Practice Standards for the Emergency Nurse Practitioner Specialty.

Abstract

THE EMERGENCY NURSE PRACTITIONER (ENP) specialty in the United States has grown rapidly since its origins during the 1980s following the establishment of the emergency medicine specialty. Initially, ENPs were prepared on the job with direct mentoring by emergency medicine physicians. Since then, in response to increasing national emergency department (ED) workforce needs and the collaborative approach to emergency care, ENPs are now participating to a greater extent as part of the emergency medicine team in the delivery of emergency care. Given the relative infancy of the ENP specialty and persistent confusion regarding nurse practitioner (NP) educational preparation and scope of practice, clarification of the unique knowledge and skills of the ENP is needed to improve their integration into ED practice. Specialized graduate academic programs to prepare ENPs did not exist until the 1990s. Consequently, NPs’ readiness to practice within the ED may vary greatly on the basis of their prior nursing experiences and NP educational preparation. This gap in emergency-specific educational preparation led to initiatives among key emergency physician and nursing organizations to establish scientifically derived emergency care competencies for NPs that delineate the knowledge and skills needed for safe practice in emergency care settings (Emergency Nurses Association [ENA], 2008). The evolving national landscape of emergency care delivery and ED benchmarking standards has driven the need to reexamine the original 2008 ENP core competencies. DEVELOPMENT OF THE COMPETENCIES FOR NURSE PRACTITIONERS IN EMERGENCY CARE Entry-level core competencies for NPs refer to the core knowledge, skills, and abilities acquired during educational preparation for the NP role as described within the Licensure, Accreditation, Certification and Education Regulatory Model, also referred to as the Consensus Model (Advanced Practice Registered Nurse [APRN] Consensus Work Group & National Council of State Boards of Nursing [NCSBN] APRN Advisory Committee, 2008). In addition to the core NP competencies, the National Organization of Nurse Practitioner Faculties (NONPF) has further established entry-level competencies based on population-specific preparation, that is, family, adult-gerontology acute or primary care, pediatric acute or primary care, women's gender specific, and psychiatric/mental health (NONPF, 2013,2017). Development of specialty competencies, however, has been delegated to professional nursing organizations as a national standard for NP practice (APRN Consensus Work Group & NCSBN APRN Advisory Committee, 2008). Specialty competencies are not considered to be entry level but rather incorporate higher level skills that build upon entry-level practice. The Competencies for Nurse Practitioners in Emergency Care, delineating the unique knowledge and skills of an ENP, were originally published by ENA in 2008 through the efforts of a diverse work group that included members of the American College of Emergency Physicians. These competencies were subsequently endorsed by the American Nurses Association and NONPF (ENA, 2008), further designating the specialty practice of ENPs. COMPETENCIES VERSUS PRACTICE STANDARDS The American Academy of Emergency Nurse Practitioners (AAENP), the ENP specialty organization representing the nation's more than 14,000 estimated ENPs (American Association of Nurse Practitioners, 2018), has established the ENP scope and standards of practice unique to the ENP specialty through an analysis of national ED census trends and ED benchmarking statistics (AAENP, 2016). The ENP scope and standards of practice are rooted in team-based care whether the ENP is a sole provider collaborating remotely with physician colleagues through technology or when practicing within an interprofessional ED team. In conjunction with the development of a new ENP certification examination offered by the American Academy of Nurse Practitioners Certification Board (AANPCB), AAENP participated in a 2016 practice analysis of ENPs in the United States; specific information regarding the sample size, methodology, and results are available from AANPCB (2016). The resulting data from this practice analysis provided support for updating the 2008 competencies. Given the robust data available following the practice analysis, expanded practice standards were delineated in place of updating the original 2008 ENP core competencies. Practice standards define the provision of competent care and foundations of patient care management for a specialty practice and support evaluation of clinician proficiencies by providing measurable outcomes that can be used to assess evolving clinical abilities through the spectrum of novice to expert. The ENP specialty practice standards separate knowledge, tasks, and procedures that are placed under the domains for which the standard is reflected. In many cases, multiple actions can be used to describe the various standards as an ENP progresses in proficiency and the ability to manage more complex patient presentations. A standard will in many cases be utilized for building upon a specific task or procedure in the clinical setting and an action or descriptor term may progress from a basic knowledge action to a synthesis or performance action. From the practice analysis, five domains of ENP practice were identified (AANPCB, 2018): Medical Screening Medical Decision Making/Differential Diagnoses Patient Management Patient Disposition Professional, Legal, and Ethical Practices The tasks reflected in the ENP practice standards fit within each of these domains as depicted in Table 1. The standards within the domains can be used to improve ENP onboarding by providing employers with a method for evaluating ENP proficiencies and to recommend areas for additional training. Table 1. - Practice standards for the emergency nurse practitioner Medical Screening 1. Classify patient acuity level 2. Stabilize critically ill patient 3. Perform a medical screening examination 4. Apply crisis management knowledge 5. Apply disaster and mass casualty management knowledge Medical Decision Making/Differential Diagnosis 6. Prioritize the list of differential diagnoses, considering the potential diagnoses with the greatest potential for morbidity or mortality 7. Evaluate patient safety/harm reduction 8. Implement medical decision making for management plan development 9. Interpret diagnostic studies (ECG, radiology, body fluid) 10. Utilize evidence-based practice Patient Management 11. Order and interpret diagnostic studies based on the pretest probability of disease and the likelihood of test results altering management 12. Perform diagnostic and therapeutic procedures/skills as indicated 13. Select and prescribe appropriate pharmaceutical agents using current evidence-based practice 14. Collaborate and consult with other health care providers to optimize patient management 15. Evaluate effectiveness of therapies and treatments provided during observation 16. Reassess to identify potential complications or worsening of condition 17. Consider additional diagnoses and therapies for a patient who is under observation and change treatment plan accordingly 18. Simultaneously manage multiple patients using situational awareness and task switching 19. Initiate/maintain emergency stabilization 20. Apply pharmacological therapies 21. Initiate and/administer resuscitation Patient Management (con't) 22. Perform observation and reassessment 23. Administer pain management according to national standards 24. Organize and administer sedation (as per facility guidelines) 25. Facilitate team-based practice/management Patient Disposition 26. Determine appropriate and timely patient disposition including admission, discharge (including follow-up plan), observation, or transfer as appropriate 27. Initiate/facilitate consultation and collaboration 28. Integrate patient and family education and counseling 29. Formulate appropriate disposition Professional, Legal, and Ethical Practices 30. Record essential elements of the patient care encounter to facilitate correct coding and billing 31. Integrate cultural competence into patient care 32. Identify needs of vulnerable populations and intervene appropriately 33. Manage patient presentation demonstrating knowledge of EMTALA regulations 34. Adhere to professional ethical standards in emergency care 35. Assess staff/personal safety 36. Support intra- and inter disciplinary communication 37. Assess for maltreatment/abuse/neglect 38. Incorporate utilization of forensic specialists when appropriate 39. Consider legal, professional, and ethical issues in practice 40. Exhibit cultural competence in practice 41. Acknowledge and intervene for vulnerable populations 42. Utilize performance improvement to provide quality patient care Note. ECG = electrocardiogram. ENP PROCEDURES ACROSS THE LIFE SPAN Beyond the technical ability to perform a procedure, knowledge of the context in which procedures may be safely performed is crucial in the provision of emergency care. The practice standards for the ENP, therefore, represent the integration of knowledge, psychomotor ability, and discernment of the need to perform procedures within emergency care settings in collaboration with the health care team. Procedures in this specialty span from simple laceration repair to lifesaving procedures. Practice analysis data ultimately identified procedures frequently performed by ENPs within 15 specific procedural areas. Table 2 lists the procedures identified during the practice analysis pertinent to ENP practice (AANPCB, n.d.). Although this is not an exhaustive list of the skills identified during the practice analysis, those included represent procedures identified as being applicable across broad clinical settings. Many of the included procedures were not performed frequently, yet represent necessary knowledge, and are thus included because of the high risk of harm if there is a failure in recognizing the need for the procedure. Differences in state regulations, provider credentialing, and collaborative practice at individual facilities as well as practice settings (e.g., critical access, academic, or tertiary care) will ultimately determine which skills an ENP may perform. This document was written by Elda Ramirez, Jennifer Wilbeck, and Dian Evans on behalf of the AAENP Board of Directors. Table 2. - Emergency nurse practitioner procedures Procedural area/system Exemplar skills and procedures Airway techniques Intubation Airway adjuncts Mechanical ventilation Noninvasive ventilatory management Ventilatory monitoring Resuscitation Cardiopulmonary resuscitation (life span) Postresuscitative care Blood, fluid, and component therapy Central venous access (US-guided) Intraosseous infusion Defibrillation Anesthesia and acute pain management Local anesthesia Regional nerve block Procedural sedation and analgesia Gastrointestinal Gastrostomy tube replacement Nasogastric tube Paracentesis Cardiovascular and thoracic Cardiac pacing Cardioversion ECG interpretation Thoracentesis Needle/tube thoracostomy Cutaneous Escharotomy Incision and drainage Trephination, subungual Wound closure techniques Wound management Head, ear, eye, nose, and throat Control of epistaxis Slit lamp examination Tonometry Tooth stabilization Corneal foreign body removal Drainage of hematoma (auricular, septal) Systemic infectious Personal protection (equipment and techniques) Universal precautions and exposure management Musculoskeletal Arthrocentesis Compartment pressure measurement Fracture/dislocation immobilization techniques Fracture/dislocation reduction techniques Spine immobilization techniques Nervous system Lumbar puncture Obstetrics and gynecology Precipitous deliveries Sexual assault examination Bartholin cyst incision and drainage Psychobehavioral Psychiatric screening examination/medical stabilization Violent patient management/restraint Renal and Urogenital Bladder catheterization Urethral catheter Testicular detorsion Toxicological Decontamination Other diagnostic and therapeutic procedures Foreign body removal Collection and handling of forensic material Diagnostic US Procedural US Note. ECG = electrocardiogram; US = ultrasonography. From Emergency Care Skills and Procedures, by American Academy of Nurse Practitioners Certification Board, n.d. Retrieved May 6, 2018, from http://www.aanpcert.org/resource/documents/Emergency%20care%20Procedures%20%20Skills%20list%20(004).pdf. Adapted with permission. AAENP Board of Directors —Theresa M. Campo, DNP, FNP-BC, ENP-BC, FAANP, FAAN —Amanda Comer, DNP, FNP-BC, ACNP-BC, ENP-BC —Dian Dowling Evans, PhD, FNP-BC, ENP-C, FAANP —Kyle Kincaid, DNP, FNP-BC —LaMon Norton, DNP, FNP-BC —Elda G. Ramirez, PhD, RN, FNP-BC, ENP-C, FAEN, FAANP, FAAN —Eric Roberts, DNP, FNP-BC, ENP-BC —Andrea Smith, DNP, FNP-BC —Ken Stackhouse, MSN, MBA, FNP-BC, ENP-BC —Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP