreements are required for APNs in many, but not all, states. Survey results revealed that nearly 60% of CNSs had collaborative practice agreements, even though these agreements are more commonly required to practice in the NP role. Also, the survey did not address the possibility of an NP having an independent practice, which would have affected the percentage of respondents with collaborative practice agreements.
Every procedure queried in this survey was performed by at least a small number of APNs, suggesting that all of the procedures identified fall within the scope of practice for some of the APNs. No procedures were identified that were not included in the listing. In retrospect, the procedures listed were biased toward a neurosurgical perspective. For example, the catheter, immobilization devices, and surgical incision questions would not apply to an APN working in a neurology‐only practice area. Respondents also were not asked to indicate specific area of practice. Having information on practice specialty and setting would have provided greater insight when examining survey results.
Billing information revealed that 41% of respondents billed for their services. APNs have been able to bill for their services since passage of the Omnibus Reconciliation Act of 1989 (Klein, 2005). Because more than half of the respondents did not bill for their services, the question that needs to be asked is why they are not billing. The survey did not query respondents as to the reason if they answered no; however, there were some written comments which did address billing. The most frequent statement as to why the respondent did not bill for services was that he or she was an employee of a hospital or medical center that does not bill for APN activities, or the procedure or activity is billed under the physician. Clearly, this is an area to explore further.
The population from which study participants were drawn consisted only of APNs with AANN membership. Therefore, one limitation was that APNs who were not AANN members were not included. Finding a way to include those individuals in the study would provide additional data informing scope of practice.
Additional open‐ended questions may have resulted in a greater understanding and application of the information obtained. For example, in regard to the question, “Do you have a collaborative agreement with a physician?”, APNs could have been asked additional questions about the reason for responding no. Also, if an APN responded that he or she did not bill for services, clarification of the reason for not doing so would have provided valuable information. The survey failed to capture whether the billing was independent or under the physician's name. Several respondents did indicate in the comment section that the billing was done under the physician's name, but the exact number of respondents billing independently is unknown.
For some CNS respondents, there was concern that the number of questions addressing the CNS role was not adequate to achieve a complete description of their role and responsibilities. The questions that asked about performing specific procedures and activities were more appropriate for the NP role. Questions asking about CNS role‐specific functions (e.g., consultation, education, interdisciplinary activities to effect system‐wide changes) were not directly addressed. However, many CNS respondents did perform the procedures included in the survey, held collaborative practice agreements, and had prescriptive authority. This supports the concern about role confusion between CNS and NP roles (Henderson, 2004). The CNS role‐specific functions are also more challenging to quantify and define as activities within a scope of practice.
Although the survey obtained information about the activities of the advanced practice neuroscience nurse, it would have been useful to have acquired practice‐specific information. In particular, it would have been valuable to know whether the NP or CNS was in a neurosurgical, neurology, or combined practice setting and whether it was an inpatient (university‐based medical center versus community hospital) or an outpatient setting.
Although the findings of this survey cannot be widely generalized, APNs did report procedures and practices they currently use. Because the scope of practice is best defined by those who perform the practice, the descriptions provided are valid indicators of the current scope. Future research should be conducted to identify data related to the limitations specified above. In addition, as this is the first survey of its type in the neuroscience APN population, research over time is necessary to capture the evolving nature of the role and scope of practice.
The number of APNs providing care to neuroscience patients continues to expand. Given the current status of the healthcare system and legislative restrictions on work hours permitted for residents, the need for APNs for care delivery in institutions with residency programs will only continue to grow. These settings include both university‐affiliated medical centers and community hospitals that provide residency rotations. Increasing numbers of APNs are also visible in the outpatient arena as the healthcare system and reimbursement issues continue to present changes to the providers of care. The care provided by the APN is governed by a number of factors, including his or her educational preparation, the scope of each APN's authorized practice as defined by state law, privileges and credentialing at his or her practice institution, and the collaborative practice agreement with the neurosurgeon or neurologist. As the scope and roles for APNs continue to expand, it is necessary for APNs to consistently quantify and articulate the outcomes of the care they provide for patients. Research is needed to develop measures that can be used by all APNs, including a common language and the resultant ability to compare and contrast practice environments.
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The Journal of Neuroscience Nursing (JNN) is seeking authors interested in submitting manuscripts for publication. Although JNN is a clinically focused journal, we do include topics addressing nursing practice as a whole; research articles are encouraged as well. Both new and experienced authors are welcome; a new author mentor program is available.
Need topic ideas? A wide variety of articles are possible. JNN is actively seeking manuscripts in the following areas:
* Case studies elaborating approaches to care for a challenging or unique patient
* Outcomes studies
* Geriatric aspects of neuroscience nursing
* Pediatric‐focused articles
* Novel drug therapies for neurologic diseases
* Intraoperative considerations and surgical instrumentation
* Focused assessment articles (e.g., spine assessment)
* New products related to neuroscience nursing care
* Literature review of a neurosciencerelated topic
* Home care of the chronic neurologically impaired patient
* Nursing management in the neuroscience outpatient settings (e.g., nurse‐managed back‐pain clinic)
* Ethical issues in neuroscience nursing
* Care of the patient undergoing neurointerventional procedures
* Noninvasive surgical and treatment techniques
* Collaborative approaches to care
Guidelines for authors can be found on the AANN Web site at www.AANN.org. To query the editor about a specific manuscript idea, send an e‐mail to email@example.com. Review time after submission is about 6‐8 weeks.