Expansion of the emergency nurse practitioner (ENP) role over the past two decades has been rooted in collaborative efforts between stakeholder organizations focused on ensuring a well-prepared workforce available to meet emergency care needs across the United States. As the role of the ENP continues to evolve, competencies, practice standards, and stakeholder support remain integral to ensuring relevance and currency for the ENP profession. However, recent attempts to update practice standards and competencies have not demonstrated the collaborative efforts previously embraced and threaten the advancement of the ENP specialty.
In 2008, the Emergency Nurses Association (ENA) NP Validation Work Team performed a three-round Delphi study that yielded the Competencies for Nurse Practitioners in Emergency Care (ENA NP Validation Work Team, Hoyt, et al., 2010). These entry-level competencies were reviewed and endorsed by stakeholders across multiple disciplines, including emergency physicians, regulatory organizations, and educational institutions. Although the process was laborious and time-intensive, the collaborative and iterative process ensured that the final work product was valid, generalizable, and recognized in diverse emergency care settings.
In 2018, a very different process was utilized when the ENA convened the ENP Competency Revision Work Group (Work Group) to review and revise the 2008 Competencies using a consensus-based framework. Although consensus-based methodology provides a more time-efficient approach, consensus bias is inherent when this design is used (Mullen et al., 1985). Results and conclusions derived from using expert opinion/small group consensus methodologies must be questioned when this approach is selected over more rigorous ones that are readily available. The approach utilized by the 2019 ENA Work Group in updating the original 2008 competencies relied on opinions from a small number, ultimately resulting in an “armchair” job analysis. Although it is beyond the scope of this editorial to provide a full critique of the methods used, the validity and usefulness of the draft updated competencies (ENA, 2019) are therefore limited to the assumptions made by a seven-member team.
An ongoing and rigorous science-based process of practice evaluation is essential to ensure that competencies reflect changes in practice trends and national survey data. One alternative approach to understanding the current ENP practice was led by the American Academy of Nurse Practitioners Certification Board (AANPCB) in 2016. A task force of emergency practice clinical experts from around the country was convened to delineate ENP practice using a consensus-building process as an initial step in the process, which were then validated through multiple rounds of surveys of nationally certified nurse practitioners working in emergency care. Statistical analyses were conducted by expert psychometricians that demonstrated content validity and reliability of the findings above the recommended threshold (Tyler et al., 2018). Unlike the consensus approach to competency revision, scheduled routine national practice analyses provide the opportunity to reassess, validate, and revise the competencies for contemporary ENP practice (Tyler et al., 2018).
Based on the 2016 AANPCB practice analysis, practice standards that identified ENPs' clinical knowledge, skills, and competencies were defined by the American Academy of Emergency Nurse Practitioners in 2018. These practice standards encompass competencies, clinical guidelines, and evaluation outcomes. Together, they provide the underpinnings for ENP specialty education and the national ENP certification examination (Hoyt et al., 2018). Following development of ENP specialty practice standards using a rigorous research methodology, isolated attempts at revision of competencies that were previously validated through collaborative input only serve to introduce confusion. Given the interdisciplinary nature of ENP practice, it is most appropriate and logical that any updates to ENP competencies involve all stakeholders representative of our practice.
Although ENA has a long history as a strong voice for emergency nurses, the most recent proposed revision of the ENA competencies for Nurse Practitioners in Emergency Care (ENA, 2019) fails to present a depth of evidence based on current research. Rather than invite early collaboration for the development of these competencies, the document indicates, “Further validation of the 2019 competencies will be conducted ... with key stakeholders” at a later date (ENA, 2019, p. 2). To ensure that competencies and practice standards remain scientifically sound and relevant to contemporary ENP practice, early collaboration is essential to ensure one collective voice comprising ENP educators, practicing clinicians, and professional organizations.
—Wesley D. Davis, DNP, ENP-C, FNP-C, AGACNP-BC, CEN, FAANP
Assistant Professor & Family/Emergency
University of South Alabama
College of Nursing
—Dian Dowling Evans, PhD, FNP-BC, ENP-BC, FAANP, FAAN
Clinical Professor & Emergency Nurse
Nell Hodgson Woodruff School of Nursing
—Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP, FAAN
Professor & Emergency Nurse Practitioner
Vanderbilt University School of Nursing
American Academy of Emergency Nurse Practitioners. (2018). Practice standards for the emergency nurse practitioner (ENP). Scottsdale, AZ: Author. Retrieved from https://aaenp.memberclicks.net/assets/docs/practice_standards_for_the_emergency_nurse_practitioner.pdf
Emergency Nurses Association (ENA). (2019). Draft 2019 competencies for nurse practitioners in emergency care. Retrieved June 30, 2020, from https://www.ena.org/docs/default-source/education-document-library/enp-competencydraft
ENA NP Validation Work Team; Hoyt K. S., Coyne E., Ramirez E., Peard A. S., Gisness C., Gacki-Smith J. (2010). Nurse Practitioner Delphi Study: Competencies for practice in emergency care. Journal of Emergency Nursing, 36(5), 439–449.
Hoyt K. S., Evans D., Wilbeck J., Ramirez E., Agan D., Tyler D., Schumann L. (2018). Appraisal of the emergency nurse practitioner specialty role. Journal of the American Association of Nurse Practitioners, 30(10), 551–559.
Mullen B., Atkins J. L., Champion D. S., Edwards C., Hardy D., Story J. E., Vanderklok M. (1985). The false consensus effect: A meta-analysis of 115 hypothesis tests. Journal of Experimental Social Psychology, 21(3), 262–283.
Tyler D. O., Hoyt K. S., Evans D. D., Schumann L., Ramirez E., Wilbeck J., Agan D. (2018). Emergency nurse practitioner practice analysis: Report and implications of the findings. Journal of the American Association of Nurse Practitioners, 30(10), 560–569.