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Columbia University's competency and evidence-based Acute Care Nurse Practitioner Program
Columbia University’s Competency and Evidence-based Acute Care Nurse Practitioner Program ................................................................................... Christine R. Curran, PhD, RN, CNA W. Dan Roberts, MS, ACNP-CS
New clinical information is being generated faster than practicing clinicians can effectively assimilate it. Since the gold standard of clinical information is evidence-based information, tools and techniques that facilitate both the building of evidence for practice and the application of evidence to practice are essential for practicing clinicians. As such, the Acute Care Nurse Practitioner (ACNP) program at Columbia University’s School of Nursing was reconfigured to incorporate both theoretically based competency evaluation standards and strategies to foster an evidence-based practice approach to clinical care. The purpose of this article is to describe a curriculum and set of learning activities used to foster both development of clinical competency and evidence-based practice in students in the Acute Care Nurse Practitioner program.
N
ew clinical information is being generated faster than practicing clinicians can effectively assimilate it. The daily need for valid, reliable, and up-to-date information on preventative therapies, diagnoses, prognoses, and interventions is a significant driving force behind the evidence-based practice (EBP) movement. Evidence-based health care is about applying the best available evidence to a specific patient care situation.1 Sackett et al2 define EBP as “the integration of best research evidence with clinical expertise and patient values.” Clinical evidence is both built from practice and applied to practice. Thus developing clinical expertise is as important as
Christine R. Curran is director of Nursing Informatics and Research, Ohio State University Medical Center, and clinical associate professor, College of Nursing, Ohio State University Columbus, Ohio. W. Dan Roberts is an assistant professor of clinical nursing, director of the Acute Care Nurse Practitioner (ACNP) program, and a doctoral student at Columbia University, School of Nursing, New York. Reprint requests: Christine R. Curran, PhD, RN, CNA, 1585 Neil Ave, Columbus, OH 43210-1289. NOTE: At the time the article was written, Curran was an assistant professor and director of the Informatics Program at Columbia University School of Nursing, New York. She also was the director of the Acute Care Nurse Practitioner (ACNP) program at the School of Nursing before W. Dan Roberts assumed the position.
Nurs Outlook 2002;50:232-237. © 2002 Mosby, Inc. All rights reserved. 0029-6554/2002/$35.00 ⫹ 0 35/1/128884 doi:10.1067/mno.2002.128884 232
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learning research assessment and utilization skills for one to achieve EBP. According to DiCenso et al,1 “clinical expertise is the crucial element that separates evidence-based nursing from cookbook nursing and the mindless application of rules and guidelines.” Nurse practitioner students need to develop both clinical competency and skills in providing EBP care. The current literature is only marginally helpful in understanding how to achieve these goals. Articles that describe an advanced practice curriculum supportive of EBP or one that uses national standards for assessing clinical competency are rare.3,4 Of the articles that describe a curriculum specific to the acute care nurse practitioner (ACNP), none speak directly about EBP content or skills.5-8 Only 1 article9 describes competency assessment on the basis of national standards, but this article is specific to 1 course and not a full curriculum. The ACNP program at Columbia University’s School of Nursing was reconfigured to incorporate both theoretically based competency evaluation standards and strategies to foster an EBP approach to clinical care. The purpose of this article is to describe a curriculum and set of learning activities used to foster both development of clinical competency and EBP in the ACNP student. THE ACNP CURRICULUM
The 47-credit masters ACNP program consists of core courses, supporting sciences, and specialty courses (Table 1). Core courses and supporting sciences for all nurse practitioners (NPs), regardless of specialty, include physiology, pathophysiology, pharmacology, introduction to primary care, advanced physical assessment, genetics, health and social policy, and theory and research. Theory and research are integrated because the philosophy of the school is that master’s-prepared practitioners are consumers of research and not necessarily originators of it. Thus understanding how theory and research are linked is critical as well as application of theory and research findings to practice. In addition, students take 3 of 4 possible “intensive” courses. These are focused 1-credit courses that have broad applicability for all practitioners and are offered in the following areas: nutrition across the lifespan, interpersonal violence, behavioral health care for advanced practice, and management of advance practice. The ACNP specialty didactic courses comprise 24 of the 47 credits. The didactic courses include Diagnosis and ManageVOLUME 50 • NUMBER 6 NURSING OUTLOOK
Columbia University’s Competency and Evidence-based Acute Care Nurse Practitioner Program Curran and Roberts ...................................................................................................................................
Table 1. ACNP Curriculum
Table 2. Case Presentation Format
Core Courses ● Theory and Research in Nursing and Applied Science ● Health and Social Policy: Context in Practice and Research ● Introduction to Primary Care ● 3 of the 4 below “intensives” (1 credit courses) 䡩 Nutrition through the Lifespan 䡩 Interpersonal Violence and Abuse 䡩 Behavorial Health Care in Advanced Practice Nursing 䡩 Management in Advanced Practice Supporting Sciences ● Advanced Physiology ● Pathophysiology (adult) ● Advanced Pharmacology ● Incorporating Genetics into Advanced Practice Nursing Specialty Courses ● Advanced Clinical Assessment ● Advanced Clinical Assessment: Acute Care* ● Diagnosis and Management of the Acutely Ill Adult: 1 ● Practicum in Acute Care* ● Diagnosis and Management of the Acutely Ill Adult: 2 ● Advanced Practicum in Acute Care* ● Acute Care Integration ● Acute Care Integration Practicum*
Time Limit: 30 minutes Choose a unique patient or treatment While the patient may have multiple problems, the focus of the case presentation should be limited to one exceptional disease state that offers a unique learning opportunity. The student must present the case orally to the class, using all appropriate visuals, as well as write-up the case presentation for submission to the faculty. The purpose of the case presentation is to allow the student 1) a teaching opportunity in oral presentation and development of differential diagnosis through dialogue with an interacting peer group. 2) another opportunity to write-up a comprehensive H&P 3) a learning experience in the use of the current Guidelines for Evaluation and Management Services that educates the student on the billing aspects of practice. First 5-10 minutes: Give a brief synopsis Documentation of History ● CC ● HPI (9 cardinals) 䡩 Onset 䡩 Timing 䡩 Duration 䡩 Quality 䡩 Associating Symptoms 䡩 Alleviating Symptoms 䡩 Aggravating Symptoms 䡩 Previous Experience (have you had it before/been treated for it before) 䡩 What have you done for it ● PMH 䡩 Medical Diagnoses only 䡩 Dates ● ROS ● FSSH (Family, Social, Surgical) Documentation of Physical Examination ● Physical Examination (General Multisystem exam) ● System specific database 䡩 Clinical findings 䡩 Tests/procedures (with supporting data) Documentation of the Complexity of Medical Decision Making (write-up only) Current Treatment ● Discussion (oral presentation only) 䡩 Class Discussion of Differential Diagnosis (Includes rational for in/out) ● Treatment Discussion 䡩 Best Practice for Treatment of Diagnosis (Evidence Base Practice)
Note: *Designates a clinical course.
ment of the Acutely Ill Adult 1 and 2 and ACNP Role Integration. The role integration course focuses on the professional and administrative aspects of being an NP (eg, how to develop a collaborative practice agreement, the American Nurses Association scope and standards of practice,10 and ethical/legal issues). There are 4 ACNP-specific clinical courses that provide a total of 720 hours of clinical time. The clinical courses are held concurrently with the didactic advanced clinical assessment course and each of the 3 didactic specialty courses previously mentioned. The initial clinical course focuses on mastering the skills of advanced physical assessment of acutely ill adults and the documentation process for NPs. This includes history taking, physical examination, and clinical decision making in either an emergency room or an intensive care setting. The student spends 60 hours in clinical time this semester. During this and subsequent semesters, students are expected to present the patient’s history and physical examination in adherence to the Evaluation and Management (E&M) Coding guidelines for the general assessment. Early introduction of the E&M guidelines is important because not only do they provide a framework for the student to document efficiently on the basis of a national standard but they also are the standard that drives reimbursement for practitioners in the practice setting. Thus, students begin to learn some of the business principles of managing a practice as well as those for delivering quality patient care. The second and third clinical courses correlate with the diagnosis and management content. Each course requires 180 hours of clinical time. This content is presented by body system. The diagnostic tools, pathophysiologic findings, and diagnosis NURSING OUTLOOK
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and management of the most common problems/conditions are discussed in depth. Students present weekly questions from their clinical experience in an appropriate, researchable question format; a clinical case of a unique learning experience; and a short EBP paper written on the basis of their clinical experiences that semester. Expectations of the (E&M)11 schema are also incorporated into the clinical portion of these 2 semesters. The clinical case is used as a teaching tool to reinforce and emphasize the ability to appropriately bill for services according to the E&M guidelines. 233
Columbia University’s Competency and Evidence-based Acute Care Nurse Practitioner Program Curran and Roberts ...................................................................................................................................
Table 3. Sample Mini Practicum Module Radiography: Chest X-ray Evaluation Tool Purpose: The purpose of this clinical rotation is for the student to gain experience utilizing the chest x-ray as a diagnostic tool. The clinical time should be used as a general review of the following information: normal anatomy, position and placement of medical devices, and pathophysiology. Objectives: At the completion of this clinical rotation, the student, utilizing a systematic approach to chest x-ray interpretation (A.I.R.: anatomy, inhalation, rotation; Five “P’s”: patient’s projection, pump, pleura, parenchyma, plastic; or other mnemonic), will be able to: 1. Identify the four basic densities of radiography: metal/bone, fat, water, and air and describe examples of each density 2. Identify normal anatomy of the chest x-ray 3. Identify medical devices with commentary on the utilization of the device and its correct positioning, if appropriate 4. Identify the following pathophysiological states: a. Pneumonia b. Pleural effusion(s) c. Pneumothorax/Hemothorax d. Unilateral elevation of the diaphragm e. Pulmonary edema 5. Utilizing a systematic approach or a process-related approach, develop a differential diagnosis for the given x-ray interpretation. Evaluation: Describe the student’s preparedness, knowledge, participation, and performance for this clinical rotation:
Faculty evaluate this decision as part of the grade for this exercise. The final clinical course is an integration practicum. The student is placed with a specifically selected ACNP to integrate all previous didactic and clinical experiences as well as components of the ACNP role. The student spends 20 hours per week in the clinical setting. Multiple case presentations, presentation of patients on clinical rounds, and an ever-increasing ability to practice independently are required during this semester. By the end of the semester, students are expected to need only minimal clinical guidance or assistance to competently practice. The preceptors chosen essentially provide an “expert vigilance only role” during the student’s rotation. Their knowledgeable oversight prevents fundamental or consequential errors by the student but also fosters autonomy in the student’s practice. EBP COMPONENTS
ACNP students need to master both building evidence from practice as well as applying evidence to practice. Building evidence from clinical practice includes accumulating individual patient data within a case, assembling cases by an individual practitioner, and analyzing cases between practitioners (ie, across patient populations). Processes of EBP include asking an answerable question; identifying, critically evaluating, and applying relevant research findings; integrating research, experiential knowledge, and personal knowledge of the patient (which includes integrating patient preferences into decisionmaking processes); and evaluating performance after application of evidence.2,12,13 Students learn these skills in the following ways: ● They are required to be in the clinical setting for at least 2 consecutive days (at a minimum) to accumulate individual 234
patient data, have more time to get to know their patient, and see the results of orders they initiated the previous day. ● Students maintain electronic clinical logs of all patients that use consistent data elements. Common data definitions and standardized terminologies for diagnoses and interventions are used to demonstrate and facilitate aggregation of data across patients for each student. ● In the near future, once a common data repository of student clinical cases is developed, patients will be aggregated between students, reports generated, and learning activities related to use of database information from practice will be added to the curriculum. Building evidence across research protocols is another aspect of building evidence for practice.14 Since a clinical question precedes the search for evidence, students are expected to generate questions each week from their clinical experiences. Feedback is given by the faculty to help the student learn how to structure searchable questions for current best practice. Students learn how to build their research knowledge about specific topics through several short EBP papers and in literature searches done when they are preparing for case presentations. In addition, they are given the opportunity to experience the use of online knowledge bases, such as those in the Cochrane Library, and the managing of literature with bibliographic referencing tools (eg, Endnote). Applying research evidence to practice involves use of valid and reliable research findings and systematic reviews. Students apply these research findings to clinical cases and case presentations. Students are required to offer current EBP when presenting their patient(s) during each clinical rotation. Table 2 depicts the content required within a case presentation. VOLUME 50 • NUMBER 6 NURSING OUTLOOK
Columbia University’s Competency and Evidence-based Acute Care Nurse Practitioner Program Curran and Roberts ...................................................................................................................................
Table 4. Sample Evaluation Page Columbia University
Student Preceptor (with credentials) Clinical Site
School of Nursing Clinical Evaluation M8825: Acute Care Integration Practicum Semester/Year Phone # # of clinical hours
Instructions: For each competency, the preceptor should circle the number that best represents the student’s level of performance at the end of this rotation. Domain 1: Management of Patients’ Health/Illness Status Obtains a complete problem focused health history from the patient. Performs a comprehensive and/or problem focused physical examination. Identifies and interprets normal, variations of normal and abnormal findings. Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to develop appropriate differential diagnosis. Formulates and maintains a problem list. Formulates a plan of care based on scientific rationale (i.e., evidence based best practices/standards). Orders appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, acceptability, adherence and efficacy. Prioritizes health problems and intervenes appropriately. Monitors and manages complex, unstable and emergent conditions considering patient’s response to his/her condition and therapies. Follows up on and evaluates therapies/orders initiated to assure that patients receive the appropriate care. Correctly identifies and manages emergent situations. Initiates appropriate and timely consultation and/or referrals when the problem exceeds the NPs scope of practice and/or expertise. Demonstrates critical thinking and diagnostic reasoning skills in clinical decision making. Demonstrates knowledge of the pathophysiology of diseases or conditions commonly seen in acute care. Demonstrates population based thinking by recognizing populations at risk, patterns of diseases and effectiveness of therapies over multiple patients.
1 2 requires guidance 1 2 Incomplete 1 2 requires guidance 1 2 requires guidance
3
4
3
4
3
4
3
4
1 2 requires guidance 1 2 requires guidance 1 2 requires guidance
3
4
3
4
3
4
1 2 requires guidance 1 2 requires guidance
3
4
3
4
1 2 requires guidance 1 2 requires guidance 1 2 does not meet standard
3
4
3
4
3
4
1 2 requires guidance 1 2 insufficient 1 2 requires guidance
3
4
3
4
3
4
Incorporating skills in EBP provides a framework for lifelong learning. Mastering skills in framing questions and gathering, analyzing, and applying evidence to practice as well as building evidence from one’s own practice, both at the individual and aggregate levels, will serve the graduate of any NP program well in the future. As a summary learning activity and evidence of mastering the process of EBP, students, for their final semester major master’s paper, are expected to select a condition of their choice, develop a state of the science paper on this condition (ie, accumulate research evidence), derive the “best practices” from the evidence to date, and apply this knowledge to their practice as an ACNP. NURSING OUTLOOK
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5 independent 5 complete 5 independent 5 independent 5 independent 5 independent 5 independent 5 independent 5 independent 5 independent 5 independent 5 meets standard 5 independent 5 sufficient 5 independent
CLINICAL COMPETENCY Knowledge and Skill Acquisition
Both theoretical and practical knowledge are needed to develop clinical expertise.15 Whereas a large part of the theoretical knowledge is gained in the traditional classroom setting, the roles of the clinical preceptor and peer group should be valued in enhancing theoretical, rather than only practical, knowledge. Case presentations are expected to be a peer review-and-discussion exercise. Students are expected to choose a unique patient or treatment and orally present the chief complaint, history of present illness, and relevant clinical data (eg, radiographic stud235
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ies). Once this information is presented, the student then seeks participation from the audience (their peers) in developing differential diagnoses and ultimately in deciding what the audience believes is a correct final clinical diagnosis from the information presented. Once all potential diagnoses are discussed, the presentation continues with the student revealing the appropriate diagnosis, the treatment ordered, and the follow-up of the patient after treatment. Students are expected to present the most current research data for their presentation. Students distribute a 1-page synopsis of their patient with the following information: (1) patient data, (2) the searchable question for this unique case, (3) the search strategy used, (4) the critique of the evidence found (including the articles), and (5) the final treatment recommendation made on the basis of evidence from the literature. Preceptors are expected to demonstrate the use of valid and reliable clinical and reference information at the point of care, (eg, use of a database such as Up-to-Date) and practice protocols and share their patient tracking methodology with the student. Preceptors encourage knowledge development and application when role-modeling the use of different databases and protocols in use within their site-specific patient populations. Students are exposed to both physicians and nurse practitioners as preceptors. This assists in the development of collaborative skills as well as providing a broad view of perspectives in clinical management. Procedural learning occurs best in the clinical arena.16 For educational programs, such as the ACNP program, priority has been placed on coordinating service-based modular learning experiences early in the program for procedures viewed as fundamental knowledge and skills required to practice as an NP in the acute care setting. Focused educational opportunities were developed for reading chest x-rays, computed tomography scans, and magnetic resonance images; sampling and analyzing arterial blood gases; inserting arterial catheters; observing and analyzing pulmonary function studies; interpreting electrocardiograms; performing cardioversions and pacing patients; inserting central venous catheters; managing airways and ventilator parameters; assessing renal function and need for hemodialysis; assessing nutritional status; and managing infectious diseases. Students spend between 4 to 12 hours of concentrated time completing specific objectives for each module (see Table 3 for a sample module). Since students spend time in the radiology department, pulmonary function laboratory, electrophysiology laboratory, etc, for these experiences, the modules involve members of the interdisciplinary team in the ACNP program. Likewise, students have the opportunity to collaborate and coordinate with these other disciplines in a role different from their “pre-NP” nursing role. Competency Evaluation
Clinical competencies for student evaluation are done on the basis of the NONPF Domains and Competencies of Nurse Practitioner Practice17 as well as additional competencies added by the authors related to EBP (see Table 4 for a sample page). 236
Competencies required of all NPs include knowing both individual patients and patient populations; being “systems” competent; practicing collaboratively; and making autonomous, sound decisions. NPs also need to know the economics of the health care delivery system and how to measure and communicate the “value-add” of their role to patient care delivery and outcomes of care.16 Payors, chief nurse executives, chief executive officers, and physicians need to understand and respect the significant contributions of the ACNP in delivery of care. SUMMARY
The gold standard of clinical information is evidence-based information. As such, it is important that our NP students understand what EBP is and how to both build evidence from practice and use evidence in practice. In addition, the use of national standards as we have done to assess competencies allows for comparison of outcomes within and among students. This revised curriculum integrates the necessary EBP and competency components to achieve these goals. 䡲
............................................................ REFERENCES
1. DiCenso A, Ciliska D, Marks S, McKibbon A, Cullum N, Thompson C. Evidence-based nursing (CD). In: Sackett DL, Haynes RB, Richardson S, eds. Evidence-based medicine, 2nd ed. New York: Churchill Livingstone; 2000. 2. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to teach and practice EBM, 2nd ed. New York: Churchill Livingstone; 2000. 3. Sebastian JG, Christman NJ, Howard PB, et al. Evidence-based practice and the advanced practice nurse: a curriculum for the future. Semin Periop Nurs 2000;9:143-8. 4. Price MJ, Martin AC, Newberry YG, Zimmer PA, Brykczynski KA, Warren B. Developing national guidelines for nurse practitioner education: an overview of the product and the process. J Nurs Educ 1992;31:10-15. 5. Simpson B. An educational partnership to develop acute care nurse practitioners. Can J Nurs Adm 1997;Jan-Feb:69-84. 6. Watts RJ. The critical care nurse practitioner curriculum at the University of Pennsylvania: update and revision. AACN Clin Issues 1997;8:116-22. 7. King JE, Lancaster L, Pierce J, Norman LD. Removing the walls and expanding the boundaries: a curriculum model for acute care nurse practitioners. N&HC: Perspectives on Community 1996;17:304-7. 8. Hravnak M, Kobert SN, Risco KG, et al. Acute care nurse practitioner curriculum: content and development process. Am J Crit Care 1995;4:179-88. 9. Hollinger-Smith L, Murphy MP. Implementing a residency program for the acute care nurse practitioner. MedSurg Nurs 1998;7:28-38. 10. American Nurses Association. Standards of clinical practice and scope of practice for the acute care nurse practitioner. Washington: American Nurses Publishing; 1995. 11. Centers for Medicare and Medical Services, 1997 documentation guidelines for evaluation and management services. Available at: http://cms.hhs.gov/medlearn/emdoc.asp. 12. Rolfe G. Insufficient evidence: the problems of evidence-based nursing. Nurse Educ Today 1999;19:433-42. 13. Friedland DJ, ed. Evidence-based medicine: framework for clinical practice. Stamford (CT): Appleton & Lange; 1998. VOLUME 50 • NUMBER 6 NURSING OUTLOOK
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Columbia University’s Competency and Evidence-based Acute Care Nurse Practitioner Program 14. Bakken S. An informatics infrastructure is essential for evidencebased practice. J Am Med Informatics Assoc 2001;8:199-201. 15. Benner P. From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley; 1984. 16. Gilliss C, Mundinger MO. How is the role of the advanced practice
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nurse changing?. In: O’Neil E, Coffman J, eds. Strategies for the future of nursing. San Francisco: Jossey-Bass Publishers; 1998. 17. National Organization of Nurse Practitioner Faculties. Domains and competencies of nurse practitioner practice. Washington: Author; 2000.
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New clinical information is being generated faster than practicing clinicians can effectively assimilate it. Since the gold standard of clinical information is evidence-based information, tools and techniques that facilitate both the building of evidence for practice and the application of evidence to practice are essential for practicing clinicians. As such, the Acute Care Nurse Practitioner (ACNP) program at Columbia University’s School of Nursing was reconfigured to incorporate both theoretically based competency evaluation standards and strategies to foster an evidence-based practice approach to clinical care. The purpose of this article is to describe a curriculum and set of learning activities used to foster both development of clinical competency and evidence-based practice in students in the Acute Care Nurse Practitioner program.
N
ew clinical information is being generated faster than practicing clinicians can effectively assimilate it. The daily need for valid, reliable, and up-to-date information on preventative therapies, diagnoses, prognoses, and interventions is a significant driving force behind the evidence-based practice (EBP) movement. Evidence-based health care is about applying the best available evidence to a specific patient care situation.1 Sackett et al2 define EBP as “the integration of best research evidence with clinical expertise and patient values.” Clinical evidence is both built from practice and applied to practice. Thus developing clinical expertise is as important as
Christine R. Curran is director of Nursing Informatics and Research, Ohio State University Medical Center, and clinical associate professor, College of Nursing, Ohio State University Columbus, Ohio. W. Dan Roberts is an assistant professor of clinical nursing, director of the Acute Care Nurse Practitioner (ACNP) program, and a doctoral student at Columbia University, School of Nursing, New York. Reprint requests: Christine R. Curran, PhD, RN, CNA, 1585 Neil Ave, Columbus, OH 43210-1289. NOTE: At the time the article was written, Curran was an assistant professor and director of the Informatics Program at Columbia University School of Nursing, New York. She also was the director of the Acute Care Nurse Practitioner (ACNP) program at the School of Nursing before W. Dan Roberts assumed the position.
Nurs Outlook 2002;50:232-237. © 2002 Mosby, Inc. All rights reserved. 0029-6554/2002/$35.00 ⫹ 0 35/1/128884 doi:10.1067/mno.2002.128884 232
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learning research assessment and utilization skills for one to achieve EBP. According to DiCenso et al,1 “clinical expertise is the crucial element that separates evidence-based nursing from cookbook nursing and the mindless application of rules and guidelines.” Nurse practitioner students need to develop both clinical competency and skills in providing EBP care. The current literature is only marginally helpful in understanding how to achieve these goals. Articles that describe an advanced practice curriculum supportive of EBP or one that uses national standards for assessing clinical competency are rare.3,4 Of the articles that describe a curriculum specific to the acute care nurse practitioner (ACNP), none speak directly about EBP content or skills.5-8 Only 1 article9 describes competency assessment on the basis of national standards, but this article is specific to 1 course and not a full curriculum. The ACNP program at Columbia University’s School of Nursing was reconfigured to incorporate both theoretically based competency evaluation standards and strategies to foster an EBP approach to clinical care. The purpose of this article is to describe a curriculum and set of learning activities used to foster both development of clinical competency and EBP in the ACNP student. THE ACNP CURRICULUM
The 47-credit masters ACNP program consists of core courses, supporting sciences, and specialty courses (Table 1). Core courses and supporting sciences for all nurse practitioners (NPs), regardless of specialty, include physiology, pathophysiology, pharmacology, introduction to primary care, advanced physical assessment, genetics, health and social policy, and theory and research. Theory and research are integrated because the philosophy of the school is that master’s-prepared practitioners are consumers of research and not necessarily originators of it. Thus understanding how theory and research are linked is critical as well as application of theory and research findings to practice. In addition, students take 3 of 4 possible “intensive” courses. These are focused 1-credit courses that have broad applicability for all practitioners and are offered in the following areas: nutrition across the lifespan, interpersonal violence, behavioral health care for advanced practice, and management of advance practice. The ACNP specialty didactic courses comprise 24 of the 47 credits. The didactic courses include Diagnosis and ManageVOLUME 50 • NUMBER 6 NURSING OUTLOOK
Columbia University’s Competency and Evidence-based Acute Care Nurse Practitioner Program Curran and Roberts ...................................................................................................................................
Table 1. ACNP Curriculum
Table 2. Case Presentation Format
Core Courses ● Theory and Research in Nursing and Applied Science ● Health and Social Policy: Context in Practice and Research ● Introduction to Primary Care ● 3 of the 4 below “intensives” (1 credit courses) 䡩 Nutrition through the Lifespan 䡩 Interpersonal Violence and Abuse 䡩 Behavorial Health Care in Advanced Practice Nursing 䡩 Management in Advanced Practice Supporting Sciences ● Advanced Physiology ● Pathophysiology (adult) ● Advanced Pharmacology ● Incorporating Genetics into Advanced Practice Nursing Specialty Courses ● Advanced Clinical Assessment ● Advanced Clinical Assessment: Acute Care* ● Diagnosis and Management of the Acutely Ill Adult: 1 ● Practicum in Acute Care* ● Diagnosis and Management of the Acutely Ill Adult: 2 ● Advanced Practicum in Acute Care* ● Acute Care Integration ● Acute Care Integration Practicum*
Time Limit: 30 minutes Choose a unique patient or treatment While the patient may have multiple problems, the focus of the case presentation should be limited to one exceptional disease state that offers a unique learning opportunity. The student must present the case orally to the class, using all appropriate visuals, as well as write-up the case presentation for submission to the faculty. The purpose of the case presentation is to allow the student 1) a teaching opportunity in oral presentation and development of differential diagnosis through dialogue with an interacting peer group. 2) another opportunity to write-up a comprehensive H&P 3) a learning experience in the use of the current Guidelines for Evaluation and Management Services that educates the student on the billing aspects of practice. First 5-10 minutes: Give a brief synopsis Documentation of History ● CC ● HPI (9 cardinals) 䡩 Onset 䡩 Timing 䡩 Duration 䡩 Quality 䡩 Associating Symptoms 䡩 Alleviating Symptoms 䡩 Aggravating Symptoms 䡩 Previous Experience (have you had it before/been treated for it before) 䡩 What have you done for it ● PMH 䡩 Medical Diagnoses only 䡩 Dates ● ROS ● FSSH (Family, Social, Surgical) Documentation of Physical Examination ● Physical Examination (General Multisystem exam) ● System specific database 䡩 Clinical findings 䡩 Tests/procedures (with supporting data) Documentation of the Complexity of Medical Decision Making (write-up only) Current Treatment ● Discussion (oral presentation only) 䡩 Class Discussion of Differential Diagnosis (Includes rational for in/out) ● Treatment Discussion 䡩 Best Practice for Treatment of Diagnosis (Evidence Base Practice)
Note: *Designates a clinical course.
ment of the Acutely Ill Adult 1 and 2 and ACNP Role Integration. The role integration course focuses on the professional and administrative aspects of being an NP (eg, how to develop a collaborative practice agreement, the American Nurses Association scope and standards of practice,10 and ethical/legal issues). There are 4 ACNP-specific clinical courses that provide a total of 720 hours of clinical time. The clinical courses are held concurrently with the didactic advanced clinical assessment course and each of the 3 didactic specialty courses previously mentioned. The initial clinical course focuses on mastering the skills of advanced physical assessment of acutely ill adults and the documentation process for NPs. This includes history taking, physical examination, and clinical decision making in either an emergency room or an intensive care setting. The student spends 60 hours in clinical time this semester. During this and subsequent semesters, students are expected to present the patient’s history and physical examination in adherence to the Evaluation and Management (E&M) Coding guidelines for the general assessment. Early introduction of the E&M guidelines is important because not only do they provide a framework for the student to document efficiently on the basis of a national standard but they also are the standard that drives reimbursement for practitioners in the practice setting. Thus, students begin to learn some of the business principles of managing a practice as well as those for delivering quality patient care. The second and third clinical courses correlate with the diagnosis and management content. Each course requires 180 hours of clinical time. This content is presented by body system. The diagnostic tools, pathophysiologic findings, and diagnosis NURSING OUTLOOK
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and management of the most common problems/conditions are discussed in depth. Students present weekly questions from their clinical experience in an appropriate, researchable question format; a clinical case of a unique learning experience; and a short EBP paper written on the basis of their clinical experiences that semester. Expectations of the (E&M)11 schema are also incorporated into the clinical portion of these 2 semesters. The clinical case is used as a teaching tool to reinforce and emphasize the ability to appropriately bill for services according to the E&M guidelines. 233
Columbia University’s Competency and Evidence-based Acute Care Nurse Practitioner Program Curran and Roberts ...................................................................................................................................
Table 3. Sample Mini Practicum Module Radiography: Chest X-ray Evaluation Tool Purpose: The purpose of this clinical rotation is for the student to gain experience utilizing the chest x-ray as a diagnostic tool. The clinical time should be used as a general review of the following information: normal anatomy, position and placement of medical devices, and pathophysiology. Objectives: At the completion of this clinical rotation, the student, utilizing a systematic approach to chest x-ray interpretation (A.I.R.: anatomy, inhalation, rotation; Five “P’s”: patient’s projection, pump, pleura, parenchyma, plastic; or other mnemonic), will be able to: 1. Identify the four basic densities of radiography: metal/bone, fat, water, and air and describe examples of each density 2. Identify normal anatomy of the chest x-ray 3. Identify medical devices with commentary on the utilization of the device and its correct positioning, if appropriate 4. Identify the following pathophysiological states: a. Pneumonia b. Pleural effusion(s) c. Pneumothorax/Hemothorax d. Unilateral elevation of the diaphragm e. Pulmonary edema 5. Utilizing a systematic approach or a process-related approach, develop a differential diagnosis for the given x-ray interpretation. Evaluation: Describe the student’s preparedness, knowledge, participation, and performance for this clinical rotation:
Faculty evaluate this decision as part of the grade for this exercise. The final clinical course is an integration practicum. The student is placed with a specifically selected ACNP to integrate all previous didactic and clinical experiences as well as components of the ACNP role. The student spends 20 hours per week in the clinical setting. Multiple case presentations, presentation of patients on clinical rounds, and an ever-increasing ability to practice independently are required during this semester. By the end of the semester, students are expected to need only minimal clinical guidance or assistance to competently practice. The preceptors chosen essentially provide an “expert vigilance only role” during the student’s rotation. Their knowledgeable oversight prevents fundamental or consequential errors by the student but also fosters autonomy in the student’s practice. EBP COMPONENTS
ACNP students need to master both building evidence from practice as well as applying evidence to practice. Building evidence from clinical practice includes accumulating individual patient data within a case, assembling cases by an individual practitioner, and analyzing cases between practitioners (ie, across patient populations). Processes of EBP include asking an answerable question; identifying, critically evaluating, and applying relevant research findings; integrating research, experiential knowledge, and personal knowledge of the patient (which includes integrating patient preferences into decisionmaking processes); and evaluating performance after application of evidence.2,12,13 Students learn these skills in the following ways: ● They are required to be in the clinical setting for at least 2 consecutive days (at a minimum) to accumulate individual 234
patient data, have more time to get to know their patient, and see the results of orders they initiated the previous day. ● Students maintain electronic clinical logs of all patients that use consistent data elements. Common data definitions and standardized terminologies for diagnoses and interventions are used to demonstrate and facilitate aggregation of data across patients for each student. ● In the near future, once a common data repository of student clinical cases is developed, patients will be aggregated between students, reports generated, and learning activities related to use of database information from practice will be added to the curriculum. Building evidence across research protocols is another aspect of building evidence for practice.14 Since a clinical question precedes the search for evidence, students are expected to generate questions each week from their clinical experiences. Feedback is given by the faculty to help the student learn how to structure searchable questions for current best practice. Students learn how to build their research knowledge about specific topics through several short EBP papers and in literature searches done when they are preparing for case presentations. In addition, they are given the opportunity to experience the use of online knowledge bases, such as those in the Cochrane Library, and the managing of literature with bibliographic referencing tools (eg, Endnote). Applying research evidence to practice involves use of valid and reliable research findings and systematic reviews. Students apply these research findings to clinical cases and case presentations. Students are required to offer current EBP when presenting their patient(s) during each clinical rotation. Table 2 depicts the content required within a case presentation. VOLUME 50 • NUMBER 6 NURSING OUTLOOK
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Table 4. Sample Evaluation Page Columbia University
Student Preceptor (with credentials) Clinical Site
School of Nursing Clinical Evaluation M8825: Acute Care Integration Practicum Semester/Year Phone # # of clinical hours
Instructions: For each competency, the preceptor should circle the number that best represents the student’s level of performance at the end of this rotation. Domain 1: Management of Patients’ Health/Illness Status Obtains a complete problem focused health history from the patient. Performs a comprehensive and/or problem focused physical examination. Identifies and interprets normal, variations of normal and abnormal findings. Analyzes and interprets history, presenting symptoms, physical findings, and diagnostic information to develop appropriate differential diagnosis. Formulates and maintains a problem list. Formulates a plan of care based on scientific rationale (i.e., evidence based best practices/standards). Orders appropriate diagnostic and therapeutic interventions and regimens with attention to safety, cost, invasiveness, acceptability, adherence and efficacy. Prioritizes health problems and intervenes appropriately. Monitors and manages complex, unstable and emergent conditions considering patient’s response to his/her condition and therapies. Follows up on and evaluates therapies/orders initiated to assure that patients receive the appropriate care. Correctly identifies and manages emergent situations. Initiates appropriate and timely consultation and/or referrals when the problem exceeds the NPs scope of practice and/or expertise. Demonstrates critical thinking and diagnostic reasoning skills in clinical decision making. Demonstrates knowledge of the pathophysiology of diseases or conditions commonly seen in acute care. Demonstrates population based thinking by recognizing populations at risk, patterns of diseases and effectiveness of therapies over multiple patients.
1 2 requires guidance 1 2 Incomplete 1 2 requires guidance 1 2 requires guidance
3
4
3
4
3
4
3
4
1 2 requires guidance 1 2 requires guidance 1 2 requires guidance
3
4
3
4
3
4
1 2 requires guidance 1 2 requires guidance
3
4
3
4
1 2 requires guidance 1 2 requires guidance 1 2 does not meet standard
3
4
3
4
3
4
1 2 requires guidance 1 2 insufficient 1 2 requires guidance
3
4
3
4
3
4
Incorporating skills in EBP provides a framework for lifelong learning. Mastering skills in framing questions and gathering, analyzing, and applying evidence to practice as well as building evidence from one’s own practice, both at the individual and aggregate levels, will serve the graduate of any NP program well in the future. As a summary learning activity and evidence of mastering the process of EBP, students, for their final semester major master’s paper, are expected to select a condition of their choice, develop a state of the science paper on this condition (ie, accumulate research evidence), derive the “best practices” from the evidence to date, and apply this knowledge to their practice as an ACNP. NURSING OUTLOOK
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5 independent 5 complete 5 independent 5 independent 5 independent 5 independent 5 independent 5 independent 5 independent 5 independent 5 independent 5 meets standard 5 independent 5 sufficient 5 independent
CLINICAL COMPETENCY Knowledge and Skill Acquisition
Both theoretical and practical knowledge are needed to develop clinical expertise.15 Whereas a large part of the theoretical knowledge is gained in the traditional classroom setting, the roles of the clinical preceptor and peer group should be valued in enhancing theoretical, rather than only practical, knowledge. Case presentations are expected to be a peer review-and-discussion exercise. Students are expected to choose a unique patient or treatment and orally present the chief complaint, history of present illness, and relevant clinical data (eg, radiographic stud235
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ies). Once this information is presented, the student then seeks participation from the audience (their peers) in developing differential diagnoses and ultimately in deciding what the audience believes is a correct final clinical diagnosis from the information presented. Once all potential diagnoses are discussed, the presentation continues with the student revealing the appropriate diagnosis, the treatment ordered, and the follow-up of the patient after treatment. Students are expected to present the most current research data for their presentation. Students distribute a 1-page synopsis of their patient with the following information: (1) patient data, (2) the searchable question for this unique case, (3) the search strategy used, (4) the critique of the evidence found (including the articles), and (5) the final treatment recommendation made on the basis of evidence from the literature. Preceptors are expected to demonstrate the use of valid and reliable clinical and reference information at the point of care, (eg, use of a database such as Up-to-Date) and practice protocols and share their patient tracking methodology with the student. Preceptors encourage knowledge development and application when role-modeling the use of different databases and protocols in use within their site-specific patient populations. Students are exposed to both physicians and nurse practitioners as preceptors. This assists in the development of collaborative skills as well as providing a broad view of perspectives in clinical management. Procedural learning occurs best in the clinical arena.16 For educational programs, such as the ACNP program, priority has been placed on coordinating service-based modular learning experiences early in the program for procedures viewed as fundamental knowledge and skills required to practice as an NP in the acute care setting. Focused educational opportunities were developed for reading chest x-rays, computed tomography scans, and magnetic resonance images; sampling and analyzing arterial blood gases; inserting arterial catheters; observing and analyzing pulmonary function studies; interpreting electrocardiograms; performing cardioversions and pacing patients; inserting central venous catheters; managing airways and ventilator parameters; assessing renal function and need for hemodialysis; assessing nutritional status; and managing infectious diseases. Students spend between 4 to 12 hours of concentrated time completing specific objectives for each module (see Table 3 for a sample module). Since students spend time in the radiology department, pulmonary function laboratory, electrophysiology laboratory, etc, for these experiences, the modules involve members of the interdisciplinary team in the ACNP program. Likewise, students have the opportunity to collaborate and coordinate with these other disciplines in a role different from their “pre-NP” nursing role. Competency Evaluation
Clinical competencies for student evaluation are done on the basis of the NONPF Domains and Competencies of Nurse Practitioner Practice17 as well as additional competencies added by the authors related to EBP (see Table 4 for a sample page). 236
Competencies required of all NPs include knowing both individual patients and patient populations; being “systems” competent; practicing collaboratively; and making autonomous, sound decisions. NPs also need to know the economics of the health care delivery system and how to measure and communicate the “value-add” of their role to patient care delivery and outcomes of care.16 Payors, chief nurse executives, chief executive officers, and physicians need to understand and respect the significant contributions of the ACNP in delivery of care. SUMMARY
The gold standard of clinical information is evidence-based information. As such, it is important that our NP students understand what EBP is and how to both build evidence from practice and use evidence in practice. In addition, the use of national standards as we have done to assess competencies allows for comparison of outcomes within and among students. This revised curriculum integrates the necessary EBP and competency components to achieve these goals. 䡲
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1. DiCenso A, Ciliska D, Marks S, McKibbon A, Cullum N, Thompson C. Evidence-based nursing (CD). In: Sackett DL, Haynes RB, Richardson S, eds. Evidence-based medicine, 2nd ed. New York: Churchill Livingstone; 2000. 2. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to teach and practice EBM, 2nd ed. New York: Churchill Livingstone; 2000. 3. Sebastian JG, Christman NJ, Howard PB, et al. Evidence-based practice and the advanced practice nurse: a curriculum for the future. Semin Periop Nurs 2000;9:143-8. 4. Price MJ, Martin AC, Newberry YG, Zimmer PA, Brykczynski KA, Warren B. Developing national guidelines for nurse practitioner education: an overview of the product and the process. J Nurs Educ 1992;31:10-15. 5. Simpson B. An educational partnership to develop acute care nurse practitioners. Can J Nurs Adm 1997;Jan-Feb:69-84. 6. Watts RJ. The critical care nurse practitioner curriculum at the University of Pennsylvania: update and revision. AACN Clin Issues 1997;8:116-22. 7. King JE, Lancaster L, Pierce J, Norman LD. Removing the walls and expanding the boundaries: a curriculum model for acute care nurse practitioners. N&HC: Perspectives on Community 1996;17:304-7. 8. Hravnak M, Kobert SN, Risco KG, et al. Acute care nurse practitioner curriculum: content and development process. Am J Crit Care 1995;4:179-88. 9. Hollinger-Smith L, Murphy MP. Implementing a residency program for the acute care nurse practitioner. MedSurg Nurs 1998;7:28-38. 10. American Nurses Association. Standards of clinical practice and scope of practice for the acute care nurse practitioner. Washington: American Nurses Publishing; 1995. 11. Centers for Medicare and Medical Services, 1997 documentation guidelines for evaluation and management services. Available at: http://cms.hhs.gov/medlearn/emdoc.asp. 12. Rolfe G. Insufficient evidence: the problems of evidence-based nursing. Nurse Educ Today 1999;19:433-42. 13. Friedland DJ, ed. Evidence-based medicine: framework for clinical practice. Stamford (CT): Appleton & Lange; 1998. VOLUME 50 • NUMBER 6 NURSING OUTLOOK
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Columbia University’s Competency and Evidence-based Acute Care Nurse Practitioner Program 14. Bakken S. An informatics infrastructure is essential for evidencebased practice. J Am Med Informatics Assoc 2001;8:199-201. 15. Benner P. From novice to expert: excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley; 1984. 16. Gilliss C, Mundinger MO. How is the role of the advanced practice
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nurse changing?. In: O’Neil E, Coffman J, eds. Strategies for the future of nursing. San Francisco: Jossey-Bass Publishers; 1998. 17. National Organization of Nurse Practitioner Faculties. Domains and competencies of nurse practitioner practice. Washington: Author; 2000.
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