- Email: [email protected]
A theoretical framework for specialty certification in nursing practice1
A Theoretical Framework for Specialty Certification in Nursing Practice ................................................................................... Barbara M. Raudonis, PhD, RN, CS Corrine M. Anderson, MSN, RN, GNP, CHPN
N
urses are committed to the safety and welfare of their patients. However, the Institute of Medicine’s report1that 44,000 to 98,000 deaths occur per year because of health care errors demands attention from every health-related discipline. The profession of nursing is accountable for the clinical competence of its practitioners. This accountability is achieved in three ways. First, each state regulates the practice of professional nursing through the statutes of its Nursing Practice Act. Therefore, the license of a registered nurse is a contract between an individual nurse and the citizens of that state for health care.2 These statutes legally define the scope and parameters of basic and advanced nursing practice in each state. The second form of accountability includes the scope and standards of clinical nursing practice. These standards are developed by members of the nursing profession, not members of state legislatures. The standards serve as guidelines for a competent level of nursing care across settings. The American Nurses Association and specialty nursing organizations have developed specialty specific scope and standards of nursing practice. The third form of accountability is certification. Certification is a valued credential offered by the American Nurses Association and many specialty nursing organizations. Certification is 1 means of demonstrating clinical competence in a particular role.3 More than 350,000 nurses in the United States and Canada hold certification.4 A recent study4 conducted by the Nursing Credentialing Research Coalition found that certification dramatically affects the personal, professional, and practice outcomes of nurses. The study’s4 findings indicated that certified nurses felt more confident and experienced fewer errors in patient care since they had become certified. The study4 linked improved health care to certification. In recognition that certification is an important method of
Barbara M. Raudonis is an assistant professor at the University of Texas at Arlington School of Nursing. Corrine M. Anderson is a clinical instructor at the University of Texas at Arlington School of Nursing. The Role Delineation Study was funded by the National Board for Certification of Hospice Nurses. Reprint requests: Barbara M. Raudonis, PhD, RN, CS, University of Texas at Arlington School of Nursing, Box 19407, Arlington, Texas 76019-0407.
Nurs Outlook 2002;50:247-252. © 2002 Mosby, Inc. All rights reserved. 0029-6554/2002/$35.00 ⫹ 0 35/1/129850 doi:10.1067/mno.2002.129850 NURSING OUTLOOK
NOVEMBER/DECEMBER 2002
increasing the accountability of nurses to the public, the American Nurses Credentialing Center made certification in the 21st century accessible to all qualified registered nurses. This policy change was made on the basis of the evolution of the credentialing processes and the need for quality indicators of competence in nursing practice.5 The process of certification includes meeting eligibility criteria and successfully completing a nationally administered examination. A certification board, usually appointed by the parent nursing specialty organization, establishes the eligibility criteria and maintains the content validity of the certifying examination.3 The blueprint of the content of a certification examination has its basis on the nursing activities and knowledge of that nursing specialty. Job analysis is the accepted method for defining and maintaining the validity of this content.6 Maintaining the content validity of certifying examinations is an ongoing process that must be done periodically or whenever significant practice changes occur.7 When initiating a role delineation study for the National Board for Hospice and Palliative Nurses, one author of this article (C. A.) found that the methodology of job analysis (or role delineation) is well established and replicable.3 However, rarely does a theoretical framework explain the concepts and relationships of the process. On the basis of the assumption that the discipline of nursing is striving to build a theory and evidence-based practice, this is a critical gap in the nursing literature. In addition, if certification is valued as a major way to increase nursing’s accountability to health care consumers, the certification process must be theoretically sound. The purpose of this article is to describe the theory of job analysis and a practice model that supports the certification process in nursing. LITERATURE REVIEW
The nursing literature review exploring the theoretical base of job analysis is presented in the Table. None of the studies identified or described a theoretical framework that guided the study. As the studies in the Table demonstrate, the established process for a job analysis follows in this manner: (1) A panel of experts is selected to draft a questionnaire that includes the activities or behaviors of job incumbents. (2) The questionnaire is reviewed by a small pilot group for format and completeness. (3) A large sample (600 to 7400) of practitioners in the specialty receive the questionnaire by mail. The respondents evaluate each activity for its frequency of occurrence and importance to the practice and return the questionnaire by mail. (4) The results are analyzed. At the least the mean and standard deviation will be computed for each activity statement and the Raudonis and Anderson
247
A Theoretical Framework for Specialty Certification in Nursing Practice Raudonis and Anderson ...................................................................................................................................
Table 1. Literature review Source 8
9
Purpose
Frame work
Design/instrument
1995 McMillan, Huesinkveld, Spray.
Role Delineation Separate Oncology Advanced Practice from Generalist
None
1997 McMillan, Huesinkveld, Spray.
Update practice information/certification exam for Oncology Nursing Society (ONS) generalist
None
Survey. Tailored Questionairre. 190 items Basis: ONS Standards of Advanced Practice (roles & functions) Survey: Tailored Quest.-201 items based on nursing process & ONS Stnds for Generalist Practice.
Practice Update for Respiratory Therapy both generalist and advanced Test agreement of content validity using Advisory Committee only vs. field survey Two studies: Spanish teachers & Chemistry teachers
None
Survey: 650 detailed items.
None
Comparative Descriptive Survey: data collected with tailored Questionnaire knowledge/and ability statements. Spanish 166 items Chemistry 181 items Survey: 110 tasks listed
10
1993 Johnson, C.
11
1993 Tannebaum, RT & Wesley, S.
12
1993 Bjerke et al
Infection Control Practitioner job analysis
None
13
1996 Doig, K.
None
14
1997 Goddard, L. presentation at NSNCO Dec., 97.
Job Task Analysis for Cytogenic Lab Tech. Am. Bd. of Neuroscience Nursing Practice Analysis for certification Exam update
15
1991 Petrosino, B. unpublished.
Assessment of hospice nurses unique body of knowledge
None
16
1988 Knight, C.F. & Knight, P.F.
None
17
1992 Amenta, M.
Assessment of subject areas important to hospice nursing Certification desired by hospice nurses?
248
None
None
Survey Q w (# not given) Practice theory w NIC as base for Questionnaire items: 3 sections: demographics conditions of patients; NIC as activity statements Delphi 3 rounds #1 open questionnaire. #2 rank #3 rank Delphi 3 rounds as above Survey Needs Assess List of 21 items.
VOLUME 50 • NUMBER 6 NURSING OUTLOOK
A Theoretical Framework for Specialty Certification in Nursing Practice Raudonis and Anderson ...................................................................................................................................
Sample
Variables/concepts
Clinical practice 1500 BSN w 619 returns 1349 w Advanced degrees (Convenience) w 637 returns 3000 w 1200 returns, random ONS members without Advanced degrees
Results
Interpretation of Findings
Frequency (scale from 6-1) 6 ⫽ more than 1x/day to 1⫽ do not perform Importance (scale from 1-5) 1 ⫽ low Frequency (scale from 0-5) Importance (scale 0-3)
Group Comparison Mean & Stnd. Dev. For each group, each item. Then Discriminate analysis per item w Chi-Square for differences between groups. Means and Stnd. Deviations of Frequency & Importance Scores combined ⫽ weighted score, then ranked highest to lowest.
Significance; Measured as a combination of frequency and importance. Scale 0-5 0 ⫽ not necessary, 5 ⫽ very significant Significance One scale 1-4 as comb. of Frequency & Importance Measured frequency (5 pt. scale) of Neuro. disorders; measured frequency (5 pt. scale) & criticality (4 pt. scale) of Interventions. Knowledge, skills, abilities, traits w Scale 1-5 on round 2-3
Mean & Stnd. Dev. on the items Comparative with earlier studies Used a “profile group” whose Asked respondents to allocate demographics equaled exam percentage of examination eligible. Checked for questions/category in conclusion congruence in perspective.
Defined differences in practice Basis for advanced oncology certification examination AOCN credential
Compared with 1992, only small changes in certification examination content, but ordered and identified differently Each of the 7400 random sample Occurrence Significance (Scales not Reviewed ranking of occurrence Cognitive Complexity assigned received 1/3 of items listed) & significance. Made “Decision (recall, application, or analysis) 2000 returns total rules” to determine which items Detailed examination blueprint significant for certification exam Spanish: Importance (scale of 0-4) 0 3 measures of agreement: relative Well selected Advisory Committee Expert Advisory ⫽ not important; 4 ⫽ very index, (product-moment can perform as well as field Spanish Committee 10 sent, 7 important Chemistry: Importance: correlation), absolute index, survey in determining job replied 0-5 0 ⫽ not important, 5 ⫽ very (intraclass correlation) & content needed for licensure in Field 838 sent/423 replied important dichotomous index (cutpoint) teaching specialty classes Chemistry: Committee 8 sent, 7 Dichotomous index provides best replied information for comparison Field 800 sent/329 replied 1600 sent with 577 returns or ⫽ 36.1%
600 w 26.3% ret. Members of Assoc. Genetic Techn. plus selected educators 1500 sent w 430 returned ⫽ 30%
68 w 52 (77%) completing all 3 rounds Practitioners 23 Content Experts from locations across U.S. 16 completed all rounds
Subject Areas to be considered for certification process
1550 self-selected respondents
Administration details, costs, eligibility, sponsorship, etc.
NURSING OUTLOOK
NOVEMBER/DECEMBER 2002
Mean of 2.5 or grtr. Used “decision criteria” for items to be in examination content (Stats not available)
Bloom’s taxonomy recall, application, analysis after complexity ratings applied to items Examination revised NIC as activity statements worked well Began developing neuronursing practice theory Mean & Stand. Dev. on all, then Lead knowledge items: pain, ranked symptom management, comfort, dying, psychosocial Useful for proposed certification process. Mean & Stnd. Dev., Rank order Items 1-10: of 70 items at end of round 3. Pain assessment, First 10 and last 10 didn’t interdisciplinary, pain change management, symptom assessment, hospice concepts, communication skills, patient assessment, nursing diagnosis, ethical issues 90% endorsed idea Not generalizable RT to sampling Strong mandate
249
Raudonis and Anderson ................................................................................................................................... A Theoretical Framework for Specialty Certification in Nursing Practice
Figure 1. Kane’s theory: model-based practice analysis and test specifications presented as a map.
statements placed in rank order. At the most a complex formula is applied to test relative weights and discriminate which items are worth including on the examination. (5) The panel of subject matter experts determines what adjustments to the content of the certification examination are needed on the basis of the study results. However, in studies from the fields of oncology and neuroscience, nurses demonstrated that purposes for doing practice/ job analysis can be amplified to provide feedback to the larger body of nursing knowledge. McMillan et al8 wanted to distinguish the practice patterns of the oncologic nurse generalist from that of the advanced practice nurse. They reported that no “precedents for this type of study were found in the research literature.” In that study,8 a theoretical model of practice became the foundation for the questionnaire so that outcomes of the study supported the validity and completeness of the model. On the basis of that success, the 1997 study9 by the same investigators used the elements of the nursing process with concerns of cancer patients to construct the job analysis questionnaire. The study results provided clarity about the relationships between each of the elements of the nursing process and the concerns of cancer patients, which were usable to the certification process and became the vehicle of communication with nurse managers and others who wanted practice definitions for the basic oncologic nurse. Goddard’s14 presentation demonstrated that it is possible to bring some uniformity to the process of job analysis, yet remain true to a specialty. The use of selected Nursing Intervention 250
Classification (NIC) statements18 as questionnaire items had not been done before. There would seem to be great potential value in this mode of study. If each specialty used a common base upon which to respond, such as the Nursing Intervention Classification, the areas of common practice and differences between specialty groups would become clear. The isolated purpose and usefulness of job analysis information have been a limitation of the research in this area thus far. Often, results are not published or appear in an organizational newsletter or other obscure format. Currently, each specialty approaches the process with a degree of freedom to design the process to meet its purposes. This allows flexibility and some sense of ownership of the process but does not promote comparison of results that can be generalized beyond that specialty. Because new questionnaires are designed each time a study is done, comparison is difficult, even within the same specialty.9 Standardization of the process of practice analysis, at least among nursing specialties, could promote camaraderie and healthy comparison. Perhaps the differences could be bridges rather than walls. Understanding the theoretical framework and model supporting practice analysis is the first step in the standardization process. DEVELOPMENT OF THE FRAMEWORK
A theoretical framework for role a delineation study or job analysis was developed by Dr Michael Kane of the University of VOLUME 50 • NUMBER 6 NURSING OUTLOOK
Raudonis and Anderson ................................................................................................................................... A Theoretical Framework for Specialty Certification in Nursing Practice
Figure 2. Application of Kane’s theory in the Hospice and Palliative Nursing Role Delineation Study.
Wisconsin at Madison to address the chain of inference inherent in the licensure and certification test development process. Kane’s19 article, “Model-Based Practice Analysis and Test Specifications,” proposes that a practice model appropriate to the specialty should be the basis for data collection during practice analysis. Kane proposes that work settings; the activities performed in those settings; and the competencies in judgment, skills, and knowledge needed to perform those activities constitute the elements of a practice model. He theorizes that the results from the analysis will have an empirical relationship to the practice, the practice framework may become validated, and the content validity of the examination is defensible.19 Theoretical Framework
Kane19 presents his theory with the 4 following mathematical statements. 1. ⌺P(Si) ⫽ 1. (The whole group of practitioners [1] represents the sum of the practitioners [P] in each setting [Si]). 2. P(ajsi) ⫽ P(aj l si) ⫻ P(si). (The relative frequency with which practitioners perform activity [aj], given that they work in setting si can be represented by P [aj l si]. The value NURSING OUTLOOK
NOVEMBER/DECEMBER 2002
of P [aj l si] can be thought of as the conditional probability of aj, given si). 3. P(aj) ⫽ ⌺P(aj lsi) ⫻ P(si). (Therefore, across all settings, the probability or relative frequency of any given activity is directly related to the setting). 4. I(ck) ⫽ ⌺I(ckajsi) ⫻ P(ajsi) ⫽ ⌺I(ckajsi) ⫻ P(ajsi) ⫻ P(si). (I [ck] can reasonably be defined as a weighted average, over activities and settings of I [ck aj si], the importance of category ck in performing activity aj in setting si. In this general formulation, I [ck, aj, si] represents the relative importance, or criticality, of competency category, ck, for activity aj in setting si. The estimated value of I [ck] provides a reasonable weight for the category, ck, in test specifications based on the competency categories). Kane’s theory, presented as a map, is illustrated in Fig 1. The map clarifies the process of the practice analysis and development of the certification test’s specifications. APPLICATION OF KANE’S MODEL TO NURSING PRACTICE
Kane’s model was the theoretical framework for the Hospice and Palliative Care Nursing Role Delineation Study.3 Fig 2 251
A Theoretical Framework for Specialty Certification in Nursing Practice Raudonis and Anderson ...................................................................................................................................
illustrates the National Board for Certification of Hospice Nurse’s (NBCHN) use of role delineation on the basis of Kane’s theory. The role delineation process implemented by NBCHN is described in detail elsewhere.3 The conceptual definitions for the components of Kane’s model are clearly defined in his article.19 However, to demonstrate the clinical relevance of Kane’s theory, the Hospice and Palliative Nursing Role Delineation Study will be used to illustrate the application of the conceptual definitions and propositions of Kane’s theoretical framework. The purpose of the role delineation study was to determine the core activities occurring in nursing practice in end-of-life care in any setting. The Advisory Committee, which consisted of nursing experts in end of life care, identified the descriptive categories of activities that described current end-of-life nursing practice. The activity statements within the categories specified the knowledge, skill, judgment, and competencies required to perform each activity. In addition, the statements were evaluated in relation to their frequency and significance to end of life care. Together these components form a practice model. The practice model provided a preliminary, working hypothesis, or theory, about what constituted nursing practice in end-of-life care and a framework for collecting and analyzing data in the role delineation process.19 At the end of the survey, participants evaluated the adequacy of the instrument. Ninety-eight percent of the respondents were satisfied that the instrument adequately described nursing care provided by hospice and palliative care nurses at the end of life.3 The results of the data analysis from the survey provided a practice description that was basically the same for hospice and non-hospice palliative nurses who participated in the role delineation study. The NBCHN concluded that the nursing practice of hospice and palliative nurses was not substantially different. Therefore, only 1 certification examination will be offered, and the credential was changed to Certified Hospice and Palliative Nurse (CHPN).3 DISCUSSION
Clinical nursing practice is dynamic. As practice changes occur, certification boards must monitor these changes and evaluate certification examinations in light of current practice. The use of periodic role delineation studies is 1 strategy for monitoring this change and keeping the examination, offering expert recognition, in step with the latest knowledge, research, and best practices of the specialty. The work of the Hospice and Palliative Nursing Role Delineation Study and the subsequent results demonstrate that Kane’s model can be used empirically to guide and define clinical practice. Nurse scientists and theorists have repeatedly called for the development of theory-based nursing practice. Theory-based nursing practice provides nurses with a context to view, analyze, and interpret the patient’s situation and the hundreds of pieces of data collected daily. Use of a theoretical perspective enables nurses to purposefully and proactively plan their patients’ care.20 In addition, clinical practice guidelines on the basis of the findings of research studies are forming the foundation of “best prac252
tices.” A major outcome of these efforts is the growing body of nursing science. Therefore, we propose that because certification is an accepted recognition of clinical expertise and competence, the role delineation process and resulting certification examinations should have their basis on a theoretical foundation. The NBCHN study demonstrated that Kane’s theory can serve as the theoretical foundation for job analysis/role delineation studies in nursing practice. The authors thank Carolyn Cason, PhD, RN, for her thoughtful critique and encouragement in the preparation of this manuscript.
............................................................ REFERENCES
1. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington: National Academy Press; 2000. 2. American Nurses Association. Nursing’s social policy statement. Washington: The Association; 1995. 3. Anderson CM, Raudonis BM, Kirschling JM. Hospice and palliative nursing role delineation study: implications for certification. J Hospice Palliative Nurs 1999;1:45-55. 4. American Nurses’ Credentialing Center. Certified nurses report fewer adverse events. [Press release; online]. Available at: http://www. nursingworld.org/pressrel/2000/pr0211a.htm. Accessed Feb 11, 2000. 5. American Nurses’ Credentialing Center. ANCC to make certification available to all registered nurses through open door 2000 program. Press release [online]. Available at: http://www.nursingworld.org/ pressrel/2000/pr0225a.htm. Accessed Feb 25, 2000. 6. American Educational Research Association. Standards for educational and psychological testing. Washington: The Association; 1985. 7. National Commission for Certifying Agencies. NCCA guidelines for certification approval. Washington: The Commission; 1991. 8. McMillan SC, Heusinkveld KB, Spray J. Advanced practice in oncology nursing: a role delineation study. Oncol Nurs Forum 1995;22:41-50. 9. McMillan SC, Heusinkveld KB, Spray J. A study of the role of the generalist oncology nurse as a basis for revision of the blueprint for certification. Oncol Nurs Forum 1997;24:1372-79. 10. Johnson CB. 1992 Respiratory care job analysis serves as basis for credentialing examinations. NBRC Horizons 1993;19:1,3,5-27. 11. Tannebaum RJ, Wesley S. Agreement between committee-based and field-based job analyses: a study in the context of licensure test. J Appl Psychol 1993;78:975-80. 12. Bjerke NB, Fabrey LJ, Johnson CB, Bennet G, Schollenberger D, Jacobsen D, et al. Job analysis 1992: infection control practitioner. Am J Infect Control 1993;21:51-7. 13. Doig K. Cytogenetics detailed content outline for the NCA certification examination. Appl Cytogenet 1996;22:128-36. 14. Goddard L. Lessons from a role delineation study. Paper presented at: National Symposium for Nursing Specialty Organizations; December 1997; Chicago. 15. Petrosino BM. Delphi study: knowledge, skills traits, and attitudes of hospice nurses [unpublished raw data]; 1991. 16. Knight CF, Knight PF. Developing a certificate course for hospice nurses: a Delphi survey of subject areas. Hospice J 1992;8:45-58. 17. Amenta MO. Certification for hospice nurses? Assessment of need. Hospice J 1992;8:73-87. 18. McCloskey JC, Bulechek GM. Nursing interventions classification (NIC). 2nd ed. St. Louis: Mosby; 1996. 19. Kane M. Model-based practice analysis and test specifications. Appl Meas Educ 1997;10:5-17. 20. Raudonis BM, Acton GJ. Theory-based nursing practice. J Adv Nurs 1997;26:138-45. VOLUME 50 • NUMBER 6 NURSING OUTLOOK
N
urses are committed to the safety and welfare of their patients. However, the Institute of Medicine’s report1that 44,000 to 98,000 deaths occur per year because of health care errors demands attention from every health-related discipline. The profession of nursing is accountable for the clinical competence of its practitioners. This accountability is achieved in three ways. First, each state regulates the practice of professional nursing through the statutes of its Nursing Practice Act. Therefore, the license of a registered nurse is a contract between an individual nurse and the citizens of that state for health care.2 These statutes legally define the scope and parameters of basic and advanced nursing practice in each state. The second form of accountability includes the scope and standards of clinical nursing practice. These standards are developed by members of the nursing profession, not members of state legislatures. The standards serve as guidelines for a competent level of nursing care across settings. The American Nurses Association and specialty nursing organizations have developed specialty specific scope and standards of nursing practice. The third form of accountability is certification. Certification is a valued credential offered by the American Nurses Association and many specialty nursing organizations. Certification is 1 means of demonstrating clinical competence in a particular role.3 More than 350,000 nurses in the United States and Canada hold certification.4 A recent study4 conducted by the Nursing Credentialing Research Coalition found that certification dramatically affects the personal, professional, and practice outcomes of nurses. The study’s4 findings indicated that certified nurses felt more confident and experienced fewer errors in patient care since they had become certified. The study4 linked improved health care to certification. In recognition that certification is an important method of
Barbara M. Raudonis is an assistant professor at the University of Texas at Arlington School of Nursing. Corrine M. Anderson is a clinical instructor at the University of Texas at Arlington School of Nursing. The Role Delineation Study was funded by the National Board for Certification of Hospice Nurses. Reprint requests: Barbara M. Raudonis, PhD, RN, CS, University of Texas at Arlington School of Nursing, Box 19407, Arlington, Texas 76019-0407.
Nurs Outlook 2002;50:247-252. © 2002 Mosby, Inc. All rights reserved. 0029-6554/2002/$35.00 ⫹ 0 35/1/129850 doi:10.1067/mno.2002.129850 NURSING OUTLOOK
NOVEMBER/DECEMBER 2002
increasing the accountability of nurses to the public, the American Nurses Credentialing Center made certification in the 21st century accessible to all qualified registered nurses. This policy change was made on the basis of the evolution of the credentialing processes and the need for quality indicators of competence in nursing practice.5 The process of certification includes meeting eligibility criteria and successfully completing a nationally administered examination. A certification board, usually appointed by the parent nursing specialty organization, establishes the eligibility criteria and maintains the content validity of the certifying examination.3 The blueprint of the content of a certification examination has its basis on the nursing activities and knowledge of that nursing specialty. Job analysis is the accepted method for defining and maintaining the validity of this content.6 Maintaining the content validity of certifying examinations is an ongoing process that must be done periodically or whenever significant practice changes occur.7 When initiating a role delineation study for the National Board for Hospice and Palliative Nurses, one author of this article (C. A.) found that the methodology of job analysis (or role delineation) is well established and replicable.3 However, rarely does a theoretical framework explain the concepts and relationships of the process. On the basis of the assumption that the discipline of nursing is striving to build a theory and evidence-based practice, this is a critical gap in the nursing literature. In addition, if certification is valued as a major way to increase nursing’s accountability to health care consumers, the certification process must be theoretically sound. The purpose of this article is to describe the theory of job analysis and a practice model that supports the certification process in nursing. LITERATURE REVIEW
The nursing literature review exploring the theoretical base of job analysis is presented in the Table. None of the studies identified or described a theoretical framework that guided the study. As the studies in the Table demonstrate, the established process for a job analysis follows in this manner: (1) A panel of experts is selected to draft a questionnaire that includes the activities or behaviors of job incumbents. (2) The questionnaire is reviewed by a small pilot group for format and completeness. (3) A large sample (600 to 7400) of practitioners in the specialty receive the questionnaire by mail. The respondents evaluate each activity for its frequency of occurrence and importance to the practice and return the questionnaire by mail. (4) The results are analyzed. At the least the mean and standard deviation will be computed for each activity statement and the Raudonis and Anderson
247
A Theoretical Framework for Specialty Certification in Nursing Practice Raudonis and Anderson ...................................................................................................................................
Table 1. Literature review Source 8
9
Purpose
Frame work
Design/instrument
1995 McMillan, Huesinkveld, Spray.
Role Delineation Separate Oncology Advanced Practice from Generalist
None
1997 McMillan, Huesinkveld, Spray.
Update practice information/certification exam for Oncology Nursing Society (ONS) generalist
None
Survey. Tailored Questionairre. 190 items Basis: ONS Standards of Advanced Practice (roles & functions) Survey: Tailored Quest.-201 items based on nursing process & ONS Stnds for Generalist Practice.
Practice Update for Respiratory Therapy both generalist and advanced Test agreement of content validity using Advisory Committee only vs. field survey Two studies: Spanish teachers & Chemistry teachers
None
Survey: 650 detailed items.
None
Comparative Descriptive Survey: data collected with tailored Questionnaire knowledge/and ability statements. Spanish 166 items Chemistry 181 items Survey: 110 tasks listed
10
1993 Johnson, C.
11
1993 Tannebaum, RT & Wesley, S.
12
1993 Bjerke et al
Infection Control Practitioner job analysis
None
13
1996 Doig, K.
None
14
1997 Goddard, L. presentation at NSNCO Dec., 97.
Job Task Analysis for Cytogenic Lab Tech. Am. Bd. of Neuroscience Nursing Practice Analysis for certification Exam update
15
1991 Petrosino, B. unpublished.
Assessment of hospice nurses unique body of knowledge
None
16
1988 Knight, C.F. & Knight, P.F.
None
17
1992 Amenta, M.
Assessment of subject areas important to hospice nursing Certification desired by hospice nurses?
248
None
None
Survey Q w (# not given) Practice theory w NIC as base for Questionnaire items: 3 sections: demographics conditions of patients; NIC as activity statements Delphi 3 rounds #1 open questionnaire. #2 rank #3 rank Delphi 3 rounds as above Survey Needs Assess List of 21 items.
VOLUME 50 • NUMBER 6 NURSING OUTLOOK
A Theoretical Framework for Specialty Certification in Nursing Practice Raudonis and Anderson ...................................................................................................................................
Sample
Variables/concepts
Clinical practice 1500 BSN w 619 returns 1349 w Advanced degrees (Convenience) w 637 returns 3000 w 1200 returns, random ONS members without Advanced degrees
Results
Interpretation of Findings
Frequency (scale from 6-1) 6 ⫽ more than 1x/day to 1⫽ do not perform Importance (scale from 1-5) 1 ⫽ low Frequency (scale from 0-5) Importance (scale 0-3)
Group Comparison Mean & Stnd. Dev. For each group, each item. Then Discriminate analysis per item w Chi-Square for differences between groups. Means and Stnd. Deviations of Frequency & Importance Scores combined ⫽ weighted score, then ranked highest to lowest.
Significance; Measured as a combination of frequency and importance. Scale 0-5 0 ⫽ not necessary, 5 ⫽ very significant Significance One scale 1-4 as comb. of Frequency & Importance Measured frequency (5 pt. scale) of Neuro. disorders; measured frequency (5 pt. scale) & criticality (4 pt. scale) of Interventions. Knowledge, skills, abilities, traits w Scale 1-5 on round 2-3
Mean & Stnd. Dev. on the items Comparative with earlier studies Used a “profile group” whose Asked respondents to allocate demographics equaled exam percentage of examination eligible. Checked for questions/category in conclusion congruence in perspective.
Defined differences in practice Basis for advanced oncology certification examination AOCN credential
Compared with 1992, only small changes in certification examination content, but ordered and identified differently Each of the 7400 random sample Occurrence Significance (Scales not Reviewed ranking of occurrence Cognitive Complexity assigned received 1/3 of items listed) & significance. Made “Decision (recall, application, or analysis) 2000 returns total rules” to determine which items Detailed examination blueprint significant for certification exam Spanish: Importance (scale of 0-4) 0 3 measures of agreement: relative Well selected Advisory Committee Expert Advisory ⫽ not important; 4 ⫽ very index, (product-moment can perform as well as field Spanish Committee 10 sent, 7 important Chemistry: Importance: correlation), absolute index, survey in determining job replied 0-5 0 ⫽ not important, 5 ⫽ very (intraclass correlation) & content needed for licensure in Field 838 sent/423 replied important dichotomous index (cutpoint) teaching specialty classes Chemistry: Committee 8 sent, 7 Dichotomous index provides best replied information for comparison Field 800 sent/329 replied 1600 sent with 577 returns or ⫽ 36.1%
600 w 26.3% ret. Members of Assoc. Genetic Techn. plus selected educators 1500 sent w 430 returned ⫽ 30%
68 w 52 (77%) completing all 3 rounds Practitioners 23 Content Experts from locations across U.S. 16 completed all rounds
Subject Areas to be considered for certification process
1550 self-selected respondents
Administration details, costs, eligibility, sponsorship, etc.
NURSING OUTLOOK
NOVEMBER/DECEMBER 2002
Mean of 2.5 or grtr. Used “decision criteria” for items to be in examination content (Stats not available)
Bloom’s taxonomy recall, application, analysis after complexity ratings applied to items Examination revised NIC as activity statements worked well Began developing neuronursing practice theory Mean & Stand. Dev. on all, then Lead knowledge items: pain, ranked symptom management, comfort, dying, psychosocial Useful for proposed certification process. Mean & Stnd. Dev., Rank order Items 1-10: of 70 items at end of round 3. Pain assessment, First 10 and last 10 didn’t interdisciplinary, pain change management, symptom assessment, hospice concepts, communication skills, patient assessment, nursing diagnosis, ethical issues 90% endorsed idea Not generalizable RT to sampling Strong mandate
249
Raudonis and Anderson ................................................................................................................................... A Theoretical Framework for Specialty Certification in Nursing Practice
Figure 1. Kane’s theory: model-based practice analysis and test specifications presented as a map.
statements placed in rank order. At the most a complex formula is applied to test relative weights and discriminate which items are worth including on the examination. (5) The panel of subject matter experts determines what adjustments to the content of the certification examination are needed on the basis of the study results. However, in studies from the fields of oncology and neuroscience, nurses demonstrated that purposes for doing practice/ job analysis can be amplified to provide feedback to the larger body of nursing knowledge. McMillan et al8 wanted to distinguish the practice patterns of the oncologic nurse generalist from that of the advanced practice nurse. They reported that no “precedents for this type of study were found in the research literature.” In that study,8 a theoretical model of practice became the foundation for the questionnaire so that outcomes of the study supported the validity and completeness of the model. On the basis of that success, the 1997 study9 by the same investigators used the elements of the nursing process with concerns of cancer patients to construct the job analysis questionnaire. The study results provided clarity about the relationships between each of the elements of the nursing process and the concerns of cancer patients, which were usable to the certification process and became the vehicle of communication with nurse managers and others who wanted practice definitions for the basic oncologic nurse. Goddard’s14 presentation demonstrated that it is possible to bring some uniformity to the process of job analysis, yet remain true to a specialty. The use of selected Nursing Intervention 250
Classification (NIC) statements18 as questionnaire items had not been done before. There would seem to be great potential value in this mode of study. If each specialty used a common base upon which to respond, such as the Nursing Intervention Classification, the areas of common practice and differences between specialty groups would become clear. The isolated purpose and usefulness of job analysis information have been a limitation of the research in this area thus far. Often, results are not published or appear in an organizational newsletter or other obscure format. Currently, each specialty approaches the process with a degree of freedom to design the process to meet its purposes. This allows flexibility and some sense of ownership of the process but does not promote comparison of results that can be generalized beyond that specialty. Because new questionnaires are designed each time a study is done, comparison is difficult, even within the same specialty.9 Standardization of the process of practice analysis, at least among nursing specialties, could promote camaraderie and healthy comparison. Perhaps the differences could be bridges rather than walls. Understanding the theoretical framework and model supporting practice analysis is the first step in the standardization process. DEVELOPMENT OF THE FRAMEWORK
A theoretical framework for role a delineation study or job analysis was developed by Dr Michael Kane of the University of VOLUME 50 • NUMBER 6 NURSING OUTLOOK
Raudonis and Anderson ................................................................................................................................... A Theoretical Framework for Specialty Certification in Nursing Practice
Figure 2. Application of Kane’s theory in the Hospice and Palliative Nursing Role Delineation Study.
Wisconsin at Madison to address the chain of inference inherent in the licensure and certification test development process. Kane’s19 article, “Model-Based Practice Analysis and Test Specifications,” proposes that a practice model appropriate to the specialty should be the basis for data collection during practice analysis. Kane proposes that work settings; the activities performed in those settings; and the competencies in judgment, skills, and knowledge needed to perform those activities constitute the elements of a practice model. He theorizes that the results from the analysis will have an empirical relationship to the practice, the practice framework may become validated, and the content validity of the examination is defensible.19 Theoretical Framework
Kane19 presents his theory with the 4 following mathematical statements. 1. ⌺P(Si) ⫽ 1. (The whole group of practitioners [1] represents the sum of the practitioners [P] in each setting [Si]). 2. P(ajsi) ⫽ P(aj l si) ⫻ P(si). (The relative frequency with which practitioners perform activity [aj], given that they work in setting si can be represented by P [aj l si]. The value NURSING OUTLOOK
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of P [aj l si] can be thought of as the conditional probability of aj, given si). 3. P(aj) ⫽ ⌺P(aj lsi) ⫻ P(si). (Therefore, across all settings, the probability or relative frequency of any given activity is directly related to the setting). 4. I(ck) ⫽ ⌺I(ckajsi) ⫻ P(ajsi) ⫽ ⌺I(ckajsi) ⫻ P(ajsi) ⫻ P(si). (I [ck] can reasonably be defined as a weighted average, over activities and settings of I [ck aj si], the importance of category ck in performing activity aj in setting si. In this general formulation, I [ck, aj, si] represents the relative importance, or criticality, of competency category, ck, for activity aj in setting si. The estimated value of I [ck] provides a reasonable weight for the category, ck, in test specifications based on the competency categories). Kane’s theory, presented as a map, is illustrated in Fig 1. The map clarifies the process of the practice analysis and development of the certification test’s specifications. APPLICATION OF KANE’S MODEL TO NURSING PRACTICE
Kane’s model was the theoretical framework for the Hospice and Palliative Care Nursing Role Delineation Study.3 Fig 2 251
A Theoretical Framework for Specialty Certification in Nursing Practice Raudonis and Anderson ...................................................................................................................................
illustrates the National Board for Certification of Hospice Nurse’s (NBCHN) use of role delineation on the basis of Kane’s theory. The role delineation process implemented by NBCHN is described in detail elsewhere.3 The conceptual definitions for the components of Kane’s model are clearly defined in his article.19 However, to demonstrate the clinical relevance of Kane’s theory, the Hospice and Palliative Nursing Role Delineation Study will be used to illustrate the application of the conceptual definitions and propositions of Kane’s theoretical framework. The purpose of the role delineation study was to determine the core activities occurring in nursing practice in end-of-life care in any setting. The Advisory Committee, which consisted of nursing experts in end of life care, identified the descriptive categories of activities that described current end-of-life nursing practice. The activity statements within the categories specified the knowledge, skill, judgment, and competencies required to perform each activity. In addition, the statements were evaluated in relation to their frequency and significance to end of life care. Together these components form a practice model. The practice model provided a preliminary, working hypothesis, or theory, about what constituted nursing practice in end-of-life care and a framework for collecting and analyzing data in the role delineation process.19 At the end of the survey, participants evaluated the adequacy of the instrument. Ninety-eight percent of the respondents were satisfied that the instrument adequately described nursing care provided by hospice and palliative care nurses at the end of life.3 The results of the data analysis from the survey provided a practice description that was basically the same for hospice and non-hospice palliative nurses who participated in the role delineation study. The NBCHN concluded that the nursing practice of hospice and palliative nurses was not substantially different. Therefore, only 1 certification examination will be offered, and the credential was changed to Certified Hospice and Palliative Nurse (CHPN).3 DISCUSSION
Clinical nursing practice is dynamic. As practice changes occur, certification boards must monitor these changes and evaluate certification examinations in light of current practice. The use of periodic role delineation studies is 1 strategy for monitoring this change and keeping the examination, offering expert recognition, in step with the latest knowledge, research, and best practices of the specialty. The work of the Hospice and Palliative Nursing Role Delineation Study and the subsequent results demonstrate that Kane’s model can be used empirically to guide and define clinical practice. Nurse scientists and theorists have repeatedly called for the development of theory-based nursing practice. Theory-based nursing practice provides nurses with a context to view, analyze, and interpret the patient’s situation and the hundreds of pieces of data collected daily. Use of a theoretical perspective enables nurses to purposefully and proactively plan their patients’ care.20 In addition, clinical practice guidelines on the basis of the findings of research studies are forming the foundation of “best prac252
tices.” A major outcome of these efforts is the growing body of nursing science. Therefore, we propose that because certification is an accepted recognition of clinical expertise and competence, the role delineation process and resulting certification examinations should have their basis on a theoretical foundation. The NBCHN study demonstrated that Kane’s theory can serve as the theoretical foundation for job analysis/role delineation studies in nursing practice. The authors thank Carolyn Cason, PhD, RN, for her thoughtful critique and encouragement in the preparation of this manuscript.
............................................................ REFERENCES
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