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The Advance Practice Exam: Understanding the 7 Domains of Advanced Practice Nursing

Reimanis, Cathryn L.

Journal of Wound, Ostomy and Continence Nursing: May/June 2015 - Volume 42 - Issue 3 - p 287–289
doi: 10.1097/WON.0000000000000140

Cathryn L. Reimanis

Correspondence: WOCNCB, 555 East Wells St Ste, 1100, Milwaukee, WI.

The author declares no conflict of interest.

Direct clinical practice role is the core, defining competency within any advanced practice nursing role. However, to limit any professional role to competency in a single domain minimizes its strength and growth. Therefore, 6 additional role domains of the advanced practice registered nurse (APRN) have been identified that are interwoven into the discipline and are germane to the graduate-level curriculum and expected clinical practice exposure.1,2 The APRN role education and preparation promote enhanced autonomy and awareness within 3 spheres of influence within the health care milieu, patient, nurse, and system. While clinical expertise varies, the core criteria and competencies act synergistically and are shared across the discipline. A novice understanding of these attributes is a part of the Practice Evaluation section found in each of the WOCNCB Advanced Practice exam specialties. (Please refer to Domain 6 of the AP detailed content outlines accessible at

The 7 domains of advanced nursing practice are briefly summarized later. The WOCNCB-AP exam candidate is strongly encouraged to review these attributes to ensure a working understanding prior to test-taking—please refer to an advanced practice nursing conceptual role and domain textbook for more detailed discussion. AP-exam eligibility criteria are found at the WOCNCB Web site.

  1. Direct Clinic Practice is the central domain of the population-based APRN roles. Proficiency in each WOCNCB specialty area (wound, ostomy and continence care) requires specific clinical knowledge. (Please refer to the July/August 2014 JWOCN Getting Ready for Certification article for examples of AP-exam questions addressing each specialty.)
  2. Guidance and Coaching are used within a therapeutic APRN-patient relationship to promote efficacious disease self-management. Synthesis of clinical observations and provider self-reflection lead to successful patient-specific clinical and institutional outcomes.
  3. Consultation is an interaction between professionals to successfully transfer expert specialty information. This results in enhanced patient and institutional outcomes, promotes clinical understanding, and builds multi-, inter-, and intradisciplinary relationships.
  4. Evidence-Based Practice/Research. The APRN is trained to use evidence-based practice principles in patient-specific clinical decision making, the development of patient care policies and procedures, and in the evaluation of clinical outcomes. The APRN has been prepared to perform scholarly research activities in addition to working in a clinical environment.
  5. Leadership is a collaborative process of facilitating activities and strategies to achieve clinical and organizational goals. The APRN exercises leadership within 4 key areas: direct clinical practice, health care systems, the nursing profession, and the health policy arena.
  6. Collaboration is an authentic interaction between individuals to build constructive solutions toward a common purpose or outcome. This holistic and dynamic relationship occurs over time and can lead to personal and professional transformation for those involved.
  7. Ethical Decision-Making for the APRN involves recognizing, contemplating, and developing equitable and just solutions to moral dilemmas within the immediate and broader health care systems.

1. APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. Consensus model for APRN regulation: licensure, accreditation, certification and education. Published 2008. Accessed August 20, 2014.

2. Hamric C, Hanson CM, Tracy MF, O'Grady ET, eds. Advanced Practice Nursing: An Integrative Approach. 5th ed. St Louis, MO: Elsevier Saunders; 2014.

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Practice Questions

  1. The CWOCN-AP is considering adding a skin substitute product for treatment of diabetic foot ulcers in the ambulatory care setting. An initial literature search to evaluate the best evidence for time to healing and a cost-benefit analysis was started. Using a hierarchical rating system to assess the robustness of the available evidence, the highest to lowest level of resources are:
    1. A well-designed control trial without randomization to a single descriptive study
    2. A well-designed randomized control trial (RCT) to a systematic review of a descriptive study
    3. A systematic review of RCTs to an expert committee report
    4. A well-designed case-control study to a well-designed cohort study
  2. The APRN specialist recommends the following actions to promote successful ostomy self-management except:
    1. Minimize the influence of cultural identity or practices
    2. Initiate the encounter with motivational interviewing
    3. Provide an environment centered in respect
    4. Apply conflict resolution strategies when needed
  3. As the APRN, you have noted an increased trend in the urinary tract infection (UTI), incident rate at a particular nursing home. With your leadership, a multidisciplinary quality improvement team is being developed to refine the current policy and procedure. The primary ARPN role domain in this team is:
    1. Consultation
    2. Collaboration
    3. Care coordination
    4. Cross-cultural advocacy

For Answers, see next page.

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Answers to Practice Questions

Question 1

Correct Answer C:

Content Outline: 060601

Defining the clinical intervention to be queried and aligning and critically appraising the literature results for research bias, study methodology, and bias are critical criteria when synthesizing research information. There are times when the best available evidence for a clinical question has not been explored in 1 or more RCTs found at the pyramid apex of an evidence hierarchy. Contributions of different types of research enquiries have grown in acceptance over the years.1,2

The highest to lowest rank order of evidence for intervention effectiveness is as follows: Level 1: Systematic reviews (preferably with meta-analyses) of RCTs or nonrandomized trials; Level 2: A single RCT or a single nonrandomized trial; Level 3: Systematic review of correlational/observational studies; Level 4: Single correlational/observational study; Level 5: Systematic review of descriptive/qualitative/physiologic studies; Level 6: A single descriptive/qualitative/physiologic study; and Level 7: Opinions of authorities and/or reports of expert committees.1–3

1. Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 8th ed. Philadelphia, PA: Wolters Kluwer Health; 2008:28–34.

2. Gray M. Evidence-based practice. In: Hamric C, Hanson CM, Tracy MF, O'Grady ET, eds. Advanced Practice Nursing: An Integrative Approach. 5th ed. St Louis, MO: Elsevier Saunders; 2014:248–259.

3. Melnyk BM, Fineout-Overholt E. Making the case for evidence-based practice and cultivating a spirit of inquiry. In: Melnyk BM, Fineout-Overholt E, eds. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice. 2nd ed. Philadelphia, PA: Wolters Kluwer Health; 2011.

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Question 2

Correct Answer A:

Content Outline: 040101 & 060301

This question addresses the guidance and coaching role domain. Creating a culturally safe encounter by drawing upon and protecting cultural identities, well-being, and practices promotes cultural competence and respect. When behavior change is needed, motivational interviewing compared with advice giving consistently demonstrates better health outcomes. A clinician's respectful approach to the patient and their family is a key engagement strategy in understanding and improving their health. Conflict resolution skills in the setting of self-reflection are important skills to enhance interpersonal interactions and successful coaching.1,2

1. Spross JA, Babine RL. Collaboration. In: Hamric C, Hanson CM, Tracy MF, O'Grady ET, eds. Advanced Practice Nursing: An Integrative Approach. 5th ed. St Louis, MO: Elsevier Saunders; 2014.

2. Nesbitt B, Murray D, Mensink A. Teaching motivational interviewing to nurse practitioner students: a pilot study. J Am Assoc Nurse Pract. 2014:26(3):131–135.

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Question 3

Correct Answer B:

Content Outline: 060401

While all of these attributes overlap and will be used, collaboration and developing a shared partnership in meeting the defined, patient-centered objective is the best answer provided. A few essential characteristics of collaboration include clinical competency and accountability, a shared purpose, effective communication, mutual respect and trust, appreciating diverse and complementary knowledge, skills and cultures, as well as the appropriate use of humor.

As a consultant, the clinical expertise of the WOCNCB continence-certified APRN will be shared within these meetings and will likely be incorporated into the final policy and procedure document. The coordination of consistent care to enhance positive patient outcomes will be a result of the quality improvement initiative; staff should be oriented to the new process with a return demonstration indicating understanding. Appreciating cross-cultural diversity will contribute to each team member's value and practice expertise; taken by itself, cross-cultural advocacy is not considered a role domain.1,2

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1. Hanson CM, Carter M. Collaboration. In: Hamric C, Hanson CM, Tracy MF, O'Grady ET, eds. Advanced Practice Nursing: An Integrative Approach. 5th ed. St Louis, MO: Elsevier Saunders; 2014.
2. O'Brien J, Martin D, Heyworth J, Meyer N. A phenomenological perspective on advanced practice nurse-physician collaboration within an interdisciplinary healthcare team. J Am Acad Nurse Pract. 2009;21(8):444–453.
© 2015 by the Wound, Ostomy and Continence Nurses Society.