Thirty-five years into the HIV epidemic, people diagnosed with HIV infection in the United States can expect to live a near-normal lifespan if they are able to take advantage of the numerous scientific advances that have resulted in HIV infection becoming a largely manageable, yet complex, chronic disease. To achieve this outcome, a cascade of events must occur (Gardner, McLees, Steiner, del Rio, & Burman, 2011), including diagnosing those who are infected, linking them to care, retaining them in care, and treating them with antiretroviral therapy (ART) to achieve viral suppression. However, approximately one in seven HIV-infected individuals in the United States is unaware of his/her HIV status (Centers for Disease Control and Prevention, 2014), only 40% are engaged in care, only 37% are on ART, and only 30% have achieved viral suppression (Bradley et al., 2014). As the United States works toward reversing these trends, the prevalence of persons living with HIV infection (PLWH) will inevitably increase, resulting in the need for more HIV clinical providers at the same time that a crisis in the HIV provider workforce is looming. According to the Health Resources and Services Administration, 69% of Ryan White Clinics in the United States report difficulty recruiting HIV clinicians (U.S. Department of Health and Human Services, Health Resources and Services Administration [DHHS/HRSA], 2010). Of the existing HIV physician workforce, 33% are expected to retire by 2020. Further, many providers are also leaving HIV clinical practice due to burnout and changes in reimbursement (DHHS/HRSA, 2010).
The HIV epidemic in the United States has also morphed from a deadly disease affecting primarily gay men in large urban centers to an epidemic affecting a more demographically and geographically diverse population. Of the 10 U.S. states accounting for 65% of all new HIV infections in 2011, seven were in the Deep South (Centers for Disease Control and Prevention, 2013), where high levels of poverty and sexually transmitted infections contribute to higher HIV incidence and mortality (Reif et al., 2014). Simultaneously, severe provider shortages exist in this geographic area and other parts of rural America (DHHS/HRSA, 2010). Thus, it is essential to implement dedicated HIV training programs to ensure that the next generation of HIV providers are available to deliver culturally appropriate, evidence-based, cost-effective, quality care in partnership with persons from diverse backgrounds in all geographic regions.
The nursing profession is uniquely positioned to respond to this need. Throughout the epidemic, nurse practitioners (NPs) have played a pivotal role in the provision of comprehensive, client-centered prevention, care, and treatment services. A 2005 study of Ryan White HIV/AIDS Program Part C Clinics documented that 20% of PLWH had the majority of their care provided by physician assistants (PAs) or NPs, who tended to see younger patients with fewer HIV complications, scored as well as infectious disease physicians and HIV experts on quality measures, and frequently scored better than internists without HIV expertise or training (U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau [DHHS/HRSA/HAB], 2008). Similarly, Wilson and colleagues (2005) documented that NPs and PAs who specialized in HIV care and had high HIV caseloads were able to function as lead HIV clinicians with outcomes equal to or better than those achieved by physician providers, especially physicians who functioned as generalist non-HIV experts.
In 2013, the Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, through announcement HRSA-13-253 (AETC Education for Nurse Practitioners and Physician Assistants) issued a funding opportunity announcement to address the looming HIV provider shortage (DHHS/HRSA, 2013). The aim of the program announcement was “to establish nurse practitioner and physician assistant HIV/AIDS primary care education programs designed to train nurse practitioners and physician assistants in HIV/AIDS care and treatment” (DHHS/HRSA, 2013, p. 1).
In response to this funding opportunity announcement, the Duke University School of Nursing submitted an application and was funded to strengthen the existing Master of Science in Nursing curriculum by offering a specialty focus in HIV within its primary care NP programs (Family, Adult/Gerontology, Women's Health). A second aim of the application was to define and validate the essential competencies necessary to provide high-quality, evidence-based, comprehensive HIV prevention, care, and treatment by entry-level primary care NPs.
The World Health Organization (WHO, 2007), in its report, Task Shifting: Global Recommendations and Guidelines, via recommendation 9, stated that, “… countries should adopt a systematic approach to harmonized, standardized and competency-based training that is needs-driven and accredited so that all health workers are equipped with the appropriate competencies to undertake the task they are to perform” (p. 4). Competencies, as defined by WHO (1993) and the International Council of Nurses (2008), included the knowledge, skills, and attitudes needed by a provider to deliver care. According to WHO (1993), knowledge included the mental abilities and cognitive learning that were obtained through didactic instruction, continuing education, and/or in-service education. Skills are the motor abilities needed to deliver care, including communication and interpersonal skills necessary to function as a member of an interdisciplinary team. Attitudes are the ability to use cognitive learning to critically think and make appropriate decisions in the clinical environment.
In the United States, there are various mechanisms to determine the competency of NPs. Licensure, as one mechanism to determine entry-level competence, is a process regulated by each State Board of Nursing with the primary aim of protecting public safety. A license to practice as an NP signals that the individual has completed the necessary training and passed a nationally recognized certification examination, and thus has the necessary entry-level knowledge and skills to practice safely (Relf, Berger, Crespo-Fierro, Mallinson, & Miller-Hardwick, 2004). In contrast, specialty certification is usually a voluntary process where a professional seeks to validate expert knowledge. Specialty certification in HIV in the United States is available to NPs through the HIV/AIDS Nursing Certification Board (HANCB, n.d.) and the American Academy of HIV Medicine (AAHIVM, n.d.).
According to the WHO (1993) definition of competence, it is important that primary care NPs providing HIV specialty care have the “ability to effectively and efficiently deliver a professional service … [and] to practice (proficiency of learning) in accordance with local conditions to meet local needs” (p. 4) on entry into practice. Collectively, NP licensure, specialty certification, and scope and standards documents, such as the Scope and Standard of HIV/AIDS Nursing Practice published by the American Nurses Association and the Association of Nurses in AIDS Care (Balt et al., 2007), provide critical insight into HIV clinical practice. However, they do not specifically describe the essential competencies needed by primary care NPs to provide HIV specialty care. We report here the results of a study designed to identify essential entry-level competencies (knowledge, skills, attitudes) of NPs in the provision of comprehensive HIV-oriented primary health care in the United States.
Our practice validation study was designed to help guide the development of a contemporary curriculum that would ensure that graduates have the essential competencies needed to enter practice as a primary care NP (family nurse practitioner, adult/geriatric nurse practitioner, women's health nurse practitioner) specializing in HIV. To identify the essential knowledge, skills, and attitudes needed by NPs in the provision of HIV-oriented primary medical care, two national documents certifying NPs in HIV specialty care were examined–the Advanced HIV/AIDS Certified Registered Nurse (AACRN) examination from HANCB (AACRN content outline accessed at: http://www.hancb.org/Index/exam_content_aacrn.php) and the Practicing HIV Specialist from AAHIVS.
Certification examination blueprints from these two national certifying bodies were utilized to develop a set of competency statements to be evaluated in the practice validation study. To establish the content validity of these statements, two advanced practice nurses–one certified as an AACRN (MVR) and one certified as an AAHIVS (JLH) – and one PA certified as an AAHIVS (Kara McGee), all with extensive experience in HIV, reviewed the proposed competency statements ensuring alignment with the performance domains. One of the content experts (MVR) chaired the national taskforce that developed the AACRN examination that included development of the initial AACRN examination blueprint.
After content validity of the competency statements were established, they were categorized under one of the six domains that guides the American Board of Medical Specialties (n.d.) program. These patient-centric domains included (a) professionalism, (b) patient care and procedural skills, (c) medical knowledge, (d) practice-based learning, (e) interpersonal and communication skills, and (f) systems-based resources (http://www.abms.org/about-abms/). A total of 141 competency statements were categorized into the six domains as follows: professionalism (16 statements), patient care and procedural skills (71 statements), medical knowledge (8 statements), practice-based learning (17 statements), interpersonal and communication skills (6 statements), and systems-based resources (13 statements).
Permission was obtained from the American Nurses Credentialing Center to replicate the method used for the 2011 Family Nurse Practitioner Role Delineation Study National Survey (American Nurses Credentialing Center, 2012b) and Adult/Geriatric Primary Care Nurse Practitioner Role Delineation Study National Survey (American Nurses Credentialing Center, 2012a). This method was used to determine how critical each competency statement was for entry into practice as a primary care NP. For each competency statement, participants were asked to select a rank ordered descriptor for (a) when the newly certified/licensed NP working with persons at risk for or living with HIV is first expected to perform the competency activity; (b) whether incorrect performance of this activity could cause harm; and (c) how often a newly certified/licensed NP working with persons at risk for or living with HIV is expected to perform the activity. Each descriptor was assigned a numeric value allowing determination of a final criticality index score for each competency statement. Competency statements with criticality index scores of 2-21 were identified as competencies that should be achieved within the first year of practice, while competency statements with scores of 22-41 were identified as competencies essential for entry into practice. Table 1 describes the scoring method for each component of the criticality index, and Table 2 provides a detailed summary associated with each possible score of the criticality index.
Sample and Data Collection
In addition to NPs, it was decided to survey physicians (doctors of osteopathy [DO], medical doctors [MD]) because many states require NPs to have a supervisory physician. The inclusion of physicians provided insight into how NPs and physicians agreed or differed in the identification of entry-level competencies required of primary care NPs providing specialty HIV care. Similarly, we also wanted to obtain the perspective of HIV certified PAs because many organizations use both NPs and PAs in clinical settings.
Mailing lists were purchased from the two national HIV certification organizations in the United States containing the names and e-mail addresses of certified HIV providers. The mailing list purchased from HANCB contained 83 NPs who were certified as either an HIV/AIDS Certified Registered Nurse (ACRN) or an Advanced HIV/AIDS Certified Registered Nurse (AACRN). The mailing list purchased from AAHIVM contained 1,454 providers (NPs, PAs, DOs, MDs) who were currently certified as HIV Specialists (AAHIVS). The two lists were then merged (n = 1,537), cleaned for multiple entries on either mailing list (n = 9), missing e-mail addresses (n = 1), provider of unknown type (n = 1), and dual certification by HANCB and AAHIVM (n = 14).
On April 2, 2014, a total of 1,512 HIV certified providers (997 MDs, 77 DOs, 113 PAs, 325 NPs) were contacted via e-mail asking them to voluntarily participate in the practice validation study that included a link to an online survey. Of the 1,512 providers who were contacted, 42 e-mails were returned as undeliverable. Another 9 individuals responded indicating that they could not participate due to either recently retiring from HIV care (n = 2), too busy to complete a 30- to 45-minute survey (n = 3), unwillingness to complete online surveys (n = 1), not practicing in the United States (n = 1), or for other reasons (n = 2). Overall, 187 individuals started the survey during the data collection period.
In order to be eligible to complete the survey, providers had to have been currently licensed as a health care provider and currently providing care to HIV-infected individuals. Of those who started the survey, four were not currently licensed and 13 were not currently providing care to HIV-infected individuals; these respondents were thanked for their willingness to participate in the study but were not allowed to complete the survey. Therefore, 170 providers who met the inclusion criteria were willing to participate in the study. Ultimately, 65 providers (31 NPs, 4 PAs, 30 MDs) completed all questions in the online Qualtrics survey (Qualtrics Labs, Provo, UT).
Human Subjects Protection
The Institutional Review Board at Duke University determined that the study met the eligibility criteria for exempt research, and this information was provided in the introductory e-mail inviting individuals to participate. Participants were also informed that voluntary completion of the survey questions implied informed consent and voluntary willingness to participate in the study.
Data Management and Analysis
Data collection occurred during April 2014. To optimize participation, potential study participants received a follow-up reminder encouraging them to participate 2 weeks before the data collection period was scheduled to end. On April 30, 2014, the link to the online survey associated with the study was deactivated. Survey data were then exported into an Excel spreadsheet (Microsoft Corporation, Redmond, WA) and imported into the statistical database (IBM/SPSS, version 22, 2013, Armonk, NY) for analysis.
To facilitate analysis, syntax was written to clean the data, identify if more than one survey was submitted from the same IP address, and create the criticality index for each proposed competency statement. Additionally, syntax was written to determine the rank ordered, weighted competency domains, which was achieved by summing the criticality index for each competency statement and dividing each sum by the number of respondents. Finally, to determine if there were differences by provider type, syntax was written to identify the rank ordered, weighted competency domains by provider type.
Of the 65 respondents completing all questions in the survey, there were nearly an equal number of females (n = 33) and males (n = 32). The mean age of the respondents was 53.3 years (range = 32 to 67 years). Correspondingly, the mean year of initial licensure as either an MD, PA, or NP was 1994 (range = 1976 to 2012). Respondents represented 22 states and Puerto Rico, with 6 (9.2%) self-identifying as Asian, 2 (3.1%) as Black or African American, 7 (10.8%) as Latino/Hispanic, and 57 (87.7%) as White.
When examining the rank of competency domains by provider type, all categories of respondents, and each sub-category (MD/DO, NP, PA) ranked Medical Knowledge-related Competencies first and Professionalism-related Competencies second. The Interpersonal and Communication and Patient Care and Procedural Skills-related Competencies were ranked third and fourth by all physicians and NPs. PAs, however, ranked Patient Care and Procedural Skills third, while Interpersonal and Communication was ranked fourth. Similarly, Practice-based Learning and Improvement-related Competencies and Systems-based Practice Competencies were ranked fifth and sixth by MDs and PAs, with NPs reverse ranking these two competency domains. Table 3 provides comparative information. Further, within each of the six competency domains, criticality indices for individual competency statements were identified based on all providers. Table 4 provides detailed information about the individual competencies identified as essential for entry into practice by all provider types.
Our study identified entry-level competencies required by primary care NPs specializing in HIV on entry into practice. As the HIV workforce faces critical provider shortages due to retirement, burn out, changes in reimbursement, and other factors, we provide critical insight into the knowledge, skills, and attitudes required by primary care NPs as they provide individualized, holistic, evidence-based, cost-effective, quality HIV prevention, care, and treatment. Although results of our study are limited due to a low response rate, the domains of competence and individual competency statements identified in the study provide valuable insight into practice expectations for entry-level primary care NPs.
To understand the representativeness of our sample, in view of the low response rate, it is important to examine the participants' demographics in comparison to national data. As identified by HRSA, more than one third of the physician workforce in the United States is 55 years of age or older. According to the 2012 National Survey of Nurse Practitioners (U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Workforce Analysis [DDHS/HRSA/NCWA], 2014), the average age within the NP workforce is 48 years. In our study, the mean age of the respondents was 53.3 years (range = 32 to 67 years) closely aligning with demographics of both the physician and NP workforces in the United States. Of physicians, African Americans and Hispanics represent only 10% of medical school graduates (DHHS/HRSA, 2010). In the U.S. NP workforce, about 86% are White and non-Hispanic (DHHS/HRSA/NCWA, 2014). In our sample, 23.1% of the participants were from diverse racial or ethnic backgrounds, which was slightly higher than the available national data. Therefore, even though the sample size was limited, it appeared to be representative of physician and NP workforces in the United States.
Although very few NP programs in the United States offer sub-specialty preparation in HIV, directors of primary care NP programs across the nation can use the competencies identified in our study to facilitate integration of HIV concepts into basic NP curricula. For example, the pathophysiology course in any NP program should include content in the medical knowledge domain related to the major routes of transmission for HIV; normal immune function and HIV-induced immunosuppression; the natural history of HIV including disease progression, classification, and staging; and direct effect of HIV on body systems. Specialty knowledge, such as understanding the chain of infection of opportunistic infections and using knowledge about the HIV life cycle and structure in patient care, could be incorporated into a specialty epidemiology and pathophysiology in an HIV specialty program. Similarly, clinical management courses in any NP program should include content from the patient care and procedural skills-related domain such as interpreting HIV testing results; implementing provider-initiated HIV counseling and testing; and implementing gender-specific, culturally relevant, evidence-based risk-reduction interventions (sex-related risk reduction, drug use-related risk reduction, vertical risk reduction). Students completing a specialty concentration in HIV should also be able to independently initiate ART in treatment-naïve persons; initiate postexposure prophylaxis; correctly analyze and utilize viral load testing in planning, implementing, and evaluating treatment; and use the CD4+ T cell count to independently initiate prophylaxis for opportunistic infections.
At the Duke University School of Nursing, the competencies identified in our study were used to strengthen HIV content in core courses within the primary care NP program and helped guide the design of the HIV specialty curriculum. All competencies with a criticality index of 22 or greater (essential at entry into practice) have been addressed in either the HIV specialty courses or the standard NP core courses taken by all students, such as advanced physiology and pathophysiology, clinical pharmacology, physical assessment, and adult primary care. For example, the patient care and procedural skills-related competency of conducting a focused, individualized HIV risk factor assessment has been included in the physical assessment course; the medical knowledge-related competency of demonstrating an understanding of normal immune function and HIV-induced immunosuppression was included in the advanced physiology and pathophysiology courses; and the patient care and procedural skills-related competencies of implementing provider-initiated HIV counseling and testing, correctly interpreting HIV testing results, and identifying and referring patients with conditions beyond the scope of practice was included in the adult primary care course.
Four courses were developed for the HIV specialty track at the Duke University School of Nursing utilizing results of our study. Two one-credit HIV specialty courses–Epidemiology and Pathogenesis of HIV/AIDS and Pharmacologic Aspects of HIV/AIDS–build on content in the core NP courses in physiology, pathophysiology, and clinical pharmacology to ensure that graduates have entry-level competence in the Medical Knowledge and Patient Care and procedural skills competency domains as identified in our study (see Table 4). Similarly, building on core courses in population health, scholarly practice, and professional transitions required of all Duke University School of Nursing advanced nursing practice students, a one-credit specialty course–Psychosocial, Political, Legal, and Ethical Aspects of HIV/AIDS–also facilitates competence development in HIV specialty graduates in professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice.
To facilitate clinical application of the various competency domains and further develop competency in patient care and procedural skills, a two-credit course–Clinical Care and Treatment Issues in HIV/AIDS–builds on the three one-credit courses that serve as prerequisites to this course. Students apply content from this clinical course by completing a total of 392 hours in clinical settings that provide primary medical care to PLWH.
As scientific advances continue to extend the length and quality of lives for PLWH and as efforts to identify and treat those who are infected expand, HIV prevalence will continue to rise, resulting in an increased need for providers who are well educated in HIV care management. NPs have been essential team players in HIV management since the beginning of the epidemic, and a growing number of NP programs around the United States are beginning to integrate more HIV content into their curricula. The results of our study can help inform the development of such programs. As HIV specialty education for NPs continues to evolve, it is important for the nursing profession to define core competencies such as those identified in this study.
The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.
- Essential entry-level knowledge, skills, and attitudes–also known as competencies–have been identified for primary care nurse practitioners specializing in HIV care.
- Competencies can guide curriculum development and integration of concepts related to HIV into primary care nurse practitioner education programs.
- Entry-level primary care nurse practitioners must have attained competence in medical knowledge, professionalism, interpersonal and communication skills, patient care and procedural skills, and practice-based learning and improvement.
This research was supported by grant number H4AHA26219 from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), HIV/AIDS Bureau. The manuscript's contents are solely the responsibility of the authors and do not necessarily reflect the official view of HRSA, HIV/AIDS Bureau. The authors would like to acknowledge Tina Johnson and Jackie Gottlieb for their assistance in developing and deploying the online survey associated with this study. Additionally, the authors would like to acknowledge Kara McGee, PA-C, for her contributions to the HIV/AIDS specialty track for primary care nurse practitioners at the Duke University School of Nursing.
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