PRESCRIBING COMPETENCIES FOR AUTONOMOUS APRN PRESCRIPTIVE
AUTHORITY: WHAT DO NURSE PRESCRIBERS NEED TO KNOW?
By
TRACY KLEIN
A dissertation submitted in partial fulfillment
of the requirements for the degree of
DOCTOR OF PHILOSOPHY
WASHINGTON STATE UNIVERSITY
College of Nursing
MAY 2011
© Copyright by TRACY KLEIN, 2011
All Rights Reserved
© Copyright by TRACY KLEIN, 2011
All Rights Reserved
To the Faculty of Washington State University:
The members of the Committee appointed to examine the dissertation of TRACY
KLEIN find it satisfactory and recommend that it be accepted.
___________________________________
John Roll, Ph.D., Chair
___________________________________
Louise Kaplan, Ph.D., ARNP, FAANP
___________________________________
Renee Hoeksel, Ph.D., RN
___________________________________
Linda Eddy, Ph.D., RN, CPNP
ii
ACKNOWLEDGMENT
The author would like to acknowledge the members of the dissertation committee: Dr. John Roll,
Dr. Louise Kaplan, Dr. Renee Hoeksel, and Dr. Linda Eddy. Your kindness, scholarly attention,
and support as I explored the nebula of competency development and assessment was
remarkable and much appreciated. Additional support throughout the dissertation process was
provided by Dr. Katherine Crabtree, Dr. Jill Budden from the National Council of State Boards
of Nursing, and the staff and members of the Oregon State Board of Nursing. Special thanks to
Dr. Ruth Bindler, who graciously accepted my transfer to this program knowing my desire to
incorporate public policy into graduate nursing study, and to Eileen Swalling who kept me
connected to the home campus even though I live in Oregon. Much appreciation is extended to
Jessie Dahl for her editorial work on this manuscript. Finally, thank you to my parents who
always encouraged my studies and supported my interests in continuing them well beyond my
teenage years, to Dr. Helen Turner, who completed the first prescribing practicum in Oregon as a
Clinical Nurse Specialist, to Dr. Peter Collier who introduced me to role socialization theory, and
to my husband Mark who rarely tires of nursing policy discussions and learned to like Spokane.
iii
PRESCRIBING COMPETENCIES FOR AUTONOMOUS APRN PRESCRIPTIVE
AUTHORITY: WHAT DO NURSE PRESCRIBERS NEED TO KNOW?
Abstract
Tracy Klein, Ph.D
Washington State University
May 2011
The United States currently has no reliable and valid model for assessing entry-level
autonomous prescriptive competency for advanced practice nurses, despite a decade of
legislative expansion in scope and autonomy. Klein and Kaplan (2007) surveyed Washington and
Oregon nurse practitioners with prescriptive authority, clinical nurse specialists with and without
prescriptive authority; and nurse practitioner students, their preceptors and faculty about the
relative importance of prescribing specific competencies (n=180). The original survey used an
instrument from the Oregon State Board of Nursing, titled Clinical Practicum in
Pharmacological Management Evaluation, containing 31 competencies. The present study used
mixed methods to further confirm essential entry-level outcomes used to meet requirements for
autonomous prescriptive authority. Three steps of analysis were conducted to determine final
domain and competency recommendations: content analysis of original survey comments,
principle component analysis (PCA) of competency ratings, and final Q-Sort of revised
competencies using Subject Matter Experts (SMEs) with prescriptive authority licensed as CNSs,
NPs, or both. PCA of the 31 original competencies identified 4 factors containing 30 items
accounting for loadings of .40 or greater for all items. Removal of 1 competency as suggested by
content and factor analysis resulted in a Cronbach’s alpha of .959, indicating item internal
consistency. Two contextually similar items were combined for the final Q-sort analysis resulting
in the final 29 competencies in 4 domains titled: Safety, Patient Specific Assessment, Clinical
iv
Reasoning, and Clinical Management. Q-Sort by SMEs clearly placed 8 competencies into the
Safety domain, 3 between Safety and Patient Specific Assessment, 7 into Patient Specific
Assessment, 1 between Patient Specific Assessment and Clinical Reasoning, 2 into Clinical
Reasoning, 3 between Safety and Clinical Reasoning, 1 into Clinical Management and 4 in more
than two categories. SMEs confirmed item validity but did not confirm discrete domain
placement for 11 competencies, indicating a need for further analysis and revision of domain
categories in order to confirm regulatory sufficiency.
v
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS………………………………………………………………………iii
ABSTRACT................................................................................................................................ iv-v
LIST OF TABLES......................................................................................................................... xi
LIST OF FIGURES ...................................................................................................................... xii
CHAPTER
1. INTRODUCTION .........................................................................................................1
Statement of the Problem .......................................................................................1
Statement of Purpose .............................................................................................2
Specific Aim and Sub Aims ..................................................................................2
Significance and Rationale ....................................................................................3
Nurse practitioner prescribing competencies in the United States ............3
Clinical nurse specialist prescribing ..........................................................4
Rationale for a prescribing specific instrument .........................................5
Prescribing competencies and state regulation ......................................... 7
Instrument development process and rationale .........................................8
2. REVIEW OF THE LITERATURE ..............................................................................11
Definitions ............................................................................................................11
Competencies ...........................................................................................11
Prescribing ...............................................................................................11
Advanced practice registered nurse (APRN) ...........................................11
Search Strategy..................................................................................................... 12
vii
Prescribing Competencies: Health Professionals .................................... 12
Validation of competencies ..................................................................................14
Competency development: Purpose .....................................................................15
Controversies in competency assessment............................................................. 16
Methods of validation........................................................................................... 18
Theoretical framework and model........................................................................ 19
The Harden Model................................................................................... 19
The Regulatory Context of Prescribing Privileges................................................22
U.S. Prescriptive Authority...................................................................... 22
Prescribing Competencies: Nursing......................................................... 23
International Prescribing Perspectives......................................................26
3. RESEARCH, DESIGN, AND METHODOLOGY......................................................28
Original Study.......................................................................................................28
Results...................................................................................................................30
Present Study: Methodology.................................................................................31
Content Analysis...................................................................................................32
Method .....................................................................................................32
Data Collection ........................................................................................ 32
Validity..................................................................................................... 33
Analysis ....................................................................................................34
Principle Component Analysis ............................................................................ 35
Method .....................................................................................................35
Reliability .................................................................................................36
viii
Analysis ....................................................................................................37
Q Sort ...................................................................................................................38
Method .....................................................................................................38
Data Collection .........................................................................................39
Analysis ....................................................................................................40
4. RESULTS ....................................................................................................................42
Sample Description ..............................................................................................42
Content Analysis Findings ...................................................................................44
Original Survey: Reflections of Faculty and Participants .......................44
Faculty Specific Responses .................................................................................47
Independent Review Using Two Experts ............................................................49
Coder Reliability ..................................................................................... 51
Principle Component Analysis Findings .............................................................54
Q Sort Findings ....................................................................................................61
SME Comments ...................................................................................................67
5. DISCUSSION ...............................................................................................................74
Theoretical Framework ........................................................................................74
Competency Concepts .............................................................................74
Domains ...................................................................................................76
Implementation and Assessment ..........................................................................80
Limitations ...........................................................................................................82
Recommendations for Future Research ............................................................. 84
Regulatory Implications ..................................................................................... 86
ix
REFERENCES .............................................................................................................................89
APPENDIX
A. CLINICAL PRACTICUM IN PHARMACOLOGICAL MANAGEMENT EVALUATION
INSTRUMENT............................................................................................................... 107
B. WSU IRB APPROVAL LETTERS ............................................................................108
C. RECRUITMENT OF SUBJECT MATTER EXPERTS LETTER............................ 110
D. INFORMED CONSENT TO PARTICIPATE IN Q SORT LETTER .......................111
x
LIST OF TABLES
1. Demographic Information: Subject Matter Experts..................................................................42
2. Comments: All Participants ......................................................................................................44
3. Faculty Specific Additional Questions .....................................................................................47
4. Tone Score Comparisons ..........................................................................................................50
5. Content Code Description with Frequency of Use ...................................................................52
6. Cronbach’s Alpha All Items .....................................................................................................54
7. Cronbach’s Alpha with Ownership Competency Removed .....................................................54
8. Initial Factors in Principle Component Analysis with Loadings ............................................. 56
9. Final Domains and Competencies ............................................................................................59
10. Q Sort Results ..........................................................................................................................61
11. SME Interview Responses .......................................................................................................68
12. Comparison of Original Communication Domain and New Safety Domain ..........................69
13. Final Revised Domains and Competencies..............................................................................71
xi
LIST OF FIGURES
1. Figure 1; Harden 3 Circle Model ...............................................................................................20
xii
CHAPTER 1
INTRODUCTION
Statement of the Problem
An improved regulatory environment has increased the number and scope of Advanced
Practice Registered Nurse (APRN) prescribers (Pearson, 2010; Lugo, O’Grady, Hodnicki, &
Hanson, 2007; Christian, Dower, & O’Neil, 2007). However, there are no US regulatory models
that identify and validate prescribing specific outcomes for the purpose of granting initial
autonomous prescriptive authority either for new graduates or an already licensed APRN. Entrylevel preparation cannot always anticipate scope of practice changes (“Changes in Health Care,”
2007). It is therefore important to facilitate readiness for change that incorporates APRN full
autonomy in the prescribing role (Kaplan & Brown, 2008).
Role and scope of practice expansion makes it increasingly likely that more APRNs will
seek prescriptive authority. Health regulatory Boards need to devise systems to evaluate and
confirm that prescribing competencies have been met. A particular gap is the lack of models for
attainment of prescribing competencies after completion of graduate education and initial APRN
licensure. In order to evaluate prescribing outcomes it is necessary to develop and validate a set
of prescribing specific competencies for autonomous practice.
The primary document addressing prescribing specific competencies for nurses was
published over a decade ago (Yocom, Busby, Conway-Welch, & Veins, 1998). Curriculum
Guidelines and Regulatory Criteria for Family Nurse Practitioners Seeking Prescriptive
Authority to Manage Pharmacotherapeutics in Primary Care (Yocom, Busby, Conway-Welch,
& Veins, 1998) was developed specifically to address one APRN role (nurse practitioner) and
one population focus (family). Since that time, the availability of prescriptive authority has
1
expanded to include all APRN roles and multiple population foci. More states have also obtained
the authority for scheduled drug prescribing, now possible for APRNs in all but two states
(Pearson, 2010).
There are no published prescribing specific competencies for nurse midwives, clinical
nurse specialists, or certified registered nurse anesthetists in the US. General competencies for
nursing incorporate practice across the spectrum that may or may not include prescriptive
authority. Specific competencies for advanced practice nurses, such as the NONPF Core
Competencies (2006) incorporate prescribing as a very limited component of overall practice.
Prescriptive authority is an integral part of autonomous practice ability. It is therefore the
position of APRN representatives from licensure, accreditation, certification and education in the
APRN Consensus Paper (APRN Joint Dialogue, 2008) that prescribing medication is substantial
part of the APRN role that distinguishes its scope from that of the basic registered nurse.
Preparation to prescribe, regardless of current legal authority, should therefore be required as a
competency for all APRN roles (APRN Joint Dialogue, 2008).
Statement of the Purpose
The purpose of this study is to identify competencies and domains for use by regulators
charged with granting prescriptive authority. Study findings will be used to promote a refined
instrument for use by state regulators as a model for authorizing autonomous prescriptive
authority.
Specific Aim and Sub Aims
The specific aim of this study is to identify prescribing competencies and domains in the
Clinical Practicum in Pharmacological Management Evaluation instrument that accurately
2
reflect essential entry-level autonomous prescriber outcomes. There are three sub aims to this
study:
Sub Aim 1. Identify prescribing competencies that may be removed or modified to
strengthen the reliability of the Clinical Practicum in Pharmacological Management
Evaluation instrument.
Sub Aim 2. Revise the domains into which the competencies can be categorized
Sub Aim 3. Confirm appropriate categorization of the competencies into representative
domains.
Significance and Rationale
Nurse practitioner prescribing in the United States. In Fiscal Year 1993, Senate
Appropriations Committee report 102-397 urged the Agency for Health Care Policy and
Research to work with the Health Resources and Services Administration to develop an
advanced practice curriculum with guidelines to prepare nurse practitioners (NPs) for
prescriptive privileges (Clancy & Gelot, 1999). Under a 16- month grant funded process, the
National Council of State Boards of Nursing (NCSBN) and the National Organization of Nurse
Practitioner Faculties (NONPF) developed curriculum guidelines for
pharmacology/pharmacotherapeutics courses appropriate for use in master’s level family nurse
practitioner (FNP) programs. These guidelines were to be used in conjunction with regulatory
guidelines for state Boards of Nursing charged with granting prescriptive authority for the FNP
(Model Pharmacology/Pharmacotherapeutics, 1998). The guidelines also cite documents
appropriate to the time as reference resources for competency development, including the
American Association of Colleges of Nursing’s The Essentials of Master’s Education for
Advanced Practice Nursing (AACN, 1996). The final document, titled Curriculum Guidelines
3
and Regulatory Criteria for Family Nurse Practitioners Seeking Prescriptive Authority to
Manage Pharmacotherapeutics in Primary Care (Yocom, Busby, Conway-Welch, & Veins,
1998), subsequently referred to as Curriculum Guidelines, included both regulatory and
curricular recommendations, and provided end-of-course competencies for a model
pharmacology course.
At the time of development of the Curriculum Guidelines, the FNP program focus was
chosen as it had the broadest scope of practice. In 1998, there were several states without
prescriptive authority for NPs. In 2010, although regulation of NPs still varies from state to state,
all states have prescriptive authority (Pearson, 2010). Ironically, the revised 2006 NONPF core
competencies include only one specifically related to prescribing: “prescribes medications within
legal authorization” (NONPF, 2006).
Clinical Nurse Specialist prescribing. Clinical Nurse Specialists are gaining regulatory
recognition and prescribing authority similar to that of nurse practitioners. It is therefore of
particular interest to develop and evaluate prescribing competencies inclusive of an APRN role
like the Clinical Nurse Specialist (CNS). The CNS has prescriptive authority in 34 states
(NCSBN, 2010) but most have not been educated to have prescriptive authority as part of their
role. Preparation for prescriptive authority includes attainment of the knowledge, skills and
ability to use differential diagnosis, identify pharmacologic intervention, and manage individual
patients. Perhaps due to existing legal barriers to implementation of prescribing competencies in
educational coursework and clinical preparation, the National Association of Clinical Nurse
Specialists (NACNS) distinguishes between advanced pharmacology included in all CNS
educational curricula and the knowledge needed for prescriptive authority. The regulatory
requirements for prescriptive authority consequently mandate many CNSs to pursue additional
4
education to prescribe (NACNS, 2005; Delaney, Hamera & Drew, 2009). Regulatory Boards
may confront the dilemma of developing a framework to evaluate initial competency to prescribe
in APRNs not prepared through traditional educational means. Prescribing specific competencies
should be developed to address the needs of practice expansion for otherwise experienced nurses.
Rationale for a prescribing specific instrument. Educational programs that prepare
students for prescriptive authority and to be safe competent prescribers do not always meet that
goal. Delaney et al. (2009) conducted a comprehensive national survey of psychiatric mental
health APRNs (n= 1, 899) regarding the adequacy of their educational preparation for practice.
The study revealed that a majority of psychiatric mental health APRNs (CNS or NP) spends over
one- third of their week prescribing (Delaney et al., 2009). While 70% were satisfied with their
initial program preparation, 534 participants responded to open ended questions regarding areas
of preparation in their programs and identified inadequate preparation in psychopharmacology
and in pharmacologic management of patients. The third most common response to an openended question regarding program preparation identified a mismatch between educational
preparation and regulatory requirements, resulting in the need to return to school to meet
requirements for prescribing authority and/or national certification. The majority of states require
national certification for initial licensure and many mandate prescriptive authority (Pearson,
2010). This finding represents a significant disconnect between curricular design and regulatory
requirements. Competencies developed for novice use, such as the Curriculum Guidelines and
NONPF Core Competencies (2006) have not been evaluated for regulatory purposes.
Furthermore, they do not encompass the experienced APRN who returns to obtain prescriptive
authority.
5
APRNs continue to increase their legal autonomy. This autonomy includes greater ability
to prescribe controlled substances, dispense medications, increase the scope of legend drugs
prescribed, and practice without physician supervision or collaboration (Kaplan, Brown, Andrilla
& Hart, 2006; Pearson, 2010). It is important to prepare NPs for a new scope of practice such as
expanded prescribing, even before it occurs in order to validate their socialization to the role and
their safety in practice (Kaplan & Brown, 2008).
Little unified political or financial support was generated to further research nurse
prescribing competencies as the role was being developed and practiced. From 1955 until 1970
the American Nurses Association Model Nurse Practice Act explicitly prohibited prescriptive
authority of nurses, although nurses had long taken on the role of medication dispensing,
administration, and monitoring of patient responses to pharmaceutical effects (O’Malley &
Mains, 2003). Many states still grant APRN practice authority without prescriptive authority,
which potentiates challenges for state Boards responding to requests to add prescriptive authority
long after the student role is finished and clinical practice has been established.
Lyon (2003) cites multiple surveys of CNSs in practice who neither require nor desire to
gain prescriptive authority. It is the position statement of the National Association of Clinical
Nurse Specialists (National Association, 2005) that prescriptive authority should be optional
under state law and should not be mandated in the educational curriculum as a presumption. The
sole statement on prescriptive authority located on the website of the American Association of
Nurse Anesthetists (Blumenreich, 1988) identifies prescribing as primarily the act of filling out a
prescription, and therefore not necessary for the CRNA working in an inpatient setting
administering medications.
6
Prescribing competencies and state regulation. The Institute of Medicine (IOM, 2003)
identified the need for significant changes in health professional education. Among many
recommendations, the IOM (2003) stressed the need to integrate competencies into oversight
processes including licensure. Oregon serves as an example of how scope of practice change
generates the need for validated prescribing competencies. Nurse Practitioners and Nurse
Midwives in Oregon have a long history of independent practice and prescribing medications,
beginning with legislative recognition in 1977 and prescriptive authority in 1979 (Oregon Nurse
Practice Act, 1953/2010). Recognition of CRNAs occurred in 1997 and of Clinical Nurse
Specialists in 2002 (Oregon Nurse Practice Act, 1953/2010). In 2004, Oregon legislation added
prescriptive authority to the scope of practice for CNSs. The new statute was broad and modeled
existing Oregon statutes that provide for autonomous NP prescribing and dispensing of
medications including Schedule II-V narcotics.
Implementation of the law presented a regulatory challenge. Not all CNS programs
prepare students to prescribe. Furthermore, the mandate did not include additional funding for
resources to develop educational programs or curricular models that could facilitate CNSs in
current practice without such authority. Frequently, states in the same position find themselves
short on resources and models with which to accommodate legislative changes to the APRN
scope of practice. It was also difficult to estimate the numbers of CNSs who would see
prescriptive authority, and their individual experiences with prior practice or coursework in
preparation for expanded authority.
As of January 1, 2011, nine nurses have completed the practicum in order to be granted
prescriptive authority in Oregon. Applicants were required to complete the practicum of 150
supervised prescribing hours either because their initial program either did not contain clinical
7
hours or courses specific to prescribing or because they had an extended gap in practice. The
Clinical Practicum in Pharmacological Management Evaluation instrument was developed by
the Oregon State Board of Nursing’s Advanced Practice Consultant for preceptors to use when
evaluating completion of a supervised prescribing practicum, as required in law.
Instrument Development Process and Rationale
The current instrument used in Oregon was developed to evaluate a prescribing specific
practicum by Board of Nursing staff. The prescribing practicum regulations which determined
the number of hours, required courses, and process for licensure were written in conjunction with
a task force of CNSs, NPs, and a pharmacist who met monthly for one year. The regulatory
purpose of the prescribing practicum was to confirm safety to prescribe for CNSs who did not
have a supervised prescribing practicum in their initial educational program and subsequently
applied for prescriptive authority. Passage of legislation authorizing Clinical Nurse Specialists
(CNSs) to obtain autonomous prescribing authority generated the initial need for this practicum.
The process of adopting prescribing regulations moved requirements for NPs into a new
section of the Oregon Nurse Practice Act that could apply to all nurse prescribers. This facilitated
the statutory requirement that a CNS complete “Clinical education in patient management,
including pharmacotherapeutics, comparable to the requirements for completion of a nurse
practitioner program” (Oregon Nurse Practice Act, 1953/2010). It also created a placeholder for
CRNAs if legislation changes enabling them to obtain prescriptive authority. Nurse Midwives
are licensed as NPs in Oregon and are therefore incorporated into all NP regulations. The task
force used a comprehensive survey of all NP programs completed in 2000-2001 (n=275, 85%
response rate) conducted by the American Association of Colleges of Nursing (AACN) and
NONPF to identify regulatory requirements for curricular content comparable to requirements
8
for an NP program (Berlin, Harper, Werner, & Stennet, 2002). Faculty on the task force further
estimated that 150 hours would be an accurate minimum percentage of the total prescribing
focused clinical time in the average 500- to 600 hour NP program.
The Clinical Practicum in Pharmacological Management Evaluation instrument (see
Appendix A for more details) was developed to provide the Oregon State Board of Nursing with
documentation of successful completion of a supervised 150 hour prescribing practicum.
Although not designed initially to evaluate NPs, evaluation criteria were generated from the
statutory mandate that the practicum be comparable to that completed by NPs prepared to
prescribe. A search of current regulatory models that incorporate a prescribing practicum
revealed limited guidelines for or use with Oregon’s scope of autonomous APRN practice.
Models for obtaining prescriptive authority vary significantly from state to state in consideration
of regulatory context and legislative mandate. All states require completion of a 30 to 45 hour
pharmacology course for authority to be granted (NSCBN, 2009). Beyond this requirement,
some require a period of supervision before prescriptive authority is granted, including Colorado,
Maine, and California (Pearson, 2010; NCSBN, 2009). This externship may be extensive, as in
Ohio where applicants must complete a 1500 to1800 hour supervised externship under a
physician and may not do so under an APRN who already has prescriptive authority (Ohio,
2010). Colorado requires an 1800- hour practicum under the supervision of a physician for any
NP, including new graduates, unless they have prescribed at least that many hours autonomously
in the past (Colorado Division, 2008). There is little evidence to support the number of
supervised hours required to develop prescribing competency, and none to validate whether
socialization to the role under an experienced nurse prescriber is an important component. As of
9
2010, Maine and Colorado grant autonomous authority upon completion of the physiciansupervised practicum, but California and Ohio do not.
Initial evaluation of the competencies by Oregon and Washington NPs, CNSs, faculty,
students, and preceptors was the subject of a study by Klein and Kaplan (2010). Results of the
study indicated a need for further analysis of which prescribing competencies are required for
autonomous prescriptive authority.
Rigorous instrument development and validation is a task rarely accomplished by
regulatory Boards. Nurse regulators face barriers to development of evidence based practice
tools, including lack of educational preparation, inability to find time to write and publish their
findings, and difficulty obtaining financial support (Spector, 2010). Additionally, resources for
conducting research or collecting data is rarely considered a priority for nursing Boards and
unlikely to be measured by benchmarking data to which Boards are accountable (Spector, 2010;
Ridenour, 2009). The use of the tool for various experience levels and APRN roles in nursing is
an example of what Simon (1995) identifies as bounded rationality. Law is often passed without
infrastructure such as available coursework and validated outcomes. Structure is then built to
accommodate it during the process of implementation and evaluation in practice. Simon (1995)
provides an example of the framers of the US Constitution, who did not have before them a
“menu of all possible constitutional provisions. Instead, they invented some provisions as they
went along.” (p. 47). Further evolution of the tool and the gathering of informed data on
autonomous prescribing will therefore strengthen the instrument for broader regulatory use.
10
CHAPTER 2
REVIEW OF THE LITERATURE
Definitions
Competencies. For the purpose of this analysis “competencies” refer specifically to
measurable outcomes consisting of a mixture of knowledge, skills, abilities, motivation, beliefs,
values, and interests (Fleishman, Wetrogen, Uhlman, & Marshall-Mies, 1995). Integration of
competencies into a professional role also incorporates additional role specific competencies,
such as those necessary to become a safe APRN prescriber, or specific legal requirements for
valid prescriptive authority.
Prescribing. As this is a study of the Clinical Practicum in Pharmacological
Management Evaluation instrument used by the OSBN the Oregon statutory definition of
“prescribe” is used. Prescribing involves instruction related to a medication or preparation for
use by human beings “to direct, order, or designate the preparation, use of or manner of using by
spoken or written words or other means” (Oregon Nurse Practice Act, 1953/2010). This
definition was adopted initially for nurse practitioner prescribers, and then amended in 2005 to
add CNS authority to prescribe and dispense medications (Oregon Nurse Practice Act,
1953/2010). CRNAs do not have prescriptive authority in Oregon currently.
Advanced Practice Registered Nurse (APRN). The Consensus Model for APRN
Regulation: Licensure, Accreditation, Certification and Education (APRN Joint Dialogue, 2008)
represents a document endorsed by forty-four nursing organizations with the authority to
implement it (ANA, 2009). The model is a significant step towards consistency in how advanced
11
practice registered nurses (APRNs) are prepared and recognized for practice. The first step in the
development of the Consensus Paper (APRN Joint Dialogue, 2008) was to define the term and
meaning of APRN. Prior to the Consensus Paper (APRN Joint Dialogue, 2008) there was great
divergence regarding what constituted “advanced nursing practice.” As one example, public
health nurses considered what they do as “advanced practice” and objected to the
characterization of advanced nursing practice in the Vision Paper (NCSBN, 2006) because it
limited advanced practice to the direct care of individuals and use of pharmacologic
interventions (Levin, Cary, Kulbok, Leffers, Molle & Polivka, 2008). The final Consensus
Paper defines four APRN roles as requiring specific advanced preparation and licensure:
certified nurse practitioner (CNP), certified nurse midwife (CNM), certified registered nurse
anesthetist (CRNA) and clinical nurse specialist (CNS).
Search Strategy
Prescribing competencies: Health professions. The act of prescribing crosses legal
professional boundaries of medicine, pharmacy, and nursing. Initial database searches for
competencies and outcomes used the terms “prescribing” and “prescribing competencies” in
conjunction with “nurse prescribers,” “APRN,” “nurse practitioners,” “clinical nurse specialists,”
“nurse midwives,” and “certified registered nurse anesthetists” in EBSCO (Academic Search
Complete), CINAHL, JSTOR, ERIC, and SOCIAL SCIENCES INDEX. Clinical psychologists
have been granted prescriptive authority in New Mexico and Louisiana, so a search was
expanded to include the search terms “clinical psychology” and “clinical pharmacology” with the
terms “prescribing” and “prescriptive authority.” Google search engine was used to scan
professional educational accreditation websites for medicine and pharmacy to identify
educational competencies, since both fields integrate pharmacotherapeutics application
12
throughout the educational process (Introductory, 2008; Aronson, 2006; Tonkin, Taverner, Latte,
and & Doecke, 2006; Maxwell & Walley, 2002) with graduate medical education in the US
having adopted prescribing competencies for medical residents in 1999 (Scott Tilley, 2008).
Research related to prescribing competencies in countries outside of the US was considered for
the purpose of secondary analysis, but was not utilized in original instrument development due to
significant differences in regulation, scope of practice, and implementation of prescriptive
authority for non-US nurse prescribers. Research related to competency assessment, continued
competency, and regulatory assessment was primarily obtained through both the public and
members only sections of the website for the National Council of State Boards of Nursing. At the
suggestion of Dr. Jill Budden from National Council of State Boards of Nursing, a search was
initiated using the term “competency modeling” to obtain additional information on
methodology used in occupational and psychological literature. Other resources included
Dissertations and Theses A & I databases and personal communications with nursing leaders and
scholars including Dr. Katherine Crabtree and Dr. Christine Tanner from Oregon Health and
Sciences University.
The field of basic nursing competency assessment itself is still at the concept analysis
stage (Scott Tilley, 2008). Literature specific to the concept of the nurse prescriber is rare, and
role competency literature primarily focuses on nursing at the basic level of education.
Therefore, the literature search was broadened to incorporate terms such as “role transition,”
“expertise,” “role identity,” and “role socialization” to clarify the role mastery piece of becoming
a nurse prescriber. Role socialization literature was found primarily in social psychology
(Brewer, 1991) or education (Kennedy, 1987), but there were also articles in medical journals
that focused on the development of clinical diagnostic reasoning as one moves from novice to
13
expert (Norman, 2006; Bowen, 2006; Harden, Crosby & Friedman, 1999). Nurse specific role
transition focused in one of three areas: basic level RN novice to expert literature (Benner,
1982), role socialization of the nurse practitioner which did not focus on prescribing (Lurie,
1981), or transition to the APRN role outside of the US health system (McKenna, 2006; Offredy,
Kendall, and& Goodman, 2008). Current National Council of State Boards of Nursing initiatives
on transition to practice focus on the registered nurse and do not therefore address prescribing
medications (NCSBN, 2009). In 2007, NCSBN completed a comprehensive role delineation
study comparing NPs and CNSs who were asked to rate the frequency (“criticality”) of their
activities in actual practice. The highest criticality ratings from NPs that were not highest for
CNSs involved both prescribing and adjusting medications (NSCBN, 2007). CNSs who choose
to prescribe may experience a different transition to practice than NPs or NP students, especially
if they lack role models or mentors.
Validation of Competencies
There is no nationally accepted method for validation of competencies at the advanced
nursing level (NACNS, 2005) and no one good method for assessing competence in practice
(Hodges, 2006; NCSBN, 2005). The most widely used methods are expert consensus panel
validation in conjunction with broader expert opinion. These may be confirmed by a number of
additional methods. The highest level of rigor is obtained by a variable combination of mixed
multiple methods reflective of setting, target populations, and intended application (Shippmannn
et al., 2000). The process for validation of the original Curriculum Guidelines (Yocom et al.,
1998) involved: (a) appointment of an eleven person advisory committee representing nursing,
medicine and pharmacy; (b) literature search of existing curricula and outcomes specific to
prescribing including those for Physician Assistants; (c) expert panel appointment of eight
14
persons representing medicine, FNP education and clinical practice, pharmacy and medical/legal
perspectives to identify competencies and the outline of topics for the curriculum guideline
component; and (d) document review and revision through distribution of the draft document and
consideration of 140 comments received in the first two drafts. Regulatory criteria incorporated
into the document were evaluated following a similar process but additionally distributed
through eight national nurse practitioner meetings and comments were received (approximately
70) from Boards of Nursing.
Because competencies for health professions are designated for use in a licensed
employment role, the use of job analysis can enhance role specific competencies for practice as
well as differentiate competencies for specific APRN roles (NACNS, 2005; NCSBN, 2007).
Competency models may be developed using a wide variety of formats depending upon
organizational needs (Marrelli, Tondora, & Hoge, 2005). Standards used for evaluating and
measuring competencies also vary depending upon whether their intended function has a legal or
regulatory component (Marrelli, et al., 2005). A conceptual framework for development should
identify how representation of the construct can be distinguished from other constructs and is
shaped by the way in which the scored competencies will be used (Joint Committee on
Standards, 2004).
Competency Development: Purpose
Competency based assessment can be used for educational, employment, or regulatory
purposes. Public-corporate models for education that adopt job specific competencies into the
educational curriculum appeal to employers (Paulson, 2001). However, competencies must also
incorporate attitudinal and personal characteristics and not just functional skills (Marrelli et al.,
2005). The ultimate goal of enforcing competency based professional education is significant
15
reduction or elimination of error (IOM, 2003; Davenport, Davey, & Ker, 2005). Medication
errors are attributed to multiple conditions including attitude of the prescriber, particularly if
prescribing is perceived as low importance compared to other job responsibilities (Dean,
Schachter, Vincent, & Barber, 2002; O’Malley, 2007). Dean et al. (2002) emphasize that safe
prescribing requires creating and enforcing a culture that sees prescribing as important. The goal
of any requirement incorporated into nursing regulation should be public protection (Ridenour,
2009).
Shippmann et al. (2000) conducted an extensive two-year review of the practice of
competency modeling and its methodological range in practice under the sponsorship of the
Society for Industrial and Organizational Psychology. Their process included an extensive
literature search and in depth interviews with 37 subject matter experts (SMEs) specializing in
the development and use of competency models. Descriptive findings included a wide variety of
definitions of the term and use of “competencies” with the concept of the “core competency”
emerging in the US business landscape during the early 90’s for human resource purposes. An
interesting finding from the SME discussion was that the majority felt job analysis is task
focused and competency modeling is worker focused (Shippmann et al., 2000). A job analysis
may be used to enhance competency development but should not substitute for evaluation of
individual traits and intelligences.
Controversies in Competency Assessment
Competencies purport to quantify desirable traits that result from a synthesis of
education, socialization, and inherent qualities. These traits are then used to evaluate and assure
some measure of competence in practice. Despite the acceptance and incorporation of
competency-based assessment into health professional education, there are several cautions
16
found in the literature regarding their widespread usage. Rees (2004) sees outcome based
learning tools as directly countering the pedagogy of problem based learning because their expert
development enforces the dominant paradigm and dis-empowers learners who might innovate or
generate new knowledge. Talbot (2004, p. 588) notes that in developing measurable
competencies “the danger is always that we ask questions related to those things that might be
more easily measured, instead of asking the difficult questions.” Models that are overly broad do
little to ensure individual safety and competency in practice; however, there are no specific rules
to guide level of detail for either competency modeling or job analysis (Shippman et al., 2000).
Incorporation of competency based testing and evaluation in the regulatory sphere involves
minimum level assessment, whereas in the educational sphere it concentrates on assessment for
improvement and learning (Erwin & Wise, Summer 2001). The ultimate goal of enforcing
competency based professional education is significant reduction or elimination of error (IOM,
2003; Davenport, Davey & Ker, 2005). However, legislatures and the public, as primary
constituents of regulatory Boards, request competency assessment for greater accountability but
not necessarily improvement (Nettles, Cole, and Sharp, 1997).
Development of competencies to reflect discipline specific goals has hindered the use of
common terminology and inter-professional models of practice (CICH, 2007). This conflicts
with recommendations from the Institute of Medicine (IOM, 2001; 2003) that all health
professionals receive education in patient centered care that emphasizes use of interdisciplinary
teams and related core competencies.
Hodges (2006) identifies four types (“discourses”) of competency models in use and their
respective pitfalls when used for measurement of competence. The first is the assessment of
competence-as-knowledge, which when overemphasized leads to potential lack of interpersonal
17
skills and poor integration of knowledge with performance. The second is competence-asperformance which developed as a reaction to the former. Competence-as-performance
generated an interest in quantifying observed skills through use of simulated patients and
Objective Structured Clinical Examination (OSCE) formats. Hodges (2006) states that excessive
reliance on this teaching process can lead to hidden incompetence through lack of authentic
connection to patients and inability to integrate content specific knowledge. The third is
competence-as-reliable test score, focusing on the psychometric reliability of measurement tools
to generate high stakes examinations for measurement of competency. Competence-as-reliabletest-score results in the concern that programs preparing students will teach to the test rather than
the desired outcomes. Hodges (2006) also observes that higher-level skills needed for clinical
practice such as pattern recognition, integration and synthesis do not measure well on
standardized testing. Finally, Hodges (2006) addresses the use of internal reflection and selfreflection in competency frameworks. He cites the work of Kruger and Dunning (1999) who
identified the wide gap in accuracy of self assessment for those who perform poorly, while
persons doing well tend to devalue their own efficacy. In a later article Dunning, Johnson,
Erhlinger & Kruger (2003) call into question whether incompetent people can be expected to
identify their deficits due to insufficient meta-cognitive skills.
Methods of Validation
Complex knowledge required for higher-level actions can be difficult to measure
(Marrelli, Tondora & Hoge, 2005; Tanner, 2006) regardless of job title or description.
Measurement of nursing regulatory models does not fit with the established evidence based
biomedical framework (Spector, 2010). Spector (2010) argues for adoption of a pragmatic model
developed by Evans (2003) that incorporates effectiveness, appropriateness and feasibility
18
criteria into a new hierarchy of evidence. Policy implementation, while difficult to validate with
randomized controlled studies, can be validated using program evaluation, audits, and other
methods of confirmation in addition to psychometric methods.
Theoretical Framework and Model
Development of the Clinical Practicum in Pharmacological Management Evaluation
instrument required use of already established nursing domains to meet time and resource
constraints. The initial model for the instrument was created using domains published in the
American Nurses Association (ANA) Nursing: Scope and Standards of Practice. The domains
were developed for all aspects of nursing practice and incorporate prescribing as a small
component.
The ANA Scope and Standards of Practice (2004) identifies one standard (5D) related to
prescriptive authority that has six measurement criteria. The overarching standard identified by
ANA is that “the advanced practice registered nurse uses prescriptive authority, procedures,
referrals, treatments and therapies in accordance with state and federal laws and regulations” (p.
30). All standards related to prescriptive authority under the domain titled Implementation. This
categorization conceptualizes prescribing as a discrete and episodic skill rather than an ongoing
complex management skill. While useful for initial development of the instrument, results of the
initial study indicate the need for refinement. The Harden model (1999) will be used as the
primary conceptual framework of this study, in order to articulate and simplify the validation of
prescribing competencies needed by an autonomous prescriber.
The Harden Model. The Harden model is based upon his educational expertise in
training physicians. However, Harden et al (1999) observe that preliminary studies suggest that a
similar framework can be applied to other professions and that if this is done his work could
19
facilitate development of inter-professional educational programs. Harden uses a three-circle
model to classify learning outcomes (Figure 1).
Figure 1. The Three-Circle Model for Outcome-Based Education. Adapted from “AMEE
Guide No 14: Outcome-based education, part 5: From competency to meta-competency: a model for
the specification of learning outcomes, by R.M. Harden, J.R. Crosby, M. H. Davis, & M. Friedman,
1999, Medical Teacher, 21, p. 547.
The Harden medical model was selected for several reasons related to the lack of an
appropriate nursing model. The first is the dearth of nursing competency assessment frameworks
to use with autonomous prescribing and prescriptive authority. In contrast, the ability to
competently and autonomously prescribe medications is assumed as a mandatory component of
medical education and residency. The second reason is the focus of practice transition models
and frameworks for nurses on either administration of medication or episodic prescribing rather
than extended pharmacologic management (NCSBN, 2009; ANA, 2004). The third reason is that
models that evaluate clinical decision-making at a complex level of practice were developed and
evaluated through observation of basic rather than advanced nursing practice (Tanner, 2006; C.
20
Tanner, personal communication August 17, 2009).
The Harden model was also selected for its simplicity, utility, and potential application to
multiple roles and levels of educational preparation. Harden et al. explicitly articulate use of the
model for both other healthcare professionals and for all phases of education including
undergraduate, post-graduate and continuing education. The model anticipates transition from
one phase to the next as well as life long learning (Harden et al., 1999). A model that can be used
for various roles and levels of entry into practice could be useful for implementing competencies
developed in response to scope or regulatory changes. A feasible, pragmatic model such as
Harden’s may help address the regulatory quandary of how to evaluate a prescribing practicum
developed for multiple roles and levels of clinical experience.
Harden incorporates twelve outcome competencies into the three-circle model. Seven are
task based and are demonstrations of the inner circle. Three describe the approach inherent to the
practitioner as he or she enact the inner circle tasks, and are represented in the middle circle. The
outer circle represents professionalism and “professional intelligences.” Harden identified his
competencies as the following:
•
Clinical skills.
•
Practical procedures.
•
Patient investigation.
•
Patient management.
•
Health promotion and disease prevention.
•
Communication.
•
Appropriate information handling skills.
•
Understanding of social, basic and clinical sciences and underlying principles.
21
•
Appropriate attitudes, ethical understanding and legal responsibilities.
•
Appropriate decision-making skills, and clinical reasoning and judgment.
•
Role of the doctor within the health service.
•
Personal development.
Harden et al. observe that the competencies can be evaluated using flexible methods such
as a portfolio or an Objective Structured Clinical Examination (OSCE). The latter is
operationalized in the specific curriculum designed by Harden for Dundee, Scotland. Harden is
credited with initial development of the OSCE exam (Major, 2005). The OSCE has been used to
evaluate student nurses for over 12 years in the United Kingdom (Major, 2005) and is used as a
licensure requirement for NPs in British Columbia. The outcome model and its competencies
have also been used specifically for a learning initiative in prudent prescribing designed to teach
safe and appropriate prescribing of antibiotics (Davenport et al., 2005).
The Regulatory Context of Prescribing Privileges
U.S. Prescriptive Authority. The regulatory process for granting prescriptive authority
in the US is state based and widely divergent. Physicians are always granted prescriptive
authority with initial licensure. No research supports or refutes the current regulatory process of
granting prescriptive authority to nurses with varying educational requirements, sometimes after
years of practice without it. Most states address the perceived discrepancy in educational
preparation and prescribing practice experience for health professionals other than physicians by
requiring some form of physician supervision or collaboration (Pearson, 2009; Christian, Dower,
& O’Neil, 2007; O’Malley & Mains, 2003) though there is no research to support its need.
Levels of evidence are defined for the purpose biomedical research by levels in descending order
I-V for rigor. Lack of level I (likely reliable) and II (mid-level) studies related to assessment of
22
competence to practice is noted in studies which relate to both medicine and nursing (Vess,
2007), which does not support physician supervision as a proxy for assessing prescribing
competency in nurse prescribers.
Clinical psychologists have published model guidelines for a postdoctoral experience that
includes pharmacology education and supervised clinical practice (APA, 2007) in order to
objectively evaluate competency in prescribing. These guidelines were developed in anticipation
of expansion of prescriptive authority through legislative changes in scope of practice. There is
conflict within the psychology profession, however, regarding whether these guidelines
appropriately prepare for autonomous prescriptive authority as opposed to supervised practice
(Heiby, 2010). There have been no published validation studies of graduates who added
prescriptive authority in autonomous practice to determine if the standards and training are
congruent (Heiby, 2010).
Prescribing competencies: Nursing. APRN prescribers function in four roles: Certified
Nurse Practitioner, Certified Nurse Midwife, Clinical Nurse Specialist, and Certified Registered
Nurse Anesthetist (APRN Joint Dialogue, 2008). Nurse prescribers have been authorized in the
US for over thirty years, yet there are limited data regarding the important transition to the
prescriber role that is specific to nurses. Prescriptive authority legislation was adopted state by
state in a piecemeal fashion, often in response to a specific geographic, financial, or political
pressure. The most common requirement for obtaining prescriptive authority is completion of a
30 to 45 contact hour pharmacology course (National Council, 2008). The presence of a separate
dedicated pharmacology course within current NP programs is evaluated through the degree
accreditation process, but is not currently required for the education of nurse midwives. CNS
programs may or may not contain pharmacology specific to prescribing. Current American
23
Association of Colleges of Nursing (AACN) guidelines and Commission on Collegiate Nurse
Education (CCNE) accreditation criteria do not specify the extent to which programs must
demonstrate application of prescribing principles within the educational program (AACN, 1996;
CCNE, 2009).
National core competencies in all the APRN specialties do not reflect the primacy of
prescribing to the APRN role, and are therefore inconsistent with its emphasis in the APRN
Consensus Paper (APRN Joint Dialogue, 2008). While practice differs based on individual role,
scope and geography, health care reform increases the likelihood that APRNs will play a primary
role in their patients’ healthcare, including prescribing (Stanley, Werner, & Apple, 2009).
Currently, not all APRNs prescribe and not all see it as a functional role competency.
A job analysis comparing the NP and CNS roles was published by the National Council
of State Boards of Nursing (NCSBN, 2007) as part of a role delineation study. As of 2007, NPs
were far more frequently engaged in all five identified activities related to prescribing and
monitoring medications. When asked to rank their activities related to its priority in their
practice, NPs ranked four of the five prescribing competencies in their top ten of all activities
critical to the performance of their role. CNSs, by comparison, ranked “prescribes medications
using principles of pharmacokinetics, drug dosage and routes, indications, interactions and
side/adverse effects” as sixty-fourth in importance, and “writes and transmits correct
prescriptions to minimize the risk of errors” as sixty-seventh. These differences were statistically
significant between the roles and consistently reflected in the job analysis, which included a total
of 92 job essential functions (NCSBN, 2007).
National consensus core competencies for CNSs from the profession (Baldwin, Clark,
Fulton and Mayo, 2009) identify 75 competencies for clinical practice in the role without
24
including one that addresses prescribing, dispensing, administering or even evaluating
medications used by individual patients. While this may reflect regulatory ambivalence, CNSs
themselves, when given the opportunity to respond to an open ended question asking for
recommendations about additional core competencies which should be included, identified that
competencies related to prescriptive authority were needed (Baldwin et al., 2009) as did CNSs
who practice in psychiatric mental health queried in a large survey of behalf of the American
Psychiatric Nurses Association (Delaney et al., 2009).
CRNAs also do not have uniform legal recognition of prescriptive authority. In Oregon,
as an example, CRNAs may select and administer medications, as well as be the primary person
responsible for development of the anesthesia plan, but they do not have prescriptive authority
(Oregon Nurse Practice Act 1953/2010). The American Association of Nurse Anesthetists
(AANA) is the professional organization responsible for setting professional and practice
standards for the CRNA role. CRNAs have a long history of administration and management of
medications that often are controlled substances and have a narrow window of safety. While
clearly functioning in an autonomous role in most states, CRNAs do not uniformly support
prescriptive authority or legal autonomous practice. Perhaps as evidence of this conflict within
the role, the most recent position statement on the AANA website which addresses prescriptive
authority was written in 1988 (Blumenreich, 1988) and clearly states that what CRNAs do in
their daily practice is not “prescribing,” but instead “administering” medications. There are no
nationally adopted prescribing competencies for CRNAs.
Finally, despite the long history of prescribing by Nurse Practitioners, core competencies
which focus on prescribing were reduced in the National Organization of Nurse Practitioner
Faculties’ (NONPF) most recent core competency document to one competency: “prescribes
25
medications within legal authorization” (NONPF, 2006). A prior document prepared jointly by
the National Council of State Boards of Nursing and the NONPF (Yocom, et al., 1998) identified
end of course and end of program competencies in pharmacotherapeutics for new graduates of
Family Nurse Practitioner programs only.
International prescribing perspectives. Competencies are used as outcomes to guide
curricula (Center for Health Policy, March 2008), licensing, and performance evaluation. A
literature search was initiated to identify published evidence-based models that addressed the
addition of prescribing authority through post-educational attainment of identified competencies.
Results revealed data from other countries regarding nurse prescribing, particularly specific to
the nurse practitioner role being enacted in Australia, Canada (Registered Nurses Association,
2003), the United Kingdom (U.K.) (Latter, Maben, Myall, and Young, 2007) and New Zealand
(Spence & Anderson, 2007). This research was being validated as the prescribing process was
being implemented in order to support expansion of practice. No research from other countries
was located which described prescribing competencies for the CNS role, though prescriptive
authority is available for CNSs in the U.K. (Dean et al., 2004). A difficulty in evaluation of
international literature is the discrepancy in role titling and recognition from the APRN role in
the U.S.
Differences in health care delivery and regulatory structure further support research on
evidence-based prescribing in other countries. Data collection is facilitated by single payer
government models which use nationalized prescribing networks and formularies. However,
despite the advantages that these systems might offer for tracking prescribing patterns and
identifying areas for competency development, limitations are still identified by critics. The
nurse prescriber role is relatively new to countries outside of the U.S. Maxwell & Walley (2003)
26
describe weaknesses in the prescribing curriculum for physicians in the U.K. resulting from
complete integration of clinical pharmacology and therapeutics under curriculum reform in the
1990s. This integration, while useful for promoting interdisciplinary clinical experiences,
resulted in a lack of clear learning outcomes and effective assessment specific to safe and
effective prescribing.
Literature regarding nurse prescribing outside of the U.S. rarely reflects experiences with
autonomous nurse prescribing analogous to the U.S. nurse practitioner role. Pulcini, Jelic, Gul &
Loke (2010) surveyed ninety one nurses from thirty two countries regarding advanced practice
nursing, education, practice and regulation. The survey revealed that while fifteen countries
allowed nurses to prescribe, the authority to do so varied widely, and ranged from autonomous
prescriptive authority to delegated, site based, or institutional authority.
As with the U.S., prescriptive authority has expanded beyond physicians and dentists in
other countries. In the U.K. Aronson (2006) discusses the governmental efforts to increase
patient access to medications that led to Patient Group Directions. This process is similar to a
collaborative agreement that permits pharmacists and nurses to supply medications to patient
under a protocol, sometimes without a generated prescription.
27
CHAPTER THREE
RESEARCH, DESIGN, AND METHODOLOGY
This is an exploratory study designed to identify prescribing competencies for APRNs for
the purpose of instrument development and refinement. It involves further analysis of survey
data collected by Klein and Kaplan in 2007 to 2008. The further analysis uses both quantitative
and qualitative exploratory approaches that allow for across-method triangulation to address
research aims and increase the likelihood of uncovering additional constructs specific to
prescribing (Williamson, 2005; Lev, 1995). The quantitative component uses data from
respondents including nurse educators, NP students, clinical preceptors, NPs with prescriptive
authority, and CNSs with and without prescriptive authority. The qualitative component uses
both solicited and unsolicited comments from the survey for further content analysis. The final
methodology is a Q sort, which provides quantification of subjective evaluation (Brown, et al.,
2008). The Q sort is a new component of the research that uses Subject Matter Experts (SMEs)
representing regulators, prescribing clinicians, and faculty with expertise in pharmacologic
management.
Original Study
The original study was a quantitative descriptive exploratory study that utilized survey
methodology. The sample included faculty, students and clinical preceptors from the Washington
State University FNP program; all CNSs licensed in Oregon, most of whom did not have
prescriptive authority; and attendees at a NP conference in Oregon who had prescribing
experience.
The Clinical Practicum in Pharmacological Management Evaluation instrument (see
Appendix A for more detail) was developed by this researcher for use in her role as the
28
Advanced Practice Consultant for the Oregon State Board of Nursing. Instrument development
was based on a literature review that was expedient and cost efficient for regulatory purposes.
Using already validated domains from the American Nurses Association’s Scope and Standards
of Practice (2004), pharmacotherapeutic specific competencies were identified from existing
U.S. based recommendations for CNSs (Tucker & Rhudy, 2003; NACNS, 2005), NPs (ANCC,
2004; Lecuyer, Desocio, Brody, Schlick & Menkens, 2005); and pharmacists (American
Pharmacists Association, 2005; National Association of Boards of Pharmacy, 2006), as well as
competencies adopted for national use by pharmacist and nurse prescribers in the U.K. (National
Prescribing Centre, 2004). The instrument follows a format already in use by the OSBN to verify
completion of a re-entry practicum for registered nurses.
The instrument was used as the basis to develop a 42- item questionnaire containing 11
demographic questions and the instrument’s 31 competencies. While the domains identified on
the OSBN instrument group the competencies according to seven domains from the ANA
Nursing Scope and Standards of Practice (2004), the survey questionnaire listed each
competency without identified domains. The version distributed to faculty members contained 10
reverse worded questions and additional comment space soliciting specific input on the
instrument itself and its utility. The intent of wording items in the same scale both positively and
negatively is to avoid acquiescence, affirmation or agreement bias (DeVellis, 2003).
After receiving IRB approval through Washington State University (#09797) (see
Appendix B for complete letter), the original survey was mailed to the WSU graduate nursing
faculty. Subsequently, the survey was mailed to WSU FNP students and their preceptors, as well
as all licensed Oregon CNSs. A second mailing was done one month later to increase the
response rate. The survey was later distributed at a regional Nurse Practitioner conference. Study
29
participants were asked to evaluate prescribing competencies using a 5-point Likert scale with
responses of not at all essential, neutral, somewhat essential, very important and mandatory.
“Mandatory” was defined as: “a nurse should not be granted prescriptive authority without it”
(Klein & Kaplan, 2010). Participants were asked to rate the importance of each prescribing
competency for safe effective prescribing. One hundred and eighty surveys were returned and
included participants from Oregon and Washington. Respondents included CNSs with and
without prescriptive authority (n= 88, 59% response rate), NP Faculty (n= 9, 69% response rate),
FNP students (n=7, 27% response rate), FNP preceptors (n=20, 39% response rate), and NPs
with prescriptive authority (n=56).
Results
Descriptive statistics were combined to create a content validity index used to rank the
competencies in order of identified importance. Once the competencies were ranked, the
domains in which the most and least important competencies occurred were analyzed.
Comparison between groups was also conducted using the ratings and the rankings (Klein &
Kaplan, 2010). Overall, the competencies were assessed within the “very important” range
(range= 3.25-3.85). The lowest responses were in the “neutral” range identified for 16 of the
competencies. No competency was ranked as “not at all essential.” Descriptive statistics and
rankings of competencies in the tool have been published (Klein & Kaplan, 2010). The five
highest-ranking competencies included:
1. Determines appropriate drug therapy.
2. Writes clear, legible and complete prescriptions.
3. Prescribes in accordance with current professional codes.
4. Demonstrates competency in drug dosage calculations.
30
5. Interprets tests and identifies client-specific factors.
The five lowest ranking competencies were:
1.
Assesses client health care risks.
2.
Evaluates own practice for continuous improvement.
3.
Assesses the client’s therapeutic self-management.
4.
Adapts communication style to meet needs of the client.
5.
Demonstrates effective working relationship with the health care team.
Results indicated differences between CNSs and NPs regarding their valuation of prescribing
competencies, and overall lower rankings for the communication domain. The latter finding is of
particular concern given the pivotal role that miscommunication plays in medication errors
(Board on Health Care Services, 2006).
Present Study: Methodology
The present study incorporates additional methodology to confirm the previously
identified prescribing competencies and their domain placement. Incorporation of qualitative and
quantitative (mixed methods) of investigation enhances the feasibility of the instrument for
applied regulatory use. Inclusion of feasibility as a criterion is critical for regulation of scope
changes (Spector, 2010). Shippmann et al (2000) identify five levels of rigor when evaluating the
quality of competency modeling processes. The highest level of methodological investigation
includes a variable combination and logically selected mix of multiple methods reflective of the
research setting, target population, and intended application (Shippmann et al., 2000). Mixed
methods are used widely for tool validation (Benzein et al., 2008; Weis & Schank, 2009; Fisher,
King, & Tague, 2001). The current study therefore incorporates principle component analysis
(PCA) and the Q Sort as quantitative methodologies and content analysis as a qualitative
31
methodology to further analyze prescribing competencies in the Clinical Practicum in
Pharmacological Management Evaluation instrument. A concurrent triangulation strategy
incorporates both methodologies equally into analysis of the prescribing competencies (Creswell,
2009). Subject matter experts are used to confirm the revised domains for potential regulatory
use. Feasibility analysis is achieved by content analysis of solicited questions specific to the
instruments application, which were asked of nursing faculty in the original survey and SMEs in
the current study.
Content Analysis
Method. Content analysis of solicited and unsolicited comments on the original survey
contributes to completion of the overall study aim of identifying prescribing competencies that
accurately reflect essential entry-level autonomous prescriber outcomes. Content analysis also
contributes to competency revision (Sub Aim 2) following PCA, and feasibility analysis of
instrument application. Once completed, a final list of competencies and domains are further
confirmed under Sub Aim 3 using SME and the Q Sort method.
Content analysis is a method that can strengthen validation of prescribing competencies
in conjunction with quantitative analysis methods (Marshall & Rossman, 2006; Doyle et al.,
2009). Content analysis assists in confirming prescribing competencies by analyzing faculty
expert input and the unsolicited comments submitted on the survey instrument. Unsolicited
comments contribute to content validation by serving as negative case sampling (Johnson, 1997).
Content analysis of the prescribing competencies using feedback provided by APRNs and their
preceptors or teachers enhances interpretive validity of the study (Johnson, 1997).
Data collection. As noted above, in the original study, WSU faculty were asked to
identify whether the competencies listed were at least entry level for advanced practice, whether
32
they were discrete in their wording, and whether there were any competencies missing from the
instrument. They were also asked questions specific to utilization of the instrument to evaluate
prescribing competency. Suggestions were solicited for refining or modifying the tool for use.
Data included both closed and open-ended response items.
Participants other than the WSU graduate nursing faculty did not have a comment space
for reflective observations and were not asked to comment on the questionnaire itself or the text
of the competencies. However, there were a number of unsolicited comments. A total of 45
solicited and unsolicited comments were obtained but not analyzed in the initial analysis of the
original study.
Validity. Lincoln and Guba (1985) identify four criteria for establishing trustworthiness
of data: credibility, dependability, confirmability, and transferability. Credibility of the original
survey data was established in several ways. The first was generating a research partnership
between experts at Washington State University and the Oregon State Board of Nursing. The
second was method triangulation using both quantitative and qualitative data collection. The
third was the study sampling technique that explored perspectives on prescribing by soliciting
input from prescribers, non-prescribers, faculty, preceptors and students, all of whom had a
potentially different view and experience of prescribing. Dependability of the data is addressed
through content analysis for thematic congruency. Confirmability and transferability is addressed
through tool revision and recommendations for further study.
Content analysis addresses the overall Study Aim, Sub Aim 2, and contributes to
development of the Q sort process. Content analysis is a method that can strengthen validation of
prescribing competencies in conjunction with quantitative analysis methods (Marshall &
Rossman, 2006; Doyle et al., 2009). Content analysis also assists in confirming prescribing
33
competencies by analyzing faculty expert input and the unsolicited comments submitted on the
survey instrument.
The inclusion of unsolicited comments contributes to content validation by serving as
negative case sampling since participants felt strongly enough about wording or content of
specific survey items that they submitted comments about them even when they were not asked
for their opinion (Johnson, 1997). Content analysis of the prescribing competencies using
feedback provided by APRNs and their preceptors or teachers also enhances interpretive validity
of the study (Johnson, 1997).
Validation can be viewed as supporting potential use and interpretation of the prescribing
competencies and their relevance to proposed use. As validation proceeds, revision to the
instrument may be indicated, as well as to the conceptual framework that shapes it (American
Educational Research Association, American Psychological Association & National Council on
Measurement in Education, 1999).
Analysis. The solicited and unsolicited comments were entered verbatim into a Word
document. The comments were further sorted into thematic categories for analysis by the
researcher in conjunction with the dissertation committee. Final category placement was done
through e-mail consultation with two qualitative methods researchers who conduct research on
APRNs and prescribing. Each was initially asked to individually review the researcher’s
established categories with the option of providing additional categories if none were
appropriate. The researcher did revision of the categories, with a final coding process using the
two consultants to independently code the comments into the thematic categories provided. In
addition to content coding, Consultants were also asked to independently analyze comments for
34
“feeling tone” to incorporate a dimension of the latent level (non-verbatim) of participant
response (Fox, 1976; Hseih & Shannon, 2005).
Accuracy of content analysis is dependent upon checking reliability of the coding process
(Bowen & Bowen, 2008). Stability and reproducibility are the primary types of reliability that
can be calculated through identification of observed agreement (Bowen & Bowen, 2008). Final
analysis is documented in a narrative format with percentage agreement calculations provided. A
kappa coefficient of greater than 0.61 indicates substantial strength of agreement (Bowen &
Bowen, 2008), however, there is no set agreement regarding how much inter-coder agreement is
“enough” (Bernard & Ryan, 2010). Fair to moderate agreement of kappa (0.21-0.60) may be
adequate for the purpose of contributing to tool revision for further analysis by a wider number
of experts.
Principle Component Analysis
Method. The primary study aim is to identify prescribing competencies and domains that
accurately reflect entry-level autonomous prescriber outcomes. Sub Aim 1 is to identify
prescribing competencies that may be removed or modified to strengthen the reliability of the
instrument. Both are addressed through principle component analysis. Principle component
analysis (PCA) is generally identified as a type of factor analysis but there are important
differences between the two as analytic techniques (DeVellis, 2003).
The primary goal of PCA is to represent a large set of observed variables by a smaller set
while still preserving the essential original information (Zwick & Velicer, 1982). This is
achieved by reducing the total number of factors (Julnes, 2008; Zwick & Velicer, 1982). PCA is
used to reorganize variables into actual items. In this study, variables are the previously
identified 31 prescribing competencies. The items obtained through PCA were subsequently
35
renamed and organized into domains. Factor analysis, in contrast, is an estimate of a hypothetical
variable ranking and does not reflect real items (DeVellis, 2003). While both can be used to
analyze domain placement of competencies, the use of factor analysis in this study could result in
categorizing variables together because they are equally “important” in the eyes of the expert
panel, rather than because they each represent the same actual domain construct. Another
significant difference is that in PCA all sources of variability are analyzed for each observed
variable, whereas in factor analysis only shared variability is analyzed and unique and error
variance is ignored (Mertler & Vannatta, 2002). PCA is the preferred method when the focus of
analysis is exploratory (Mertler & Vannatta, 2002).
PCA further contributes to Sub Aim 2, revising the domains into which prescribing
competencies can be categorized, by identifying items that do not clearly represent the construct
for domain inclusion. Items are selected for domain inclusion based upon their numerical scores
under each factor heading. Items whose scores split equally between two factors (cross loading)
or have a weak factor loading likely do not adequately reflect their construct and should be
removed or revised (Thompson & Daniel, 1996). Final determination of domains requires
synthesis of analytic data and subject matter expert (SME) input in order to address Sub Aim 3
and is discussed below. As noted by Julnes (2008), choosing the number of principle components
to include in the analysis is not objective “and represents a tension between parsimony and
retention of the information contained in the original variables.”
Reliability. Components with four or more loadings above .60 in absolute value are
reliable, regardless of sample size (Stevens, 1992). Components with approximately 10 or more
low loadings defined as less than .40 are reliable as long as the sample size is greater than 150
(Stevens, 1992). In this study, the survey sample size of 170 supports use of .40 as the lowest
36
cutoff point for factor loading, since the final number of components is unknown. Zwick and
Velicer (1982) and Linn (1968) support .40 as the lowest limit for factor loading, therefore those
items scoring below .40 are too weak for domain placement.
Bartlett’s sphericity test should also be used if sample sizes are small (Mertler &
Vannatta, 2001). Reliability can be further assessed through evaluation of the internal
consistency of the scale using Cronbach’s alpha. Items that rate lower than .70 should be
dropped from the final SME analysis. DeVellis (2003) also observes that multiple items much
above .90 should invite consideration of shortening the scale, though scales intended for
employment or academic purposes should have a higher level of reliability “in the mid-90s.”
Analysis. PASWStatistics 18.0 was used to conduct PCA for initial variable reduction
and to prepare for SME domain categorization. Mertler & Vannatta (2001) identify four criterion
for factor retention: (a) Eigenvalues greater than one; (b) a scree test that identifies eigenvalues
in descent before a visual leveling off; (c) factors that account for at least 70% of total variance;
and (d) path analysis for goodness of the model fit. Mertler & Vannatta (2001) advise using more
than one criterion to achieve maximal parsimony. Orthogonal varimax rotation was also used due
to the exploratory nature of the data (Mertler & Vannatta, 2001).
Initial factor extraction provided eigenvalues and a scree plot. The scree plot results
determine how many factors to submit to factor rotation, suggesting retention of all factors in
sharp descent before the eigenvalues level off (Green & Salkind, 2008). Retained factors were
submitted to varimax rotation and Bartlett’s sphericity testing. A correlation matrix was also
generated to provide visual representation of the 31 competencies for analysis and reduction of
factors (Green & Salkind, 2008). Final correlations were calculated using Cronbach’s alpha.
37
Items greater than .70 were retained, with repeat analysis of Cronbach’s after removal of outliers
(DeVellis, 2003). Final Cronbach’s reliability criteria are discussed in the results section.
The final number of factors was initially represented in a grid using a numerical title:
Factor 1, Factor 2, etc. A list of the competencies with their accompanying loading percentage
number from the PCA results, minus those that have been deleted as unreliable or weak per the
stated criteria was generated under each heading. A suggested domain name was then provided
for each factor by the researcher according to theoretical categorization that is thematically
grouped. There is no standardized method to conduct this process as its initial methodology is
subjective (J. Budden, personal communication, July 9, 2010; Mulaik, 1987; Bowen & Bowen,
2008). Category generation for this study is grounded in competency and clinical decisionmaking theory found in review of both nursing and medical literature.
Members of the dissertation committee served as expert reviewers and were asked via
Survey Monkey ™ to confirm three criteria: (a) agreement that domain names represent discrete
concepts; (b) agreement that domain names represent role appropriate categories for prescribers
generally; and (c) agreement that domain names are desired traits for prescribers. Results of the
Survey Monkey ™ were used in conjunction with content analysis to develop the Q sort survey
including final domains and revised competencies for SME review.
Q Sort
Method. Using Q sort methodology, Subject matter experts (SMEs) were asked to
evaluate the prescribing competencies that remained after PCA and content analysis. The
purpose was to confirm sorting of competencies into appropriate domains (Sub Aim 3). The Q
sort methodology involves the following components: (a) identification of the topic of interest;
(b) creating a sample of the concourse of the topic; (c) selecting the people of interest to carry
38
out the sort; (d) administering the sort; (e) conducting a statistical analysis of the completed sort;
and (f) interpreting the Q factors that emerge from the analysis (Brown, Durning & Seldon,
2008). Content for the Q sort consists of revised competencies and domains determined during
the current study’s qualitative and quantitative analyses. Results were further analyzed to
confirm or correct domain placement using descriptive analysis.
Data collection. A diverse panel of subject matter experts (SME) was recruited initially
by email to verify their inclusion criteria and interest in participation. The selection process
yielded a purposive sample of SME with pharmacologic and/or prescribing expertise outreach to
members of the American Academy of Nurse Practitioners Fellows and NCSBN APRN internal
list serves. Additional experts were identified through an internal list serve for experienced
faculty teaching NP certification review and continuing education courses, including
pharmacology. Confirmation of expert panel participation was done by the researcher in
consultation with the dissertation committee, by sending identified subject matter experts an
email attachment letter confirming their eligibility to participate (see Appendix C for complete
letter). Representation on the panel included two regulators affiliated with state boards of nursing
and familiar with authorization of prescriptive authority for APRNs; two nurse practitioner
educators who teach pharmacology to family or adult NP students; and four expert clinicians
who have been prescribing medications for a minimum of five years. Some participants met
more than one category of inclusion, as indicated on their demographic profile. For example, a
nurse regulator could also have a clinical practice in which they actively prescribed. Inclusion
criteria specified that all participants were required to indicate that they hold current
unencumbered prescriptive authority, and have had prescriptive authority as an APRN for at least
five years.
39
The researcher entered revised domains and the final 29 competencies that remained after
revision and PCA into the Q-Assessor online program. The Q-Assessor survey was piloted with
the dissertation committee and with Dr. Jill Budden, a psychometrician from the National
Council of State Boards of Nursing. Participants were then sent a letter of consent (see Appendix
D for complete letter), and provided a dedicated email link to Q-Assessor (http://q-assessor.com)
to individually complete a series of questions regarding the revised competencies and the revised
domains. Q-Assessor was configured to capture basic demographic questions as well as three
open ended responses. Additionally, Q sort technique (Cross, 2005) was used to ask experts to
re-sort the competencies into identified domains using a forced sort technique for goodness of fit.
Experts were asked if there were any aspects of the competencies or domains missing using the
open-ended response option. The process is not iterative and does not require consensus.
Analysis. The final data analysis of SME input is critical to interpretation of the PCA and
content analysis. One of the primary criticisms of PCA as a methodology is its indeterminacy.
However, such indeterminacy need not be a flaw (Mulaik, 1987). Exploration of appropriate
prescribing outcomes will be bounded in the context of role and practice, and their identification
is therefore by nature exploratory as scope of practice evolves for nurse prescribers. The nature
of the data itself involves attitudinal assessment and judgment. As noted by Mulaik (1987), the
focus of analysis is that whatever inferences we do form from data with inductive methods must
be evaluated with additional confirmation. Q methodology can be used to extract subjective
opinion and evolved from factor analytic theory (Cross, 2005).
Analysis of the Q sort involves interpretation of resulting positioning of competencies
into domains. Descriptive statistics were obtained through Q-Assessor data. Results are
presented in table format with final domain categories and competencies. Comparative analysis
40
includes agreement between researcher and expert domain placement, and comparison of
perspectives between experts. Several comments obtained from SMEs were incorporated into
recommendations for further instrument refinement.
41
CHAPTER 4
RESULTS
Sample Description
Participants were solicited for two parts of the present study: content analysis and Q sort
analysis. Content analysis was achieved using two experts with extensive expertise in research
on APRN prescribing as well as teaching nurse prescribers at the university level. Both are
Washington licensed ARNPs in active clinical practice, each having over 20 years of experience
as a prescribing nurse practitioner. One expert is certified as a family nurse practitioner and has
specialty training as a women’s health care nurse practitioner, while the second is a family nurse
practitioner. Content analysis of overall participant comments was also utilized by the researcher
for final domain revision.
Q sort analysis was done as the final stage of the study using experts solicited for their
expertise in one or more areas of pharmacotherapeutics. Consent to participate was obtained (see
Appendix D for complete letter) and participants were informed of criteria which would make
them ineligible to participate in the study. All experts were required to have expertise in one or
more areas of pharmacology and have current unencumbered prescriptive authority. Experts
could have expertise in more than one area (such as regulation and teaching).
Table 1
Demographic Information: Subject Matter Experts (n=8)
Mean= 54.8 years
Age
Sd= 7.3 years
Range= 44-65
42
APRN Licensure
NP= 6
NP and CNS= 2
Total Number of Years of Clinical
Mean= 19 years
Practice
Sd= 6.4 years
Range= 10-27 years
Total Number of Years of Prescriptive
Mean= 18.75
Authority
Sd= 5.4 years
Range= 12-27 years
DEA Number (Yes/No)
Yes= 6
No= 2
State(s) of current licensure
State(s) of current practice
Licensed
Practice
Alaska
1
1
Arizona
2
1
Idaho
1
1
Iowa
1
1
Massachusetts 1
1
Oregon
1
1
Texas
1
1
Department
of Defense
a
1
a
SME is licensed in Arizona but may practice within the Department of Defense in multiple
states under one license as per federal law.
43
Area of Expertise
Nursing regulation
n=2
Research
n=0
Prescribing law/policy
n=2
Pharmacologic management of
n=7
patients
n=4
Teaching pharmacology to APRNs
n=5
Faculty supervision of APRN students
seeking prescriptive authority
n=2
Other
• Faculty for pharmacy and
family practice medicine
residents
• Department of Defense
Military
Content Analysis Findings
Original survey: Reflections of faculty and participants. Comments were distributed
across the survey as follows. Questions specific to tool design and use were asked on the faculty
questionnaire only and are noted as 1-10A. All participants were asked to rate the competencies
for level of importance to autonomous prescriptive authority.
Table 2
Comments: All Participants
Competency
Accurately performs a comprehensive, problemfocused, or interval medical history including
current and previous diseases or conditions.
44
Number of
Comments
1
Assesses client health care risks including
environmental, cultural, educational and other risks
which may impact therapeutic decision-making.
Collects and documents data appropriate to
individual client’s health needs.
Assesses the client’s therapeutic self-management
including any use of complementary/alternative
therapies.
Documents and validates data from patient
interview and comprehensive evaluation of
available clinical information regarding client’s
physical and overall health status.
Establishes and documents medical diagnosis and
appropriate differential diagnosis to serve as basis
for pharmacological management.
Interprets client information including laboratory
and diagnostic testing and identifies client-specific
factors which determine pharmacologic
management planning.
1
Interprets and applies pharmacokinetic,
pharmacodynamic, and pharmacogenomic
principles in evaluation and selection of drug
therapy.
Critically analyzes prescribing standards,
references, and decision support tools to provide
evidence-based recommendations to clients which
optimize clinical efficiency.
Plans drug regimens which consider interactions,
expected effects and potential side effects, client
characteristics, illness and co-morbidity,
absorption, distribution, metabolism and excretion
and cost or accessibility to patient.
4
Determines appropriate drug therapy including
dose, dosage form, route and frequency of
administration.
1
Considers no treatment, non-drug and drug
treatment options and refers as indicated.
0
Identifies and validates client-specific needs while
incorporating informed consent from client or
health care representative regarding treatment
planning.
0
45
0
1
1
2
1
4
1
Prioritizes and develops treatment plan in
accordance with mutually agreed upon
client/provider goals.
0
Writes clear, legible, and complete prescriptions
which comply with state and federal regulations.
1
Demonstrates competency in drug dosage
calculation.
4
Uses appropriate references and consultation to
implement drug regimens (may include
collaboration as appropriate).
0
Prescribes based on knowledge of pharmacological
and physiological principles.
0
Provides client specific education regarding use of
medication and anticipated effects including
cautions.
1
Monitors the safety and efficacy of drug therapy
treatment plan.
1
Modifies treatment plan as appropriate based upon
therapeutic outcome and response.
1
Incorporates and orders periodic lab testing or
monitoring as indicated.
1
Demonstrates effective working relationship with
other members of healthcare team including
collaboration, consultation, and referral resources.
0
Demonstrates ownership of and responsibility for
the welfare of the client by providing safe,
effective, and appropriate care specific to the Nurse
Practitioner or Clinical Nurse Specialist role and
scope of practice.
8
Evaluates own practice for continuous
improvement opportunities.
0
Provides ethical care for clients including but not
limited to incorporating principles of
confidentiality, patient self-determination, and
2
46
Provides ethical care for clients including but not
limited to incorporating principles of
confidentiality, patient self-determination, and
issues related to use of information technology.
2
Prescribes in accordance with current professional
codes of practice and standards.
0
Adapts communication style to meet the needs of
the client regarding pharmacologic treatment and
recommendations.
0
Gives clear written and/or verbal instruction to
clients regarding obtaining, using, and monitoring
their medications.
0
2
Protects sensitive client communications while
enhancing therapeutic
information
sharing.
Accurately
and promptly
records clinical
notes
which reflect client assessment and
pharmacological management plan.
0
General Comments
5
Total
48
Faculty Specific Responses
The graduate nursing faculty from WSU (n= 9) received an additional section in the
original survey (1A-10A) for solicited comments that focused specifically on the content of the
competencies and the utility of the tool. They were asked to rate each question on a scale of 1-5
with 5 being strong agreement and 1 being strong disagreement. Responses were as follows:
47
Table 3
Faculty Specific Additional Questions
Question
Response
1A. The tool will be useful for evaluation
of students.
Strongly Agree= 2
Agree= 4
Not Sure= 3
Disagree=0
Strongly Disagree= 0
Strongly Agree= 2
Agree= 2
Not Sure= 4
Disagree= 1
Strongly Disagree=0
Strongly Agree= 3
Agree= 2
Not Sure= 3
Disagree= 1
Strongly Disagree=0
Strongly Agree= 2
Agree= 6
Not Sure= 1
Disagree= 0
Strongly Disagree=0
Strongly Agree= 0
Agree= 5
Not Sure= 1
Disagree= 2
Strongly Disagree=1
Strongly Agree= 1
Agree= 5
Not Sure= 2
Disagree= 1
Strongly Disagree=0
Strongly Agree= 0
Agree= 5
Not Sure= 0
Disagree= 4
Strongly Disagree=0
Strongly Agree= 1
Agree= 7
Not Sure= 1
Disagree= 0
Strongly Disagree=0
2A. The tool will be useful for already
practicing Nurse Practitioners seeking
prescriptive authority.
3A. The tool will be useful for already
practicing Clinical Nurse Specialists
seeking prescriptive authority.
4A. The tool is easy to administer.
5A. The tool has too many items for
evaluation.
6A. The competencies can be evaluated
through direct observation of the student or
Advanced Practice Nurse.
7A. The competencies listed in the tool
contain many similar items which are not
clear and distinct from one another.
8A. Competencies reflect at least entry
level prescribing skills and behaviors.
48
Weighted
mean
3.8
3.5
3.8
4.1
3.1
3.6
3.1
4.0
9A. The competency checklist will take too
long for users to complete.
10A. There are important competencies for
prescribing which are missing from the
tool.
Strongly Agree= 0
Agree= 3
Not Sure= 1
Disagree= 5
Strongly Disagree=0
Strongly Agree= 0
Agree= 0
Not Sure= 3
Disagree= 5
Strongly Disagree=0
Missing= 1
2.7
2.4
Independent Review Using Two Experts
Two data points, content and tone of comments, were obtained from the independent
reviewers further analyzing verbatim feedback on the survey instrument. Comments were
reflected as obtained from both faculty and participant input, and therefore contained opinions of
both the content of the competency and the use of the tool.
Using a coding key representing both content and tone, each rater was asked to use the
supplied code and was given the option of suggesting a new code if she determined it necessary
to describe the content. Each rater was supplied with a code for tone ranging from 1-5 with the
following legend:
• 1= positive
• 2= positive and negative (mixed)
• 3=neutral
• 4= negative
• 5= unable to determine
When coding for tone of survey responses, there were a total of 50 usable codes with
72% (n=36) agreement. The majority of comments were coded as “neutral” (n= 28). There was
49
minimal discordance related to tone when the reviewers disagreed, with the bulk of variance
between neutral and negative (n=7). Kappa = .70 indicating very high inter-rater agreement.
Codes were broken down as follows:
Table 4
Tone Score Comparisons
Score
3/3
3/4
4/4
4/3
3/2
1/1
1/2
2/2
5/4
Total Number
28
7
5
3
2
2
1
1
1
Content coding was done independently by each reviewer using a coding sheet provided
by the researcher. Reviewers were asked to provide additional codes if they felt the provided
codes were not an accurate fit. Eleven topic codes were offered with an additional ten codes
generated by the reviewers for a total of 21. The results were calculated as a free marginal Kappa
with a total of 0.36, indicating fair agreement on the initial coding run.
A list of new and old topic codes was developed in order to refine the coding schema.
Initial exclusion decisions for coding included codes which were not used by either reviewer
(n=0) or codes that had zero use by at least one reviewer (n=4). Based upon initial categorization
the following topic codes were identified as the most discordant between the two reviewers:

Not all parts equally important

May require assistance from colleagues

Reflection on competence of others

Reflection on legal authority
50
Initial independent coding by two content experts resulted in the generation of 11 new codes.
The following new codes were suggested by reviewers, and were analyzed further for
congruence with the original thematic categories:

Elaborating the competencies in a supportive way

Multiple competencies in item

Grammatical correction

Affirming importance

Pertains to some specialties but not others

Questioning accuracy of the tool

Questions/challenges use of the tool

Explanatory comment

Emphatic agreement

Delegation

Collaboration
Coder Reliability. Codes were selected for revision. The first step was to identify codes that
received no selection by at least one expert. These codes were marked for recoding into an
existing concept, a newly suggested concept, or potential removal if both experts did not use
them at all. Tone codes were not repeated in the second code run since they achieved a
substantial Kappa of 0.70 in the first run.
Recoding also involved determination by the researcher regarding the subject themes of the
codes generally. New and revised codes were examined to see if they fit into the initially
identified themes of comments:

Question itself
51

Tool

Competency

Reflective observation on prescribing practice
All revised codes were congruent with the original theme areas, however, there were
unique concepts identified by the researcher that were monitored for further analysis,
including those of “delegation” and “collaboration” which were identified by the original
survey participants as notations on the competencies which seemed to imply they should
be added. A set of revised codes was then supplied to each reviewer for a second round of
independent coding.
Table 5
Content Code Description with Frequency of Use
Code
Reviewer 1
QW- Question uses poor
9
wording or grammar
CC-Disagreement with a
7
concept in the competency
Reviewer 2
10
CU- Competency is
unrealistic
CD-Competency may
require collaboration or
delegation
CS-Competency pertains
to some specialties but not
others
CA-Competency is
missing
CNP-Competency not
limited to prescribing
CMI- Competency
contains multiple
concepts/ideas
RCS-Reflection:
evaluating own
competence
6
4
0
6
2
2
0
0
2
3
5
5
1
1
5
52
REA- Reflection:
emphatic agreement
RAI- Reflection:
affirming the importance
of the competency
RES- Reflection:
elaborating the
competency in a
supportive way
REC- Reflection:
explanatory comment
TA- Questioning tool
accuracy
TU- Questioning tool
utility
TI- Questioning tool
practicality
1 (marked REA/CA)
0
3
7
3
0
9
6
0
0
3
1
2
2
The greatest discrepancies between reviewers were for the concepts expressed in CD (0/6), RAI
(3/7), RES (3/0), REC (9/6) and TU (3/1). Of particular note is that one reviewer did not use CD
or RES at all. Comments coded CD (Competency may require collaboration or delegation) by
the first reviewer were coded by the second reviewer as CC (1), RES (2) or REC (3).
Competencies coded RES by the first reviewer were coded CD (2) or RAI (1) by the second
reviewer.
The code RAI (“Reflection: Affirming importance of the competency”) was established
as a way to express a supportive stance towards incorporation of the competency. However,
experts differed in 6 instances regarding their interpretation of when this was the emergent
concept in comments. The code REC (“Reflection: Explanatory comment”) was frequently
chosen by both reviewers but differed in 7 instances. Finally, the code TU (“Questioning tool
utility”) was used with 2 instances of disagreement out of the 3 times noted.
The following code was not used by either reviewer: TA (“Questioning tool accuracy”).
The repeat free-range kappa was 0.40, an increase of 0.04 points from the first run. By most
53
agreement standards this still ranks in the “fair” (0.21-0.40) category (Bernard & Ryan, 2010)
but is not a significant increase from the first coding run.
Principle Component Analysis Findings
PCA contributes to both reduction and placement of competencies into domains.
Reliability statistics were initially evaluated for all items using Cronbach’s alpha. In the content
analysis phase of this study one competency was repeatedly identified by participants as
problematic (n=8 comments) and was therefore identified for removal: “Demonstrates ownership
of and responsibility for the welfare of the client by providing safe, effective, and appropriate
care specific to the Nurse Practitioner or Clinical Nurse Specialist role and scope of practice.”
Participants particularly objected to the term “ownership” and the tone of the competency
wording which some felt was “paternalistic.” No item individually ranked lower than .70. Table 6
Cronbach’s Alpha All Items
Cronbach's
Alpha
.878
Cronbach's
Alpha Based on
Standardized
Items
.958
N of Items
31
Table 7
Cronbach’s Alpha with Ownership Competency
Removed
Cronbach's
Alpha
Cronbach's
Alpha Based on
Standardized
Items
.959
.961
N of Items
30
54
Although a Cronbach’s of .878 is considered acceptable, the decision was made to
acknowledge the potential regulatory impact of the competency use in targeting a range of the
90s for acceptable reliability. As previously noted, DeVellis (2003, p.96) states that multiple
items much above .90 should invite consideration of shortening the scale, though scales intended
for employment or academic purposes should have a higher level of reliability “in the mid-90s.”
The final decision to remove the problematic competency achieved a Cronbach’s of .959 with a
total of 30 items remaining.
Principle Component Analysis was then conducted using PASWStatistics 18.0. Using
prior identified criteria of factor component retention for those factors which are .40 or higher
(Zwick & Velicer 1982; Linn, 1968), a matrix of factors was developed for review with the
dissertation committee with headings and factor loading scores. There were four competencies
that cross loaded between two domains:
1. Monitors the safety and efficacy of drug therapy treatment plan. (.548, Factor 1; .545
Factor 3)
2. Protects sensitive client communications while enhancing therapeutic information
sharing. (.570, Factor 1; .568 Factor 2)
3. Plans drug regimens which consider interactions, expected effects and potential side
effects, client characteristics, illness and co-morbidity, absorption, distribution,
metabolism and excretion and cost or accessibility to patient. (.522 Factor 2; .583
Factor 3)
4. Prescribes based on knowledge of pharmacological and physiological principles. (.505,
Factor 3; 507, Factor 4)
55
SurveyMonkey ™ was used with the dissertation committee to determine if cross loading factors
should be retained, reworded, or reorganized within their domains. Domain names were initially
developed by the researcher and then confirmed by the committee after the PCA had been
completed. Based upon committee feedback, one domain was reworded to less resemble its
preceding domain. See Table 9 for final competencies and domains after completion of PCA.
Changes made to the competencies included reduction and wording clarification. Changes made
to the domains included domain naming, and domain relocation for competencies which loaded
similarly between two domains. Competencies were ordered in placement for sequential flow,
with the understanding that the Q sort results would revise and reorder the competencies based
upon SME input. The dissertation committee identified too much similarity between “clinical
reasoning” (Factor 3) and “clinical decision-making” (Factor 4) in the initial naming process.
The domain name “clinical decision-making” was subsequently changed to “clinical
management” to help distinguish the two domains and emphasize that pharmacologic prescribing
includes ongoing management and evaluation (Davenport et al, 2005; Harden et al, 1999;
DeVries, Henning, Hogerzeil & Fresle, 1994).
Table 8
Initial Factors in Principle Component Analysis with Loadings
Factor Adapts communication style to meet the needs of the client regarding
1
pharmacologic treatment and recommendations. (.677)
Writes clear, legible, and complete prescriptions which comply with state and
federal regulations. (.572)
Provides client specific education regarding use of medication and anticipated
effects including cautions. (.510)
Monitors the safety and efficacy of drug therapy treatment plan. (.548)
Evaluates own practice for continuous improvement opportunities. (.653)
56
Provides ethical care for clients including but not limited to incorporating principles
of confidentiality, patient self-determination, and issues related to use of
information technology. (.653)
Prescribes in accordance with current professional codes of practice and standards.
(.677)
Gives clear written and/or verbal instruction to clients regarding obtaining, using,
and monitoring their medications. (.668)
Accurately and promptly records clinical notes which reflect client assessment and
pharmacological management plan. (.760)
Protects sensitive client communications while enhancing therapeutic information
sharing. (.570)
Demonstrates effective working relationship with other members of healthcare team
including collaboration, consultation, and referral resources. (.710)
57
Factor Critically analyzes prescribing standards, references, and decision support tools to
2
provide evidence-based recommendations to clients which optimize clinical
efficiency. (.546)
Assesses client health care risks including environmental, cultural, educational and
other risks which may impact therapeutic decision-making. (.506)
Collects and documents data appropriate to individual client’s health needs. (.504)
Assesses the client’s therapeutic self-management including any use of
complementary/alternative therapies. (.550)
Documents and validates data from patient interview and comprehensive evaluation
of available clinical information regarding client’s physical and overall health
status. (.678)
Plans drug regimens which consider interactions, expected effects and potential side
effects, client characteristics, illness and co-morbidity, absorption, distribution,
metabolism and excretion and cost or accessibility to patient. (.522)
Identifies and validates client-specific needs while incorporating informed consent
from client or health care representative regarding treatment planning. (.605)
Prioritizes and develops treatment plan in accordance with mutually agreed upon
client/provider goals. (.651)
Protects sensitive client communications while enhancing therapeutic information
sharing. (.568)
Factor Plans drug regimens which consider interactions, expected effects and potential side
3
effects, client characteristics, illness and co-morbidity, absorption, distribution,
metabolism and excretion and cost or accessibility to patient. (.581)
Accurately performs a comprehensive, problem-focused, or interval medical history
including current and previous diseases or conditions. (.547)
Interprets client information including laboratory and diagnostic testing and
identifies client-specific factors which determine pharmacologic management
planning. (.735)
Interprets and applies pharmacokinetic, pharmacodynamic, and pharmacogenomic
principles in evaluation and selection of drug therapy. (.419)
Establishes and documents medical diagnosis and appropriate differential diagnosis
to serve as basis for pharmacological management. (.454)
58
Prescribes based on knowledge of pharmacological and physiological principles.
(.505)
Determines appropriate drug therapy including dose, dosage form, route and
frequency of administration. (.690)
Monitors the safety and efficacy of drug therapy treatment plan. (.545)
Factor Demonstrates competency in drug dosage calculation. (.504)
4
Uses appropriate references and consultation to implement drug regimens (may
include collaboration as appropriate). (.645)
Prescribes based on knowledge of pharmacological and physiological principles.
(.507)
Modifies treatment plan as appropriate based upon therapeutic outcome and
response. (.517)
Incorporates and orders periodic lab testing or monitoring as indicated. (.536)
Considers no treatment, non-drug and drug treatment options and refers as
indicated. (.658)
Delete Demonstrates ownership of and responsibility for the welfare of the client by
providing safe, effective, and appropriate care specific to the Nurse Practitioner or
Clinical Nurse Specialist role and scope of practice.
59
Table 9
Final Domains and Competencies
Factor 1:
Writes clear, legible, and complete prescriptions that comply with state and
federal regulations.
Safety
Prescribes in accordance with current professional codes of practice and
standards.
Demonstrates ethical care for clients regarding confidentiality,
self-determination, and issues related to use of information technology
Prescribes based on knowledge of pharmacological and physiological
principles.
Demonstrates competency in drug dosage calculation.
Provides client specific education regarding obtaining, using, and monitoring of
medication including cautions or anticipated side effects.
Adapts communication style to meet the needs of the client regarding
pharmacologic treatment and recommendations.
Accurately and promptly records clinical notes that reflect client assessment
and pharmacological management plan.
Demonstrates effective working relationship with other members of healthcare
team including collaboration, consultation, and referral.
Monitors the safety and efficacy of drug therapy treatment plan.
Factor 2:
Client
Specific
Assessment
Evaluates own practice for continuous improvement opportunities.
Critically analyzes prescribing standards, references, and decision support tools
to provide evidence-based recommendations to clients which optimize clinical
efficiency.
Assesses client health care risks including environmental, cultural, educational
and other risks that may impact therapeutic decision-making.
Assesses the client’s therapeutic self-management including any use of
complementary/alternative therapies.
Collects and documents data appropriate to individual client’s health needs.
Identifies and validates client-specific needs while incorporating informed
60
consent from client or health care representative regarding treatment planning.
Documents and confirms data from patient interview and comprehensive
evaluation of available clinical information regarding client’s overall health
status.
Prioritizes and develops treatment plan in accordance with mutually agreed
upon client/provider goals.
Protects sensitive client communications while enhancing therapeutic
information sharing.
Factor 3:
Clinical
Reasoning
Accurately performs a comprehensive, problem-focused, or interval medical
history including current and previous diseases or conditions.
Interprets client information including laboratory and diagnostic testing and
identifies client-specific factors which determine pharmacologic management
planning.
Establishes and documents medical diagnosis and appropriate differential
diagnosis to serve as basis for pharmacological management.
Interprets and applies pharmacokinetic, pharmacodynamic, and
pharmacogenomic principles in evaluation and selection of drug therapy.
Plans drug regimens which consider individual patient characteristics such as
absorption, distribution, metabolism and excretion, comorbidity, drug cost or
accessibility.
Determines appropriate drug therapy including dose, dosage form, route and
frequency of administration.
Factor 4:
Uses appropriate references and consultation to implement drug regimens (may
include collaboration as appropriate).
Clinical
Management Modifies treatment plan as appropriate based upon therapeutic outcome and
response.
Incorporates and orders periodic lab testing or monitoring as indicated.
Considers no treatment, non-drug and drug treatment options and refers as
indicated.
61
Q Sort Findings
The Q sort was conducted using the online program Q-Assessor. Participants were sent a
dedicated link which enabled them to sort competencies into the four categories. The results of
the Q sort provided descriptive data as well as open-ended responses. The process of Q sorting
followed a forced sort process where participants were provided a set number of domain spaces
based upon PCA results. In accordance with the PCA results, domain placement was not forced
into a normal distribution pattern. Each participant was instead instructed to sort the
competencies one by one into the “best” fit while using all provided domain spaces as a forced
sort configuration.
Table 10
Q Sort Results
Competency
Original
Domain
Expert Domains
Writes clear,
legible, and
complete
prescriptions that
comply with state
and federal
regulations.
Safety
Safety
Assessment
Reasoning
Management
6
0
0
2
Prescribes in
accordance with
current
professional codes
of practice and
Safety
Safety
Assessment
Reasoning
Management
2
0
5
1
62
Expert
Agreement
with
Original
Domain/
Agreement
Among
Experts
75%/75%
New
Domain
25%/62%
Reasoning
Safety
standards.
Demonstrates
Safety
ethical care for
clients regarding
confidentiality,
self-determination,
and issues related
to use of
information
technology
Safety
0
Assessment 2
Reasoning 4
Management 2
0%/50%
Reasoning
Assessment/
Management
Prescribes based
on knowledge of
pharmacological
and physiological
principles.
Safety
Safety
5
Assessment 0
Reasoning 2
Management 1
62%/62%
Safety
Demonstrates
competency in
drug dosage
calculations.
Safety
Safety
8
Assessment 0
Reasoning 0
Management 0
100%/100%
Safety
Provides client
specific education
regarding
obtaining, using,
and monitoring of
medication
including cautions
or anticipated side
effects.
Adapts
communication
style to meet the
needs of the client
regarding
pharmacologic
treatment and
recommendation.
Accurately and
promptly records
clinical notes that
reflect client
assessment and
pharmacological
Safety
Safety
6
Assessment 0
Reasoning 1
Management 1
75%/75%
Safety
Safety
Safety
1
Assessment 6
Reasoning 1
Management 0
12.5%/75%
Assessment
Safety
Safety
3
Assessment 4
Reasoning 1
Management 0
37%/50%
Assessment/
Safety
63
management plan.
Demonstrates
effective working
relationship with
other members of
healthcare team
including
collaboration,
consultation, and
referral.
Safety
Safety
0
Assessment 0
Reasoning 2
Management 6
0%/75%
Management
Monitors the
Safety
safety and efficacy
of drug therapy
treatment plan.
Safety
5
Assessment 1
Reasoning 1
Management 1
62%/62%
Safety
Evaluates own
practice for
continuous
improvement
opportunities
Safety
Safety
2
Assessment 0
Reasoning 5
Management 1
25%/62%
Reasoning
Critically analyzes
prescribing
standards,
references, and
decision support
tools to provide
evidence-based
recommendations
to clients which
optimize clinical
efficiency.
Client
Specific
Assessment
Safety
4
Assessment 0
Reasoning 3
Management 1
0%/50%
Safety/
Reasoning
Assesses client
health care risks
including
environmental,
cultural,
educational and
other risks that
may impact
therapeutic
decision-making.
Client
Specific
Assessment
Safety
2
Assessment 5
Reasoning 0
Management 1
62%/62%
Assessment
64
Assesses the
client’s
therapeutic selfmanagement
including any use
of
complementary/alt
ernative therapies.
Client
Specific
Assessment
Safety
2
Assessment 5
Reasoning 0
Management 1
62%/62%
Assessment
Collects and
documents data
appropriate to
individual client’s
health needs.
Client
Specific
Assessment
Safety
5
Assessment 3
Reasoning 0
Management 0
37%/62%
Safety
Identifies and
validates clientspecific needs
while
incorporating
informed consent
from client or
health care
representative
regarding
treatment
planning.
Client
Specific
Assessment
Safety
1
Assessment 5
Reasoning 0
Management 2
62%/62%
Assessment
Documents and
confirms data
from patient
interview and
comprehensive
evaluation of
available clinical
information
regarding client’s
overall health
status.
Prioritizes and
develops treatment
plan in accordance
with mutually
agreed upon
client/provider
goals.
Client
Specific
Assessment
Safety
1
Assessment 5
Reasoning 2
Management 0
62%/62%
Assessment
Client
Specific
Assessment
Safety
0
Assessment 6
Reasoning 1
Management 1
75%/75%
Assessment
65
Protects sensitive
client communications while
enhancing
therapeutic
information
sharing.
Client
Specific
Assessment
Safety
0
Assessment 7
Reasoning 0
Management 1
87%/87%
Assessment
Accurately
Clinical
performs a
Reasoning
comprehensive,
problem-focused,
or interval medical
history including
current and
previous diseases
or conditions.
Safety
4
Assessment 2
Reasoning 2
Management 0
25%/50%
Safety
Assessment/
Reasoning
Interprets client
information
including
laboratory and
diagnostic testing
and identifies
client-specific
factors which
determine
pharmacologic
management
planning.
Clinical
Reasoning
Safety
4
Assessment 3
Reasoning 0
Management 1
0%/50%
Safety/
Assessment
Establishes and
documents
medical diagnosis
and appropriate
differential
diagnosis to serve
as basis for
pharmacological
management.
Clinical
Reasoning
Safety
1
Assessment 3
Reasoning 3
Management 1
37%/37%
Assessment/
Reasoning
Interprets and
applies
pharmacokinetic,
pharmacodynamic
Clinical
Reasoning
Safety
4
Assessment 0
Reasoning 4
Management 0
50%/50%
Safety/
Reasoning
66
and pharmacogenomic
principles in
evaluation and
selection of drug
therapy.
Plans drug
regimens which
consider
individual patient
characteristics
such as
absorption,
distribution,
metabolism and
excretion,
comorbidity, drug
cost or
accessibility.
Determines
appropriate drug
therapy including
dose, dosage form,
route and
frequency of
administration.
Clinical
Reasoning
Safety
4
Assessment 3
Reasoning 1
Management 0
12.5%/50%
Safety/
Assessment
Clinical
Reasoning
Safety
6
Assessment 0
Reasoning 1
Management 1
12.5%/75%
Safety
Uses appropriate
references and
consultation to
implement drug
regimens (may
include
collaboration as
appropriate).
Clinical
Management
Safety
3
Assessment 0
Reasoning 3
Management 2
25%/37%
Safety/
Reasoning
Modifies
treatment plan as
appropriate based
upon therapeutic
outcome and
response.
Clinical
Management
Safety
0
Assessment 4
Reasoning 2
Management 2
25%/50%
Assessment
Reasoning/
Management
67
Incorporates and
orders periodic lab
testing or
monitoring as
indicated.
Clinical
Management
Safety
5
Assessment 2
Reasoning 1
Management 0
0%/62%
Safety
Considers no
treatment, nondrug and drug
treatment options
and refers as
indicated.
Clinical
Management
Safety
2
Assessment 0
Reasoning 2
Management 4
50%/50%
Management
Safety/
Assessment
SME Comments
Experts were provided with several options to give feedback during the Q-sort, in
addition to domain placement. The Q-Assessor tool posed the following questions:
•
Should any of the competencies be eliminated?
•
Should any of the domains be eliminated?
Participants were given the option of responding: “yes,” “no,” or “no but should be reworded.”
They were then given several open field areas with which they could respond to the following
queries:
•
Please comment regarding suggested rewording of domains or competencies
•
Please comment regarding any competencies you think are missing and should be
added
•
Please comment regarding any domains you think are missing and should be
added
One participant felt that competencies should not be eliminated but should be reworded.
The same participant also stated that it may be possible to eliminate one of the two final domains
due to the overlap perceived between “clinical reasoning” and “clinical management.” A second
68
participant felt that the domain “safety” should be reworded to state “patient safety” in order to
emphasize that competencies are in place to protect the public from unsafe prescribing.
Table 11
SME Interview Responses
Question
Yes
No
Should any of the
competencies be
eliminated?
0
7
Should any of the
domains be eliminated?
1
6
No, but
Comment
should be
reworded
1
• All of the individual
statements are
appropriate, it is the
overlap in category
placement that posed
difficulty.
1
• Hard to separate clinical
reasoning and clinical
management because
there is overlap. I felt
that some components
were duplicate and due
to the limited options
for placement, clinical
reasoning and clinical
management could have
some overlap.
• Would suggest
rewording safety to say
patient safety. It is
important to point out
that the competencies
are not there to ensure
provider safety.
• Probably prescribing in
accordance with current
professional codes &
standards covers this,
but what about
consideration of
promotion of
information sharing or
prescribing sharing
when two or more
prescribers are treating
Please comment on any
domains or competencies
you think should be
added.
69
•
the client
concurrently?
Recognition of personal
limitations related to
scope of practice and
personal knowledge,
skills and abilities.
It was anticipated that a category called “Safety” would incorporate a significant
communication component to experts in the Q sort follow-up, based upon literature review of
medication error and safety initiatives to which expert prescribers would likely have been
exposed (Kohn, Corrigan & Donaldson, 1999; Joint Commission, 1999). Once renamed “Safety”
and submitted for expert review however, the SMEs viewed this category as much more
prescriber task focused, which Harden calls “technical intelligences” in the domain of “doing the
right thing.” Only one competency from the original communication domain fell clearly into the
new Safety domain (Table 9). Eight other competencies clearly fell within the Safety domain
according to SMEs, while 6 more fell between safety/assessment or safety/reasoning. The
following were clearly placed in the “Safety” domain:
Table 12
Comparison of Original Communication Domain and New Safety Domain
Revised Safety Competencies
Original Communication Competencies
(*with new categories of classification)
Writes clear, legible, and complete
Accurately and promptly records clinical
prescriptions that comply with state and federal notes which reflect client assessment and
regulations.
pharmacological management plan.
(*Safety/Assessment)
Prescribes based on knowledge of
pharmacological and physiological principles.
Adapts communication style to meet the
needs of the client regarding pharmacologic
treatment and recommendations. (*Patient
Specific Assessment)
70
Demonstrates competency in drug dosage
calculations.
Provides client specific education regarding
obtaining, using, and monitoring of medication
including cautions or anticipated side effects.
Protects sensitive client communications
while enhancing therapeutic information
sharing. (*Patient Specific Assessment)
Gives clear written and/or verbal instruction
to clients regarding obtaining, using, and
monitoring their medications. (*Eliminated,
combined with “Provides client specific
education” to form one competency)
Monitors the safety and efficacy of drug
therapy treatment plan.
Collects and documents data appropriate to
individual client’s health needs.
Determines appropriate drug therapy including
dose, dosage form, route and frequency of
administration.
Incorporates and orders periodic lab testing or
monitoring as indicated.
The “Safety” domain did not include any of the previously identified professional role
competencies. The competency in the OSBN instrument that closely matches Harden’s “personal
intelligences” or professional role competency is the competency “evaluates own practice for
continuous improvement opportunities.” Experts placed this competency under the domain of
“Clinical Reasoning.” Conceptually, SMEs identified “Clinical Reasoning” not as the
development of a diagnosis or treatment plan, but as the incorporation of professional role
behaviors. This is illustrated by including the second competency in this category “prescribes in
accordance with current professional codes of practice and standards.” One expert commented
that it might be important to add a competency that incorporates “recognition of personal
limitations related to scope of practice and personal knowledge, skills and abilities.”
71
Table 13
Final Revised Domains and Competencies
Factor 1: (Patient)
Writes clear, legible, and complete prescriptions that comply with state
and federal regulations.
Safety
Prescribes based on knowledge of pharmacological and physiological
principles.
Demonstrates competency in drug dosage calculations.
Provides client specific education regarding obtaining, using, and
monitoring of medication including cautions or anticipated side effects.
Monitors the safety and efficacy of drug therapy treatment plan.
Collects and documents data appropriate to individual client’s health
needs.
Determines appropriate drug therapy including dose, dosage form,
route and frequency of administration.
Incorporates and orders periodic lab testing or monitoring as indicated.
Safety/Assessment
Accurately and promptly records clinical notes that reflect client
assessment and pharmacological management plan.
Interprets client information including laboratory and diagnostic testing
and identifies client-specific factors which determine pharmacologic
management planning.
Plans drug regimens which consider individual patient characteristics
such as absorption, distribution, metabolism and excretion,
comorbidity, drug cost or accessibility.
72
Factor 2:
Patient Specific
Assessment
Adapts communication style to meet the needs of the client regarding
pharmacologic treatment and recommendations.
Assesses client health care risks including environmental, cultural,
educational and other risks that may impact therapeutic decisionmaking.
Assesses the client’s therapeutic self-management including any use of
complementary/alternative therapies.
Identifies and validates client-specific needs while incorporating
informed consent from client or health care representative regarding
treatment planning.
Documents and confirms data from patient interview and
comprehensive evaluation of available clinical information regarding
client’s overall health status.
Prioritizes and develops treatment plan in accordance with mutually
agreed upon client/provider goals.
Protects sensitive client communications while enhancing therapeutic
information sharing.
Assessment/Reasoning Establishes and documents medical diagnosis and appropriate
differential diagnosis to serve as basis for pharmacological
management.
Factor 3:
Prescribes in accordance with current professional codes of practice and
standards.
Clinical Reasoning
Evaluates own practice for continuous improvement opportunities
Safety/Reasoning
Critically analyzes prescribing standards, references, and decision
support tools to provide evidence-based recommendations to clients
which optimize clinical efficiency.
Interprets and applies pharmacokinetic, pharmacodynamic, and
pharmacogenomic principles in evaluation and selection of drug
therapy.
Uses appropriate references and consultation to implement drug
regimens (may include collaboration as appropriate).
73
Factor 4:
Demonstrates effective working relationship with other members of
healthcare team including collaboration, consultation, and referral.
Clinical
Management
More than two
categories
Demonstrates ethical care for clients regarding confidentiality,
self-determination, and issues related to use of information technology.
Accurately performs a comprehensive, problem-focused, or interval
medical history including current and previous diseases or conditions.
Modifies treatment plan as appropriate based upon therapeutic outcome
and response.
Considers no treatment, non-drug and drug treatment options and refers
as indicated.
74
CHAPTER 5
DISCUSSION
Evans (2003) proposes a hierarchy of evidence for evaluation of healthcare interventions
which Spector (2010) suggests might be more appropriate for nursing regulation than classical
evidence based approach: effectiveness, appropriateness, and feasibility. It is evident from this and
other studies that there is no one “right way” to develop and evaluate competencies. Utility, clarity,
and defensibility are important components if the instrument will be adapted for regulatory use.
Using a 5 point scale (see Table 3 for more detail), initial faculty input on the Oregon State Board
of Nursing’s instrument did confirm that faculty felt the original competencies were appropriately
leveled for the beginning prescriber (4.0), and that the tool was easy to use (4.1). They were
somewhat less certain regarding use of the tool with students (3.8) or CNSs seeking prescriptive
authority (3.8) with 4.0 indicating “agreement” and 3.0 indicating “not sure.” SMEs also
confirmed the reliability and consistency of the competency items, however, they did not agree
regarding the appropriate domains when compared to those selected by the researcher. Further
testing of the revised tool with Boards of Nursing outside of Oregon is advised to determine
sufficiency for regulatory use.
Theoretical Framework
Competency concepts. Under Harden’s model a discrete domain describes the doctor
as a professional who encompasses “personal intelligences” which contains two competencies
(Harden et al., 1999). Harden defines these as the “role of the doctor within the health service”
and “personal development” (p. 548). In the circle model (Figure 1) this has the overall
description of “the right person doing it” generally understood as role socialization. The
75
competencies identified in the original Oregon State Board of Nursing’s instrument which
pertain to role/professional components are the following:
• •
Demonstrates effective working relationship with other members of healthcare
team including collaboration, consultation, and referral resources. (Factor 1)
•
Demonstrates ownership of and responsibility for the welfare of the client by
providing safe, effective, and appropriate care specific to the Nurse
Practitioner or Clinical Nurse Specialist role and scope of practice.
(Eliminated)
•
Evaluates own practice for continuous improvement opportunities. (Factor 1)
•
Provides ethical care for clients including but not limited to incorporating
principles of confidentiality, patient self-determination, and issues related to
use of information technology. (Factor 1)
•
Prescribes in accordance with current professional codes of practice and
standards. (Factor 1)
All of the previously identified professional role competencies factored into Factor 1 in
the analysis of the original survey. However, they did not appear to be a discrete category as they
were in the Harden model. Instead, Factor 1 also included all the competencies that were
previously identified in the communication domain:
•
Adapts communication style to meet the needs of the client regarding pharmacologic
treatment and recommendations. (.677)
•
Gives clear written and/or verbal instruction to clients regarding obtaining, using,
and monitoring their medications. (.668)
•
Accurately and promptly records clinical notes which reflect client assessment and
pharmacological management plan. (.760)
•
Protects sensitive client communications while enhancing therapeutic information
sharing. (.570)
76
The additional competencies in Factor 1 included:
•
Writes clear, legible, and complete prescriptions which comply with state and federal
regulations. (.572)
•
Provides client specific education regarding use of medication and anticipated effects
including cautions. (.510)
The final competency in Factor 1 that also factored equally into Factor 3 so was not strongly
identified as one of the professional or communication domains: “Monitors the safety and
efficacy of drug therapy treatment plan.”
The Harden model includes communication competencies under two domains:
Communication and Appropriate Information Handling Skills. Harden also includes
competencies which did not appear until recently within nursing specific domains such as
“communication with media/press” (Harden et al, 1999). Information handling is captured in two
competencies in the OSBN instrument “protects sensitive client communications while
enhancing therapeutic information sharing” (placed by experts into “patient specific
assessment”) and “demonstrates ethical care for clients regarding confidentiality, selfdetermination, and issues related to use of information technology.” Experts placed the latter
across more than one category, possibly indicating that information handling is seen as an
overarching concept. As APRNs play a greater role in policy development, the importance
placed upon communication competencies may change and be further related to prescribing
specific issues. Emerging issues such as pharmaceutical marketing require that APRNs who
prescribe are adept at evaluating media influence strategies (Crigger, Barnes, Junko, Rahal &
Sheek, 2009).
Domains. The Harden model (Harden et al, 1999) presumes that domains represent
77
“discrete components of competence and can be taught as such and evaluated in performance
assessments” (p. 550). However, SMEs did not confirm discrete domains as re-conceptualized by
the researcher using further analysis including PCA. Several interesting results emerged from the
forced Q sort. While it was clear that the domain “Safety” was well populated by prescribing
competencies (14 of the competencies fit into the Safety domain in some manner) the domains of
Clinical Reasoning and Clinical Management confounded the experts. As discussed, experts
seemed to view Clinical Reasoning as incorporating professional behaviors rather than
diagnostic synthesis and planning. One expert commented that the domain names seemed to
signify overlapping concepts “Hard to separate clinical reasoning and clinical management
because there is overlap. I felt that some components were duplicate and due to the limited
options for placement, clinical reasoning and clinical management could have some overlap.”
This finding is inconsistent with the literature review that defines clinical reasoning as a distinct
concept in both nursing and medicine (Tanner, 2006; Bowen, 2006) and pharmacologic
prescribing as including ongoing management and evaluation (Davenport et al, 2005; Harden et
al, 1999; DeVries, Henning, Hogerzeil & Fresle, 1994).
The absence of clear placement of competencies into the Management domain is
concerning and indicates need for further analysis and research to determine if these results
indicate a lack of clarity with the competency content, the domain name, or the conceptualization
of “Clinical Management” itself. The latter is particularly problematic for several reasons. The
first is the fact that the original instrument was designed in order for the Oregon State Board of
Nursing to evaluate a clinical practicum in pharmacological management [emphasis added] as
required by Oregon statute. Clinically and conceptually, management of the patient connotes
ongoing responsibility for the patients’ treatment and outcomes resulting from autonomous
78
prescribing actions. Harden et al (1999) identify “patient management” as a discrete technical
intelligence that demonstrates that the competent and reflective practitioner knows how to “do
the right thing” Experts identified only one competency as fitting discretely into this domain:
“Demonstrates effective working relationship with other members of the healthcare team
including collaboration, consultation, and referral.” This competency, which in the original instrument was identified in a domain called
Professional Behavior (see Appendix A) was identified by 75% of SMEs as a clinical
management specific behavior. One SME also specifically commented on the task of comanagement as conceptually important for prescribing: “Probably prescribing in accordance with
current professional codes & standards covers this, but what about consideration of promotion of
information sharing or prescribing sharing when two or more prescribers are treating the client
concurrently?”
It is possible that nurses, as opposed to other types of prescribers, view the concept of
patient management as more team oriented. Recently educated APRNs are exposed to concepts
such as inter-professional educational competencies, which were recommended in 2003 by the
Institute of Medicine (IOM, 2003) and subsequently adapted into curricular competencies
(AACN, 2006). However, Flavell, Vanstolk, Bainbridge & Nasmith (2009) found that the
concept of inter-professional collaboration as a competency is poorly defined and therefore
difficult to incorporate consistently into competency based education, so conceptualization of
patient management may also be influenced by practice setting. Teamwork may also imply a
more subordinate role to nurses. Clinical Nurse Specialists in the original survey (most of whom
did not have prescriptive authority) made several observations regarding the use of the
pharmacist or other members of a team for medication provision, which was noted in the content
79
analysis. Even when instructed that the competencies were designed to grant legal autonomous
prescriptive authority, CNSs referred to delegation or collaboration as a necessary component of
prescribing.
Views of teamwork and collaboration differ among different levels of nursing as well as
among nursing roles. Cott (1998, p. 852) reported that physicians viewed teamwork as a form in
which registered nurses were subordinate, while nurses viewed it as a way of directly influencing
patient care and as a ‘means of gaining status’. Nurse Practitioners demonstrate a high level both
collaboration and high levels of autonomy (Maylone, Ranieri, Quinn Griffin, McNulty &
Fitzpatrick, 2011), as compared to CRNAs who most frequently use a compromising mode when
working with other professionals (Alves, 2005). Xyrichis & Ream (2007, p. 238) did an
extensive concept analysis of published research on teamwork as understood across disciplines
and proposed the following definition:
A dynamic process involving two or more health professionals with complementary
backgrounds and skills, sharing common health goals and exercising concerted physical
and mental effort in assessing, planning, or evaluating patient care. This is accomplished
through interdependent collaboration, open communication and shared decision-making.
This in turn generates value-added patient, organizational and staff outcomes.
The above complements the comments from an SME who identified the need for two or more
prescribers to collaborate in order to determine the best plan of care for patient co-management.
Further examination of the conceptual meaning of “Clinical Management” is warranted in order
to understand its meaning in the context of nurse prescribers, particularly as they legislatively
move towards an autonomous prescribing role.
80
Implementation and assessment
One of the challenges of implementing the Oregon instrument was its use for persons
obtaining prescriptive authority after many years of clinical practice. The Harden model
presumes use of tools such as the Objective Structured Clinical Examination (OSCE) that was
developed by Dr. Harden in the 1970s. As of 2009 the OSCE is required for at least one
clerkship and the final comprehensive examination for 101 medical schools in the US
(Barzansky & Etzel, 2011), but is not required for graduation from APRN programs. Use of the
OSCE for professionals seeking to add a new competency after many years of practice has not
been evaluated.
The Harden model (Harden et al, 1999) was further evaluated by Davis and Harden
(2003) once it was implemented into the medical curriculum. Assessment in the Dundee medical
school where Harden teaches incorporates a portfolio assessment as part of the final exam, in
addition to the use of OSCE and self-assessment methods throughout the program. There are
several recommendations that Davis and Harden (2003) make based upon data collected through
student diaries and examination data, formal accreditation review, external examiner reports, and
faculty evaluation. One change that was implemented was transferring pharmacology teaching to
an earlier phase (first year) of the curriculum. A second was establishing an introductory course
at each phase of the curriculum that introduced new learning outcomes for the exit learning
outcomes for the overall courses. The authors note that, though conceptually appealing, the
logistics of organizing a clinical assessment at the end of each course in form of an OSCE was
too difficult and was abandoned (Davis & Harden, 2003). They also discuss many of the logistic
issues in implementing curricular change in terms of funding, administrative and faculty support.
Integration of prescribing competencies into a curriculum requires thoughtful mapping and
81
agreement regarding assessment methods, particularly when implementation cannot presume a
novice practitioner as with Harden’s medical school curriculum.
Morris et al (2001) evaluated faculty incorporation of the only published nurse specific
prescribing competencies in the US, those developed by NONPF and NCSBN in 1998 (Yocom
et al, 1998). These competencies were not used for regulatory purposes, though their introduction
suggested utility for development of model rules and standards (Yocom et al, 1998). Evaluation
strategies were described by respondents as multiple choice exam questions, short answer exam
questions, oral case studies, written case studies, and other written assignments (Morris et al.,
2001). Respondents were not asked about achievement of the end of course competencies
specified in the guidelines (Morris et al., 2001).
The Clinical Practicum in Pharmacological Management Evaluation instrument does not
specify an evaluation methodology. Further research in this area is recommended, particularly if
the tool will be used for applicants of diverse backgrounds, roles, and clinical preparation. The
Oregon practicum mandated in conjunction with the tool is accomplished under a limited license
that specifies direct supervision of all clinical practice hours related to prescribing. However,
emerging technologies are challenging the boundaries of what constitutes direct supervision for
regulatory and educational purposes. Technology such as videoconferencing, email, simulation,
and telemedicine generally will continue to reshape how evaluation and supervision are
addressed in regulation. Electronic prescribing may obviate or change the competency currently
articulated as “writes clear, legible, and complete prescriptions that comply with state and federal
regulations.” In the original survey, a nursing faculty member expressed concern regarding how
the tool might be implemented to evaluate prescribing within the educational program for
eventual licensure because attainment of all the competencies originally listed might be
82
unrealistic “if they are expected to accomplish the competencies within their clinical practicum
in an educational program” (Table 2). Despite concerns about the breadth of the curriculum,
APRN faculty are currently expected to verify to both licensing agencies and national certifiers
that their graduates are fully prepared to prescribe medications for their target population,
practice competently in states which currently do not require supervision, collaboration, or a
mandated practicum. The emergence of the Doctor of Nursing Practice (DNP) as entry into
practice has potential to further expand the number of hours of prescribing practice that are
integrated into the curriculum, with graduates completing 1000 instead of 5-600 hours of clinical
practice. However, the current definition of hours for the DNP does not necessarily include direct
patient care or prescribing practice and does not therefore assure achievement of autonomous
prescribing competencies (AACN, 2006).
Limitations
Competency development and evaluation is frequently done using expert panels
(NONPF, 2006; Yocom et al., 1998), as is instrument review and revision (Davis, 1992). Experts
were used in the current study to analyze content and to confirm domain placement. Experts
were selected for their broad expertise in nursing regulation, practice, or faculty roles related to
pharmacology and prescribing. All but one expert is active in current clinical practice with
individual patients. None had less than 12 years of prescribing experience, and most had
practiced or were currently practicing under autonomous prescriptive authority (10/12 or 83%).
Although representing a wealth of expertise on the topic of prescribing, there are challenges in
using expert panels to draw representative conclusions. Harden et al. (1999, p. 547) caution that
the outcomes anchored in the inner circle he calls “doing the right thing” are anchored in the past
and may have to be unlearned when circumstances change. He and his colleagues also stress that
83
adaptation and reflection are critical components for a good practitioner: “A student or trainee
may have all the technical competences in the inner circle, but not be a good doctor. The
outcomes in the middle and outer circles mean that the student has to think as a doctor”.
The original survey solicited evaluation of the competencies by FNP students, FNP
faculty, practicing NPs and CNSs with and without prescriptive authority. As the target of the
newly passed prescriptive authority in Oregon, CNSs were over-represented in the original
survey and their views of competency to prescribe were not well-known. Lack of national
agreement regarding the need to prescribe for the CNS role complicated the ability to locate and
evaluate prescribing specific competencies, or research on prescribing practices, when
developing the original competencies (Lyon, 2003; NACNS, 2005). Current study experts, even
those licensed or experienced as CNSs, had the majority of their prescribing experience as NPs.
This is not surprising, since many states do not offer prescriptive authority to CNSs or provide it
as an optional status as in Oregon (NCSBN, 2010). The lack of published information and
diverse prescribing among CNSs, many of who practice in clinical subspecialties (Baldwin et al.,
2009) limits the availability of expert members with CNS prescribing expertise.
Certified Nurse Midwives and Certified Registered Nurse Anesthetists were also
underrepresented in the expert panel. As practitioners who have role specific rather than
population based practice competencies, nurse anesthetists and nurse midwives may have role
specific competencies for prescribing which do not exist for other prescribers (ACNM, 2008;
AANA, 2007). However, a review of both ACNM and AANA competencies does not identify
competencies which include the word “prescribe” or “pharmacologic management.” AANA
competencies address medication administration (AANA, 2007), while ACNM (2008) mentions
use of therapeutics in the management of specific conditions, but does not specify whether
84
therapeutics are pharmacologic or non-pharmacologic. Based upon the current lack of core
competencies and core licensing requirements for prescriptive authority, prescribing specific
regulatory criteria is difficult to evaluate for all APRNs, but more so for CNSs, CRNAs, and
CNMs than for NPs. Further research regarding role specific prescribing competencies within
each of the individual APRN roles may yield valuable information which can contribute to the
development of an overall document for APRN autonomous prescriptive authority.
Recommendations for Future Research
Final analysis includes recommendations for further research using the refined instrument.
Recommendations for further instrument development include potential modifications to the
theoretical framework, content of competencies and domains, and identification of additional
previously unidentified competencies.
A meta-analysis done of competency based medical or medicine articles published from
1966 to 2002 defined four steps to competency development:
1. Competency identification,
2. Determination of competency components and performance levels,
3. Competency evaluation, and
4. Overall assessment of the process (Carraccio, Wolfsthal, Englander, Ferentz & Martin,
2002).
However, the authors found little evidence to support one methodology of competency
identification over the other, and few models which evaluate and compare specific outcome
measurement tools (Carraccio, et al, 2002). The development of this instrument and its validation
for the Oregon State Board of Nursing satisfies step one. Further work is needed to determine the
85
appropriate evaluation assessment tools, particularly when incorporating the competencies for
different APRN roles, settings, and levels of prior clinical and educational preparation.
Ideally, incorporation of prescribing competencies into educational preparation would be
accompanied by increasing their presence in either licensure or certification testing plans. As an
example, the test plan for the American Nurses Credentialing Center’s Family Nurse Practitioner
certification exam includes content in “knowledge of pharmacology,” “skill in managing
conditions with pharmacological and non-pharmacological interventions,” and “evaluating the
effectiveness of pharmacological and non-pharmacological interventions” (ANCC, 2010). It does
not, however, evaluate whether an applicant can write or electronically transmit a legible legal
prescription, which was unanimously evaluated by Subject Matter Experts as an essential
competency for safety in prescribing. Clinical Nurse Specialists, have prescriptive authority in 34
states (NCSBN, 2010) but are not tested on prescribing specific competencies when obtaining
national certification, unless they are seeking certification as an adult psychiatric mental health
CNS (ANCC, 2011). Many CNSs have found it clinically expedient to become licensed and
educated as a Nurse Practitioner in addition to their CNS preparation if they want to have full
prescriptive authority. One SME stated that she practiced as a CNS for twelve years before
obtaining her NP license, as she practices in a state that does not grant prescriptive authority to
CNSs. A second SME in Idaho has a license and prescriptive authority as both a CNS and an NP
and is certified nationally in each role.
The use of competency based evaluation serves a policy purpose. Outcomes based
education provides benchmarks that help inform decisions regarding funding, public safety
initiatives, and workforce skill assessment (Carraccio, et al, 2002; Shippmann, et al, 2000). The
ability to verify by objective assessment the APRN competency to prescribe autonomously has
86
significant implications for licensing law, which currently restricts many APRNs to prescribing
under physician supervision or collaboration, within a prescribed formulary, or without
categories of necessary drugs such as controlled substances. There is little research to validate
restrictive prescribing law as protective of public health and safety. Nevertheless, expansion of
autonomy requires responsive change in how APRNs are licensed, educated, and certified; and in
how their programs are accredited (APRN Joint Dialogue, 2008).
Regulatory Implications
Prescribing specific curricula has been developed using the Harden model (Davenport et
al, 2005). The only US document to date that articulates nurse prescribing specific competencies,
in this case for family nurse practitioners, was published by NONPF and NCSBN in 1998
(Yocom, et al., 1998) and is accompanied by a model curriculum. Development of prescribing
specific competencies requires integration into the curriculum that prepares prescribers.
However, Harden and others identified barriers to this process. A study by Morris, Possidente &
Muskus (2001) evaluated integration of the model curriculum published by NONPF and NCSBN
in 1998 (Yocom, et al, 1998) and found that 85% of programs had not yet evaluated the model
curriculum three years after its publication. Common themes which were reported included too
much content to address in a 3 or 4 credit course and the difficulty of meeting the needs of a
diverse group of students who have varied knowledge levels, interests, and clinical backgrounds
(Morris et al., 2001). Another difficulty identified by faculty was the student’s inadequate
understanding of physiology and pathophysiology (Morris et al., 2001). NP and CNS applicants
to Oregon for prescriptive authority are required to demonstrate completion of pharmacology,
pathophysiology, and physical assessment before they are granted prescriptive authority. Those
needing to complete the prescribing practicum because they do not meet the clinical hours
87
requirement, either because they did not have it in their original program or their practice
experience is too old, must demonstrate completion of the courses as well but there are no
mandated requirements for order of completion before starting the practicum. The Morris et al
(2001) study suggests that regulatory Boards may want to consider further guidance regarding
appropriate course sequencing for applicants who want to add prescribing to their scope of
practice, and work in conjunction with graduate educational institutions preparing licensees for
the APRN roles.
More is known about NP prescribing than the three other APRN roles of CNS, CRNA,
and CNM. Until prescriptive authority is both mandatory and consistently documented as a
unique authority in licensing statistics, it is difficult to evaluate whether differences exist
between the roles. Variability of state authority, titling, and regulatory transparency limit data
gathering specific to APRN prescribing on a national level. Practice environment for APRNs are
influenced by multiple regional and contextual factors. As an example, many CRNAs choose not
to prescribe despite the legal option to do so (Kaplan, Brown & Simonson, 2011). Lyon (2003)
asserts that this is also true of CNSs, though more recent data is lacking regarding trending for
this role related to prescribing practices. As with Oregon, many states license Nurse Midwives as
NPs, which confounds data collection specific to CNM prescribing habits and competence.
Benner (2001) cautions that nursing is faced with two conflicting mandates: to
individualize patient care, and to minimize error. Nowhere is this more apparent than in the act
of prescribing medications for individual patients. However, Benner (2001) also observes that
efforts to standardize practice through mechanisms such as identifying competencies for practice
can “at the same time prevent the individualization of that care” by expert practitioners (p. 176).
88
She emphatically states that expert practice always involves a level of discretionary judgment
and often risk as well, and that such expertise is difficult to quantify or standardize.
Nonetheless, Nursing Boards have been charged with establishing and enforcing a
standard level of competence in order to protect the public. Regulators must first determine if
prescriptive authority is a mandatory part of the APRN role in order to establish objective
perimeters for competence. While prescribing is not the only function that differentiates the
APRN from the registered nurse, all APRNs of the future will be prepared to prescribe for
individual patients (APRN Joint Dialogue, 2008). Regulatory boards will then be charged not
only with establishing initial competency to prescribe, but also evaluating continued competency
using defensible instruments and criteria. The Oregon State Board of Nursing’s Clinical
Practicum in Pharmacological Management Evaluation instrument has been tested using long
term autonomous prescribers, novice prescribers, faculty and non-prescribers who may or may
not seek this authority. APRNs seeking to expand their authority may already be competently
prescribing under mandated legal constraints that merely serve to hamper their mobility and
service to their patients. The researcher acknowledges that APRNs as a whole have been shown
to provide safe and competent care under these constraints, as well as under the autonomous
practice environments found in Oregon and Washington. Further refinement of instruments and
models that can be freely available to every Nursing Board, contributes to the eventual goal that
all APRNs will be licensed to prescribe autonomously, regardless of their clinical role or
physical location.
89
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APPENDIX A
“Clinical Practicum in Pharmacological Management Evaluation” Instrument
108
APPENDIX B
WSU IRB Letters of Approval
Original IRB Letter of Approval
109
Final IRB Letter of Approval
110
APPENDIX C
Recruitment of Subject Matter Experts Letter
111
APPENDIX D
Informed Consent to Participate in Q Sort Letter
112