INTRODUCTION
M. Katherine Crabtree, DNSc, ANP, RNC
Chairperson, NONPF Education Committee
Background
This document presents the newly revised core competencies for nurse practitioner
practice. The revisions are based on the seminal work Advanced Nursing Practice:
Curriculum Guidelines and Program Standards for Nurse Practitioner Education
published by the National Organization of Nurse Practitioner Faculties (NONPF) in
1995. Developed by a national task force under the leadership of Christine Boodley,
PhD, RN, FNP, this document was endorsed by ten national nursing organizations.
The 1995 curriculum guidelines contain a set of core competencies describing the
generic practice behaviors of nurse practitioners upon entry into practice. The
competencies were based on research done by Patricia Benner, PhD and Karen
Bryckzynski, PhD, who defined the domains for advanced nursing practice. The six
domains include (1) Management of Client Health Status, (2) The Nurse-Client
Relationship, (3) The Teaching-Coaching Function, (4) Professional Role, (5)
Managing and Negotiating the Health Care Delivery System, and (6) Monitoring and
Ensuring the Quality of Health Care Practice. These domains were developed from
observation of and interviews with nurse practitioners in primary care practice.
The core competencies developed for each of these domains have been used as
national guidelines for curriculum development among nurse practitioner programs
and remain the basis for evaluating nurse practitioner practice. They have formed
the basis for comparison of educational programs and evaluation of their adequacy in
terms of curriculum. The core competencies have served these purposes well and
remain the foundation upon which the revised competencies are built.
Revision of the Core Competencies
Because the core competencies are intended to accurately describe nurse practitioner
behaviors upon entry into practice, practice changes necessitate their revision.
Periodic review and revision of core competencies must be ongoing. This is the first
revision since 1995, but, because of the fluid nature of practice, further revisions will
be needed. Expansion of the scientific knowledge base along with emerging trends in
society and health care has led to revision of curricular content.
The newly revised core competencies reflect the current nature of nurse practitioner
practice. In addition to the original six domains listed above, a new domain titled
Cultural Competencies has been added. This domain emphasizes the need for
1
culturally competent care and addresses the nurse practitioner’s role in relation to
spirituality. Other competencies have been added to clarify the role in light of
increasing demands on nurse practitioners to demonstrate competency in
understanding how community health issues such as literacy, violence, and poverty
impact the health care of their clients. Nurse practitioners are expected to ensure
quality through evidence-based practice, adoption of practice guidelines, and the use
of technology. With the advent of health care reform and shift to manage care
environments, there has been greater need for understanding how the organization
and financing of health care affect delivery of quality care. Nurse practitioners must
understand sound business strategies and legal regulations regarding reimbursement
for services and be able to use data systems to monitor and improve care outcomes.
In other instances, the changes represent minor refinements of skills already
described in the 1995 competencies.
The mapping of the human genome is emerging as a major influence on curricular
content related to screening, identification of genetic disease, prevention of disease,
counseling, treatment, and perhaps eventually genetic intervention. While the full
impact of this scientific revolution will continue to be felt for many years to come, we
can already anticipate some of its implications for the preparation of nurse
practitioners.
Process Used to Revise the Core Competencies
The process used to revise the competencies entailed several steps in an effort to
ensure broad participation of nurse educators from across the nation. Several task
forces participated in the process. Members of the Core Competencies Task Force,
drawn from the Education Committee of NONPF, reviewed the core competencies
and suggested revisions, as did the specialty task forces working on competencies
for the adult, family, geriatric and women’s health nurse practitioner specialties. A
draft of the revisions was submitted to a validation panel for review. The national
panel of nurse practitioner educators met face to face for an active exchange during
the review process. The validation panel was comprised of NONPF members who
represented diverse geographical regions, large and small programs, public and
private programs, as well as newer and well-established nurse practitioner programs.
Some of the validation panel had participated in the original task force that wrote the
core competencies published in 1995. Revisions were made and again reviewed by
the Core Competency Task Force and the specialty task forces. The NONPF task
force on increasing cultural diversity reviewed competencies for the new domain. In
addition, several external nurse experts were asked to review competencies related
to spirituality included in the new cultural domain. Final revisions were submitted to
and approved by the NONPF Board of Directors.
The impending release of core competencies in genetics for all health care
professionals by the National Coalition for Health Professional Education in Genetics
2
(NCHPEG) has led us to acknowledge their work here. Rather than await final release
of their document, which would delay publication of the revised core competencies,
we are proceeding with this version of the core competencies. An asterisk denotes
the core competencies that reflect the role of the nurse practitioner in relation to
genetics screening, counseling, prevention, and treatment of genetic disease. We
wish to make this role more explicit in the revised core competencies in light of this
scientific advancement and the role of nurse practitioners in incorporating this new
knowledge to benefit patients. The NONPF Board of Directors endorsed in concept
the NCHPEG core competencies related to genetics and expects to advocate the
adoption of these core competencies when they are publicly released. In the
meantime, we refer interested individuals to the NCHPEG Web site for further
information: http://www.nchpeg.org.
Revision of the Curriculum Guidelines
The demonstrated value of the original curriculum guidelines suggests that an
updated publication could benefit nurse educators as well. To this end we are
planning a revision of the curriculum guidelines for advanced practice. The
publication will contain a brief history of the document and include a collection of
position papers on nurse practitioner education. The revised curriculum guidelines
will include brief state-of-the-art position papers on important and emerging
curricular issues such as ethics and end of life issues, behavioral change strategies,
community health, genetics, complementary/alternative therapies, cultural
competency, and increasing cultural diversity among nurse practitioner students and
faculty. The business aspects of practice, including data management, will be
addressed, as will the use of technology to improve practice, evidence-based care,
quality of care, and peer review. We will also feature topics such as distance
education, credentialing, national certification, and post-master’s education. We
intend, as well, to include highlights from the results of the national NP program
survey done collaboratively with American Association of Colleges of Nursing. The
curriculum guidelines revision task force will serve as reviewers, and the document
will be submitted to the Board of Directors for approval in July 2001.
National Project to Validate Specialty Competencies
NONPF, in partnership with the American Association of Colleges of Nursing, received
funding from the Division of Nursing in September 2000 to conduct a project to validate
primary care specialty competencies for adult, geriatric, family, pediatric, and women’s
health nurse practitioners. Together these specialties represent over 80% of the primary
care specialties. The funding allows us to bring together national nursing organizations
representing NP education, practice, certification, and credentialing to develop
consensus-based competencies for primary care nurse practitioners in the areas of
adult, family, geriatric, pediatric, and women’s health. During the 18-month project
we will be working with Drs. Madeleine Hess and Madeline Turteltaub from the
3
Division of Nursing. We have hired a consultant, T. Dary Erwin, PhD, from James
Madison University, who has expertise in psychology and education and experience
working with groups to develop competencies and conduct outcome assessments.
In October, NP educators in these NP specialties and representatives from accrediting
organizations and credentialing bodies met for two days with Dr. Ewin in Washington,
DC to develop a set of competencies for each specialty that builds on the work done
previously by each of the organizations. I represented NONPF as Chair of the Education
Committee, and other representatives included the four chairpersons of the NONPF
specialty task forces: Toma Guberski, ANP Task Force; Melinda Swenson, FNP Task
Force; Vaunette Fay, GNP Task Force; and Linda Andrist, WHNP Task Force. Joan
Stanley represented AACN and is serving as the project co-director. Other
representatives participating in the meeting included the following: Anne Moore of the
Association of Women’s Health, Obstetric, and Neonatal Nursing (AWHONN); Susan
Wysocki of the National Association of Nurse Practitioners in Women’s Health
(NANPWH); Sandy Worthington of the National Certification Corporation for the
Obstetrics, Gynecologic, and Neonatal Nursing Specialties (NCC); Pamela Hellings of the
Association of Faculties of Pediatric Nurse Practitioner and Associate Programs
(AFPNP/AP); Mary Smolenski of the American Nurses Credentialing Center (ANCC); Jan
Towers of the American Academy of Nurse Practitioners Certification Program
(AANPCP); and Jan Wyatt of the National Certification Board for Pediatric Nurse
Practitioners and Nurses (NCBPNP/N). Both Madeleine Hess and Madeline Turkeltaub
were present on behalf of the Division of Nursing.
NONPF, AWOHNN, NANPWH, AANP, AFPNP/AP, and NCBPNP have published
competencies that provided a starting point for the process. We identified similarities
and gaps among the existing competencies and recommended revisions. Four groups
(AANPAP, NCBPNP, NCC, and ANCC) also had completed role delineation studies that
they used to guide development of credentialing examinations in various specialties.
The representatives, or “stakeholders,” who attend the meetings will speak for their
organizations and participate in the development of a unified set of competencies
reached by consensus. The competencies we agree upon will then be sent to a panel
of experts for validation. The responses by the validation panel will be collated and
the revised set of competencies sent back to the stakeholders for review and final
revision. Relevant nursing organizations will be asked to endorse the final set of
competencies, and the competencies will be widely distributed by the government
printing office. The competencies will not be the product of any one organization but
a collaborative effort. Diskettes will also be available for use by national nursing
organizations to post the final competencies on their web sites.
The Division of Nursing views these specialty competencies as useful to evaluating
quality in nurse practitioner programs that seek federal funding. These competencies
may serve as a model for the future development of competencies for the other
specialties (e.g., mental health, acute care, etc.)
4
We plan to have the consensus-based competencies for each of the five specialties
identified by the end of January 2001. The validation process will then run from
February through May followed by completion of the final set of consensus-based
competencies in June. We will seek endorsement of the validated consensus
competencies by national nursing organizations and the credentialing and accrediting
bodies before publication. Dissemination of the competencies begin in July 2001.
Future Revision of Core Competencies
With the completion of a set of consensus competencies for these nurse practitioner
specialties, we anticipate there may be need for further revision in the core
competencies developed by NONPF; however, we did not wish to delay this
publication of the revised core competencies because we have had repeated requests
for their release. Therefore, we are advising users that the core competencies will be
reviewed and periodically revised as necessary to capture important changes in the
practice of nurse practitioners. The fluid nature of curriculum development and the
need for on-going monitoring of changes is apparent. Scientific advances such as
genetics and societal trends affecting the health of populations and health care as
delivered by nurse practitioners will continue to influence the role of advanced
practice nurses. NONPF, as a leader in nurse practitioner education, will continue to
provide resources to raise the quality of preparation for this complex and valuable
role.
5
DOMAINS AND COMPETENCIES
OF NURSE PRACTITIONER PRACTICE
-- 2000 --
DOMAIN 1.
Management of Client Health/Illness Status
COMPETENCIES
The nurse practitioner demonstrates competence in the domain of management of
client health/illness status when s/he performs the following behaviors in the
following areas.
A.
Health Promotion/Health Protection and Disease Prevention
1.
Differentiates between normal, variations of normal, and abnormal findings.*
2.
Provides health promotion and disease prevention services to clients who are
healthy or have acute and chronic conditions.*
3.
Provides anticipatory guidance and counseling to promote health, reduce risk
factors, and prevent disease and disability. *
4.
Develops or uses a follow up system within the practice to ensure that clients
receive appropriate services.*
5.
Recognizes environmental health problems affecting clients and provides
health protection interventions that promote healthy environments for
individuals, families, and communities.*
B.
Management of Client Illness
1.
Analyzes and interprets history, presenting symptoms, physical findings, and
diagnostic information to develop appropriate differential diagnoses.
2.
Diagnoses and manages acute and chronic conditions while attending to the
client’s response to the illness experience.
3.
Prioritizes health problems and intervenes appropriately including initiation
of effective emergency care.
6
4.
Employs appropriate diagnostic and therapeutic interventions and regimens
with attention to safety, cost, invasiveness, simplicity, acceptability,
adherence, and efficacy.
5.
Formulates an action plan based on scientific rationale, evidence-based
standards of care, and practice guidelines.
6.
Provides guidance and counseling regarding management of the health/illness
condition.*
7.
Initiates appropriate and timely consultation and/or referral when the problem
exceeds the nurse practitioner’s scope of practice and/or expertise.*
8.
Adequately assesses and intervenes to assist the client in complex, urgent, or
emergency situations
a. Rapidly assesses the client’s unstable and complex health care
problems through synthesis and prioritization of historical and immediately
derived data.
b. Diagnoses unstable and complex health care problems utilizing
collaboration and consultation with the multidisciplinary health care
team as indicated by setting, specialty, and individual knowledge and
experience.
c. Plans and implements diagnostic strategies and therapeutic
interventions to help clients with unstable and complex health care
problems regain stability and restore health in collaboration with the
client and multidisciplinary health care team.
d. Rapidly and continuously evaluates the client’s changing condition and
response to therapeutic interventions, and modifies the plan of care
for optimal client outcomes.
Appropriate to Both Subdomains
1.
Demonstrates critical thinking and diagnostic reasoning skills in clinical
decision making.
2.
Obtains a comprehensive and/or problem focused health history from the
client.
3.
Performs a comprehensive and/or problem focused physical examination.
7
4.
Analyzes the data collected to determine health status.
5.
Formulates a problem list.
6.
Assesses, diagnoses, monitors, coordinates, and manages the health/illness
status of clients over time and supports the client through the dying process.
7.
Demonstrates knowledge of the pathophysiology of acute and chronic
diseases or conditions commonly seen in practice.
8.
Communicates the client’s health status using appropriate terminology,
format, and technology.
9.
Applies principles of epidemiology and demography in clinical practice by
recognizing populations at risk, patterns of disease, and effectiveness of
prevention and intervention.
10.
Uses community/public health assessment information in evaluating client
needs, initiating referrals, coordinating care, and program planning.
11.
Applies theories to guide practice.
12.
Applies/conducts research studies pertinent to area of practice.
13.
Prescribes medications based on efficacy, safety, and cost as legally
authorized and counsels concerning drug regimens, drug side effects, and
interactions.
14.
Evaluates the use of complementary/alternative therapies used by clients for
safety and potential interactions.
15.
Integrates appropriate nonpharmacologic treatment modalities into a plan of
management.
16.
Orders, may perform, and interprets common screening and diagnostic tests.*
17.
Evaluates results of interventions using accepted outcome criteria, revises the
plan accordingly, and consults/refers when needed.
18.
Collaborates with other health professional and agencies as appropriate.*
19.
Schedules follow-up visits to appropriately monitor clients and evaluate
health/illness care.
8
DOMAIN 2.
The Nurse-Client Relationship
COMPETENCIES
The nurse practitioner demonstrates competence in the domain of the nurse clientrelationship when s/he:
1.
Creates a climate of mutual trust and establishes partnerships with clients.
2.
Validates and verifies findings with clients.
3.
Creates a relationship with clients that acknowledges their strengths and
assists clients in addressing their needs.
4.
Communicates a sense of “being present” with the client and provides comfort
and emotional support.
5.
Evaluates the impact of life transitions on the health/illness status of clients
and the impact of health and illness on clients (individuals, families, and
communities).
6.
Applies principles of self-efficacy/empowerment in promoting behavior
change.
7.
Preserves the client’s control over decision making, assesses the client’s
commitment to the jointly determined, mutually acceptable plan of care, and
fosters client’s personal responsibility for health.*
8.
Maintains confidentiality while communicating data, plans, and results in a
manner that preserves the dignity and privacy of the client and provides a
legal record of care.*
9.
Monitors and reflects on own emotional response to interaction with clients
and uses this knowledge to further therapeutic interaction.
10.
Considers the client’s needs when termination of the nurse-client relationship
is necessary and provides for a safe transition to another care provider.
9
DOMAIN 3.
The Teaching-Coaching Function
COMPETENCIES
The nurse practitioner demonstrates competence in the domain of the teachingcoaching function when s/he:
Timing
1.
Assesses the client’s on-going and changing needs for teaching based on a)
needs for anticipatory guidance associated with growth and developmental
stage, b) care management that requires specific information or skills, and c)
client’s understanding of his/her health condition.
2.
Assesses client’s motivation for learning and maintenance of health related
activities using principles of change and stages of behavior change.
3.
Creates an environment in which effective learning can take place.
Eliciting
1.
Elicits information about the client’s interpretation of health conditions as a
part of the routine health assessment.
2.
Elicits information about the client’s perceived barriers, supports, and
modifiers to learning when preparing for client’s education.
3.
Elicits from the client the characteristics of his/her learning style from which to
plan and implement the teaching.
4.
Elicits information about cultural influences that may affect the client’s
learning experience.
Assisting
1.
Incorporates psycho-social principles into teaching that reflect a sensitivity to
the effort and emotions associated with learning about how to care for one’s
health conditions.
2.
Assists clients in learning specific information or skills by designing a learning
plan that is comprised of sequential, cumulative steps and that acknowledges
relapse and the need for practice, reinforcement, support, and re-teaching
when necessary.
10
3.
Assists clients to use community resources when needed.
Providing

Communicates health advice, instruction and counseling appropriately
using evidence based rationale.
Negotiating
1.
Negotiates a mutually acceptable plan of care based on continual assessment
of the client’s readiness and motivation, resetting of goals, and optimal
outcomes.
2.
Monitors the client’s behaviors and specific outcomes as a useful guide to
evaluating the effectiveness and need to change or maintain teaching
strategies.
Coaching

Coaches the client throughout the teaching processes by reminding,
supporting, encouraging, and the use of empathy.
DOMAIN 4.
Professional Role
COMPETENCIES
The nurse practitioner demonstrates competence in the domain of professional role
when s/he:
Develops and Implements Role
1.
Uses scientific theories and research to implement the nurse practitioner role.
2.
Functions in a variety of role dimensions: health care provider, coordinator,
consultant, educator, coach, advocate, administrator, researcher, and leader.
3.
Interprets and markets the nurse practitioner role to the public, legislators,
policy-makers, and other health care professions.
11
Directs Care
1.
Prioritizes, coordinates, and meets multiple needs and requests for culturally
diverse clients.
2.
Uses sound judgment in assessing conflicting priorities and needs.
3.
Builds and maintains a therapeutic team to provide optimum therapy.
4.
Obtains specialist and referral care for clients while remaining the primary
care provider.
5.
Advocates for the client to ensure health needs are met.
6.
Consults with other health care providers and private/public agencies.
7.
Incorporates current technology appropriately in care delivery.
8.
Uses information systems and to support decision-making and to improve
care.
Provides Leadership
1.
Is actively involved in a professional organization.
2.
Evaluates implications of contemporary health policy on health care providers
and consumers.
3.
Participates in legislative and policy-making activities that influence advanced
nursing practice and the health of communities.
4.
Advocates for access to quality, cost-effective health care.
5.
Evaluates the relationship between community/public health issues and social
problems as they impact the health care of clients (poverty, literacy, violence,
etc.)
12
DOMAIN 5.
Managing and Negotiating Health Care
Delivery Systems
COMPETENCIES
The nurse practitioner demonstrates competence in the domain of managing and
negotiating health care delivery systems when s/he:
Managing
1.
Demonstrates knowledge about the role of the nurse practitioner in case
management.
2.
Provides care for individuals, families, and communities within integrated
health care services.
3.
Considers access, cost, efficacy, and quality when making care decisions
4.
Maintains current knowledge of the organization and financing of the health
care system as it affects delivery of care.
5.
Participates in organizational decision making, interprets variations in
outcomes, and uses data from information systems to improve practice.
6.
Manages organizational functions and resources within the scope of
responsibilities as defined in a position description.
7.
Uses business and management strategies for the provision of quality care
and efficient use of resources.
8.
Demonstrates knowledge of business principles that affect long-term financial
viability of a practice, the efficient use of resources, and quality of care.
9.
Demonstrates knowledge of relevant legal regulations for nurse practitioner
practice including reimbursement of services.
Negotiating
1.
Collaboratively assesses, plans, implements, and evaluates primary care with
other health care professionals using approaches that recognize each one’s
expertise to meet the comprehensive needs of clients.
13
2.
Participates as a key member of an interdisciplinary team through the
development of collaborative and innovative practices.
3.
Participates in the planning, development, and implementation of public and
community health programs.
4.
Participates in legislative and policy-making activities that influence health
services/practice.
5.
Advocates for policies that reduce environmental health risks.
6.
Advocates for policies that are culturally sensitive.
7.
Advocates for increasing access to health care for all.
DOMAIN 6.
Monitoring and Ensuring the Quality of Health
Care Practice
COMPETENCIES
The nurse practitioner demonstrates competence in the domain of monitoring and
ensuring quality health care practice when s/he:
Ensuring Quality
1.
Interprets own professional strengths, role, and scope of ability to peers,
clients, and colleagues.
2.
Incorporates professional/legal standards into practice
3.
Acts ethically to meet the needs of clients.*
4.
Assumes accountability for practice and strives to attain the highest standards
of practice.
5.
Engages in self-evaluation concerning practice and uses evaluative information
to improve care and practice.
6.
Collaborates and/or consults with members of the health care team about
variations in health outcomes.
14
7.
Uses an evidence-based approach to client management that critically
evaluates and applies research findings pertinent to client care management
and outcomes.
8.
Evaluates the client’s response to the health care provided and the
effectiveness of the care.
9.
Uses the outcomes of care to revise care delivery strategies and improve the
quality of care.
10.
Accepts personal responsibility for professional development and the
maintenance of professional competence and credentials.
Monitoring Quality
1.
Monitors quality of own practice and participates in continuous quality
improvement.
2.
Evaluates client follow-up and outcomes including consultation and referral.
3.
Monitors research in order to improve quality care.
DOMAIN 7.
Cultural Competence
COMPETENCIES
The nurse practitioner demonstrates cultural competence when s/he:
1.
Shows respect for the inherent dignity of every human being, whatever their
age, gender, religion, socioeconomic class, sexual orientation, and ethnic or
cultural group.
2.
Accepts the rights of individuals to choose their care provider, participate in
care, and refuse care.
3.
Acknowledges personal biases and prevents these from interfering with the
delivery of quality care to persons of other cultures.
4.
Recognizes cultural issues and interacts with clients from other cultures in
culturally sensitive ways.
15
5.
Incorporates cultural preferences, health beliefs and behaviors, and traditional
practices into the management plan.
6.
Develops client-appropriate educational materials that address the language
and cultural beliefs of the client.
7.
Accesses culturally appropriate resources to deliver care to clients from other
cultures
8.
Assists clients to access quality care within a dominant culture.
Spiritual Competencies
1.
Respects the inherent worth and dignity of each person and the right to
express spiritual beliefs as part of his/her humanity.
2.
Assists clients and families to meet their spiritual needs in the context of
health and illness experiences, including referral for pastoral services.
3.
Assesses the influence of clients’ spirituality on their health care behaviors and
practices.
4.
Incorporates clients’ spiritual beliefs in the plan of care appropriately.
5.
Provides appropriate information and opportunity for clients and families to
discuss their wishes for end of life decision-making and care.
6.
Respects wishes of clients and families regarding expression of spiritual
beliefs.
* Denotes competencies that reflect the role of the nurse practitioner in relation to genetics screening,
counseling, prevention, and treatment of genetic disease. NONPF wishes to highlight this role in light
of the recent scientific advancements and the role of nurse practitioners in incorporating this new
knowledge to benefit patients. The National Coalition for Health Professional Education in Genetics
(NCHPEG) has developed core competencies in genetics essential for all health care professionals.
The NONPF Board of Directors endorsed in concept these core competencies related to genetics and
expects to advocate the adoption of these core competencies when they are publicly released. In the
meantime, we refer interested individuals to the NCHPEG for further information,
http://www.nchpeg.org.
16