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Exploration of Specialty Certification for Nurse Anesthetists: Nonsurgical Pain Management as a Test Case
Original Article Exploration of Specialty Certification for Nurse Anesthetists: Nonsurgical Pain Management as a Test Case Steven Wooden, DNP, CRNA,*,‡ Sharron Docherty, PhD, CPNP-AC/PC,* Karen Plaus, PhD, CRNA, FAAN,† Anthony Kusek, MD,‡ and Charles Vacchiano, PhD, CRNA* ---
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From the *Duke University School of Nursing, Durham, North Carolina; † National Board of Certification and Recertification for Nurse Anesthetists, Chicago, Illinois; ‡Boone County Health Center, Albion, Nebraska. Address correspondence to Steven Wooden, DNP, CRNA, Boone County Health Center, 406 South 8th Street, Albion, NE 68620. E-mail: Steve@ stevewooden.com Received July 22, 2013; Revised August 15, 2013; Accepted August 16, 2013. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2013.08.002
ABSTRACT:
Certification is the outcome of the demonstration of knowledge and skills, which is an important link to licensing and credentialing. Considering the essential role that Certified Registered Nurse Anesthetists play in the practice of nonsurgical pain management, it is important that a certification process be developed that provides the necessary support to licensing and credentialing at the local, state, and federal levels. The goal of this project was to develop the foundational elements for a specialty certification in nonsurgical pain management. The Delphi method for the systematic solicitation and collation of information was used to query experts in the field of nonsurgical pain management regarding the elements necessary to establish such a specialty certification. Results of the query were compiled, analyzed, and compared to feedback about the elements from a sample of certified registered nurse anesthetists involved in nonsurgical pain management to assess reliability. The results provided identification of a target population for competency evaluation, tools for evaluation, resources for knowledge and skills testing, and a table of specifications for testing. A valid process to develop a specialty certification for nurse anesthetists with demonstration of knowledge and skills will help bridge the gap between continuing education and an actual demonstration that an individual practitioner possesses the necessary knowledge and skills to practice nonsurgical pain management. Ó 2013 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol -, No - (--), 2013: pp 1-9
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INTRODUCTION Certified registered nurse anesthetists (CRNAs) play an important role in the treatment of chronic pain. This group of professionals receives graduate level education in the provision of anesthesia care, including the framework for nonsurgical pain management (NSPM) (Council on Accreditation of Nurse Anesthesia Educational Programs, 2010). Throughout the United States, CRNAs are providing NSPM care and are frequently the only provider within the community with the knowledge and skills to provide such services (American Association of Nurse Anesthetists, 2005). Like many physicians, CRNAs obtained the knowledge and skills to provide these services through formal and informal education and training. Those NSPM services vary depending on the capability of the individual CRNA and the needs of the community. According to practice surveys by the American Association of Nurse Anesthetists and the National Board of Certification and Recertification for Nurse Anesthetists, those NSPM services provided by CRNAs range from the minimally complex interlaminar epidural steroid injection to a more comprehensive and complex service dealing with patient assessment, pharmacologic treatment, interventional strategies, imaging, and follow-up. Surveys also indicate that CRNAs work closely with physicians and other health care providers to address the NSPM needs of the patient. State legislators, regulators, and policy makers have a mandate to protect the health and safety of the public and, therefore, expect to be assured that health care professionals possess the knowledge and skills necessary for a particular scope of practice, such as NSPM, before licensing them. Licensing and certification are two different types of occupational credentials. A license is a governmental authorization to engage in a particular occupation or activity, and a certification declares that an individual has been found to meet certain competency standards established by a private agency for a particular occupation or activity. Certification is the outcome of demonstrating specific knowledge and skill set competencies identified as necessary to the profession and is a critically important link to licensing (Chornick, 2008). However, the specificity and scope of competency in the area of NSPM has not been well delineated, nor has a certification process been developed that would assist in setting a national standard for the knowledge and skills required to ensure safe and quality pain management care provided by CRNAs. The National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) has autonomous authority to carry out certification functions for the
CRNA community (National Board of Certification and Recertification for Nurse Anesthetists, 2010). A practice analysis conducted by the NBCRNA in 2007 indicated a need to describe and define CRNA practice in the area of pain management. Findings from the practice analysis supported competency evaluation and certification in the specialty area of NSPM (Thiemann, 2010). The concept of specialty certification is consistent with the National Council of State Boards of Nursing’s Consensus Model for APRN Regulation, which supports the development of specialty certification beyond the core role competencies and population foci (Partin, 2009). Competency evaluation in a specialty area of health care practice is not a new concept. It often takes the form of a certificate or additional credential beyond the general certification process. The process of evaluating competency in a specialty area is different from an initial certification in the profession with its focus on testing for knowledge and skills required by the novice-generalist nurse anesthetist. Certification in a specialty area validates that a practitioner has the knowledge and skills necessary for competent practice in the particular specialty beyond the minimal requirements for licensure. ‘‘Certification yields benefits to the individual nurse, the profession, and the public, including improved patient safety and a commitment to lifelong learning’’ (Williams & Counts, 2013). Continuing education requirements for CRNAs already exist, but there is no mechanism in place to assess the individual benefits of continuing education. A 2001 report from the Institute of Medicine (IOM) suggested that certification should include demonstration of competency because traditional methods of continuing education by themselves have not been shown to be effective indicators of competency (Institute of Medicine, 2001). The IOM report, and others (Burns, 2009; Swankin, LeBuhan, & Morrison, 2006), suggests that health care professionals should not rely solely on continuing education to maintain competency and that periodic demonstration of knowledge, skills, attitude, and judgment are critical to public safety. It is apparent that continuing education, without demonstration of acquired knowledge, does not assure that a health care provider is maintaining an adequate knowledge base for contemporary practice. Many continuing education programs rely on self-evaluation and self-determination of competency. Studies that assess the relationship between self-evaluation and measured competency found that there was little connection between the two and that the results of self-evaluation are often an inflated sense of knowledge and skills (Davis et al., 2006). To determine if an individual possesses fundamental knowledge, it is necessary to objectively
Specialty Certification for Nurse Anesthetists
assess their knowledge base. To determine that an individual has a needed skill set, it is necessary to objectively assess those skills. Designing and implementing a competency evaluation that tests fundamental knowledge of NSPM, followed by evaluation of the technical skill set necessary to practice NSPM, may help bridge the gap between continuing education and a more evident assurance that an individual practitioner possesses the necessary knowledge and skills to practice NSPM competently. The Quality Assurance Project of the U.S. Agency for International Development (USAID) stated that ‘‘Documenting competence is becoming essential, not optional, and is likely to become mandatory in the near future for initial and continuing licensure and certification, and perhaps even for employment’’ (Kak, Burkhalter, & Cooper, 2001). The USAID went on to say that written tests are a method to measure health care competence in applied knowledge. A specialty certification in NSPM would benefit the profession, would benefit CRNAs in this type of practice, and at a regulatory level, would strengthen the scope of practice rights of CRNAs to practice NSPM. More importantly, specialty certification will provide validation to the public that the nurse anesthesia practitioner providing their care has the necessary knowledge and skill set, which meets the national standard, to provide safe and competent diagnosis and treatment. The goal of this project was to develop the foundational elements for a specialty certification in nonsurgical pain management. The project objectives were to (1) identify the qualifications for competency and identify tools to assess the knowledge base and skill set to be used for certification, (2) identify sources for fundamental test items to evaluate competency, (3) develop a knowledge and skill set test blueprint to evaluate competency, and (4) identify the educational and practice prerequisites for the target group of CRNAs eligible to take a NSPM specialty certification exam.
MATERIALS AND METHODS Design Overview A literature review provided initial assumptions regarding potential NSPM certification assessment tools, test items, test blueprint, and target group. Sources of information for the initial assumptions included recommendations from a 2009 pain specialty workgroup, NSPM educational material, and other relevant material (American Academy of Pain Management, 2007; American Association of Nurse Anesthetists, 2009; National Board of Certification and Recertification for Nurse Anesthetists, 2008). The assumptions were
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used to initiate a discussion among an expert panel of CRNAs who practice NSPM concerning what qualifications should be required to be eligible for certification, how the required knowledge base and skill set to be certified in NSPM should be assessed, what test items should be included and the nature of the testing paradigm, and the test specifications. Repeated rounds of listing or ranking of the fundamental assumptions for each objective were performed by the expert panel until a consensus on the content was achieved. Finally, a sample of CRNAs were surveyed and asked to comment on the content to assess reliability of the expert panel recommendations. Materials Advisory Panel. To validate the literature-based assumptions for each objective of the project, an Advisory Committee (AC) was formed. To qualify, a prospective AC member must be highly trained and competent within the specialized area of knowledge, well known by the issue population, and respected (Hsu & Sandford, 2007). This AC could be made up of individuals who were teachers or publishers in the area of interest and should be representative of those in the specialty practice. There is no consensus or recommendation for the number of AC members required, but most experts agree that the number should allow for a diverse group in the field of interest, which can be obtained even with a relatively small group size (Akins, Tolson, & Cole, 2005). The NBCRNA was asked to provide the names and contact information of 6 to 10 CRNAs who practice NSPM from their practitioner database to create an AC that was both geographically diverse and represented different practice environments. This request resulted in a list of eight potential AC candidates. The candidates were contacted and provided information about the aims of the project, a consent form describing their responsibilities, and assurance of their anonymity as participants. All eight of the proposed candidates consented to participate in the project. The AC was composed of CRNAs from various geographic locations and with a variety of backgrounds, educational preparation, and experiences. The group included CRNAs from the East, West, North, South, and Midwest areas of the United States. They practiced in military, academic, urban, and rural settings. The Delphi Method. Once the AC was composed, the Delphi method was used to engage the committee in systematic evaluations to validate the literaturebased assumptions for each of the 4 project objectives. The Delphi method, developed in the 1950s by the Rand Corporation for use in U.S. military intelligence,
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was conceived as a judgment tool in which group experts evaluate the reliability and validity of subject matter. This empirical method makes use of structured group opinion and discussion to generate consensus, assess priorities, and quantify the judgments of experts (Aron & Pogach, 2008). The characteristics that make it an effective decision-making tool are anonymity, interaction with feedback, statistical group response, and expert input. It is considered effective as long as domination by individuals can be minimized, the feedback is controlled, and the information is compiled statistically to reduce group pressure for conformity (Hsu & Sandford, 2007).
Methods After internal review board approval of all methods and materials associated with this project and with the written consent of each AC member, the AC was presented with the fundamental assumptions for each objective of the project and asked to list or rank each item to validate its inclusion in the framework of the specialty certification. Objective 1. Delineate expected qualifications for competency in NSPM and identify tools to assess the knowledge base and skill set to be certified in the specialty. To delineate the expected qualifications a CRNA should possess to demonstrate competency in NSPM practice and identify potential assessment tools for NSPM certification, the AC was asked to consider a list of qualifications and mechanisms recovered from the literature that is used by health care professions to evaluate competency and award certification (Table 1). The AC members were asked to rank the item using a 3-point Likert scale based on whether or not the item should be accomplished by a CRNA practicing non-surgical pain management to be credentialed in that specialty area. The items were ranked as 1 ¼ agree, 2 ¼ somewhat agree, or 3 ¼ disagree. All items with a mean score equal to or greater than 2.0 were removed from the list. This threshold provided for a determination that an item was at least somewhat acceptable. If the variance for any item was 0.75 or greater, a determination was made regarding why the AC was so widely split on the item. Objective 2. Identify sources for fundamental test items to evaluate competency in NSPM practice. Each AC member was asked to provide a list of sources they used as common NSPM references for education and clinical practice. These sources were considered to represent primary resources in the development of testing tools for a competency evaluation.
TABLE 1. Identification of Assessment Tools Question: Which of the following do you feel should be completed by a CRNA practicing non-surgical pain management in order to be credentialed in that specialty area? Rank as: 1 ¼ agree, 2 ¼ somewhat agree, or 3 ¼ disagree Continuing education requirements Written exams Oral exams Peer Review and Quality Assessment Chart review Reference from other specialists Self-assessment Holding credentials at an accredited facility Demonstration of technical skills Clinical practice requirements (# of hrs and/or procedures) Completion of an established curricular content
Objective 3. Develop a knowledge and skill set test blueprint to evaluate competency in NSPM practice. An important step in developing a competency evaluation exemplar for NSPM was to construct an outline of critical performance domains that reflect the knowledge, skills, and abilities needed for competent and contemporary practice of NSPM. A table of proposed performance domains, with specific categories in each domain, and specific evaluation items in each category was constructed based on a set of performance domains validated and proffered by NBCRNA recertification practice analyses conducted in 2007 and 2009 (Thiemann, 2010). The evaluation items associated with each performance domain and category were generated using curriculum content from pain management courses available to CRNAs (Table 2). The percentage weight attached to each proposed performance domain was determined according to the time allocated to the curriculum content proposed by a pain specialty workgroup (National Board of Certification and Recertification for Nurse Anesthetists, 2008) (Table 3). The proposed knowledge and skill set blueprint was presented to the AC, and the members were asked to rank the appropriateness of each domain, each category, and each item using the same 3-point Likert scale and threshold criteria that was used to evaluate the qualifications and assessment tools in objective 1. The AC had an opportunity to add additional items during the first evaluation round. The committee was also asked if they agreed with the assigned percentage weight for each domain. Disagreement about the percentage weight of a particular domain that involved more than 20% of the AC would initiate further discussion until a consensus was achieved.
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TABLE 2. Table of Specification for Knowledge and Skills Evaluation (Weight of Test) Theoretical foundation of pain (8%) Clinical Practice Anatomy and physiology of the spine Factors influencing pain Cellular response to pain and treatment Practice Evaluation and Improvement Evidence based principles Opportunities for practice improvement Pain classifications Professional Responsibility Standards of care Sources of contemporary information Imaging and radiation safety (8%) Clinical Practice Evaluation of equipment Equipment safety Radiation safety Safe practices with imaging equipment Indications for advanced imaging Practice Evaluation and Improvement Patient Safety Provider and Staff Safety Professional Responsibility Statutory requirements Facility regulations Sources of contemporary information Assessment/diagnosis/integration/referral (26%) Clinical Practice Pathophysiology Physical Examination Health History Diagnostic studies Documentation Data interpretation Practice Evaluation and Improvement Evaluation of clinical judgment Consultation Care coordination Reporting Professional Responsibility Statutory requirements Facility regulations Pharmacological treatment (8%) Clinical Practice Pharmacology of pain Drugs for pain intervention Drug interactions Risks and benefits of drug therapy
Objective 4. Identify the educational and practice prerequisites for the target group of CRNAs eligible to take a NSPM specialty certification exam. Identifying the educational and practice prerequisites of the target group of CRNAs who should be eligible to take a NSPM certification exam was accomplished by asking the AC to respond to 2 questions. The first question required the AC to agree or disagree
Practice Evaluation and Improvement Patient safety Professional Responsibility Statutory requirements Safe drug practices Interventional pain strategies (34%) Clinical Practice Diagnosis of pain generators Targeted treatment of pain Global treatment of pain Development of care plan Implementation of care plan Consideration of patient’s health status Treating myofascial pain Trigger point pathology and treatment Imaging strategies Intervention for complications Practice Evaluation and Improvement Treatment goals Professional Responsibility Collaboration strategies Sources of contemporary information Comprehensive pain treatments (16%) Clinical Practice Informed Consent Protection of patient rights Patient monitoring Consideration of patient needs Post-procedure follow-up Multidisciplinary pain management Practice Evaluation and Improvement Outcome measurements Patient follow-up Professional Responsibility Multidimensional pain management Sources of contemporary information Skill Set Recognition of anatomical structure in various view planes Identification of anatomical components under fluoroscopy Proper and safe needle placement for various approaches in: Cervical region Thoracic region Lumbar region Sacrum
with a set of potential prerequisites including completion of specific pain management curriculum content, participation in continuing education, an active NSPM practice or a combination of these options. The second question asked the AC to agree or disagree on the appropriate number of NSPM practice hours and procedures recommended as one of the qualifiers for specialty certification. A baseline of 320 practice hours
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TABLE 3. Proposed Minimum Curriculum Content for NSPM Practice
Content Theoretical foundation of pain Imaging and radiation safety Assessment/diagnosis/integration/ referral Pharmacological treatments Interventional pain strategies Comprehensive pain treatments
Minimum Contact Hours (60 minutes ¼ 1 contact hour) 10 10 30 10 40 20
project. Descriptive statistics, including the mean, median, standard deviation, minimum, maximum, and valid numbers of responses as appropriate for each project objective, were determined after each round of questioning. Likert scale rankings were evaluated by calculating the mean, standard deviation, and median to determine the overall opinion and consistency of the AC members’ responses. Interrater reliability between the AC and CRNA survey sample group was assessed using the Kappa statistic (PASW v17.0.2). This statistic measures the agreement between two or more observers and evaluates the agreement scores against the level that would occur simply by chance (Viera & Garrett, 2005).
RESULTS per year and 10 procedures per week for 5 years was established as a starting point for this discussion. The threshold for determination of consensus by the AC was 80% agreement on a given prerequisite, number of practice hours, or number of procedures. If the 80% agreement criterion for a given option was not met during the first voting period, then the options that received more than a 20% agreement were sent back to the AC for an agree or disagree decision. During subsequent rounds, the AC members were asked to justify their responses. The final step in the process to examine the reliability of the AC consensus content contained in each of the four objectives was to survey an expanded group of CRNAs who practice NSPM to comment on the content. The sample survey group contained CRNAs in the NBCRNA database who self-identified as practicing NSPM (n ¼ 611). Of the 611 electronic surveys distributed, 155 were returned (25.36%). An 80% agreement threshold between the survey group and the AC group was used to confirm acceptance of the content. Reliability of the content was examined by testing interrater reliability between the AC and CRNA sample group and by comparing the ‘‘face validity’’ of the AC generated content with the competency evaluation and specialty certification recommendations from the 2007 NBCRNA practice analysis (Thiemann, 2010). Data Collection and Analysis Procedures Interaction between the primary investigator (S.W.) and the AC members occurred by phone and email between September and December of 2010. There was no group interaction by any communication mode and anonymity was thereby maintained. The 3-point Likert scale was chosen because intensity or direction of opinion was not important in this
Objective 1 Consideration of the expected qualifications for competency in NSPM and identification of tools to assess the knowledge base and skill set to be certified in the specialty required one round of deliberation by the AC and was responded to by all eight members. The AC identified continuing education, clinical practice requirements, completion of an established curriculum, and holding credentials at an accredited facility as expected competency qualifiers for eligibility for NSPM certification. The AC identified written examination, demonstration of technical skills, and peer review/quality assessment as acceptable assessment tools for specialty certification in NSPM (Table 4). Objective 2 Five members of the AC provided 27 references, which included books, journals, and web sites that they most frequently used for knowledge and technical skills information in their NSPM practice (Table 5). Objective 3 Each domain, category, and evaluation item on the draft knowledge and skill set blueprint to evaluate competency in NSPM practice was acceptable to the AC with a mean Likert score of between 1.0 and 1.25 (Table 2). There were no recommended additions to the blueprint and therefore no further discussions required to acquire consensus. Objective 4 Consensus on the educational and practice prerequisites for the target group of CRNAs eligible to take a NSPM specialty certification exam required three rounds of scoring. The final consensus was that the target group should have completed an established curriculum in NSPM, completed a required amount of
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Specialty Certification for Nurse Anesthetists
TABLE 4. Qualification Requirements and Competency Assessment Tools 1
2
3
Variance
Mean
Qualifying Requirements
4 3 6 7 2
2 3 2 0 3
2 2 0 1 3
0.69 0.61 0.19 0.44 0.61
1.75 1.87 1.25 1.25 2.12
Continuing education requirements Holding credentials at an accredited facility Clinical practice requirements Completion of an established curricular content Reference from other specialists
1
2
3
Variance
Mean
Competency Assessment Tools
5 4 3 2 2 2
2 2 4 4 3 3
1 2 1 2 3 3
0.50 0.69 0.44 0.50 0.61 0.61
1.50 1.75 1.75 2.00 2.12 2.12
Written exams Peer Review and Quality Assessment Demonstration of technical skills Chart review Self-assessment Oral exams
Key to rankings: 1 ¼ Agree; 2 ¼ Somewhat appropriate; 3 ¼ Inappropriate.
continuing education in NSPM, and demonstrated that they have an active practice in NSPM (Table 6). The AC could not agree on the number of practice hours and procedures that should be required to be eligible to take the specialty certification exam. All but one of the eight AC members felt that the numbers offered as a starting point were too high, or that specific numbers would be difficult to confirm, or they would not be valid in determining active practice. Therefore, this effort did not result in a recommendation for the number of practice hours or procedures that would make a CRNA eligible to take a NSPM specialty certification examination. Analysis of the interrater reliability between the AC and CRNA survey sample demonstrated a significant level of agreement with a kappa ¼ 0.68.
DISCUSSION Recommendations resulting from the advisory committee input regarding specialty certification in NSPM included four specific competency qualifications for eligibility for certification and three assessment tools to evaluate those competencies. The AC agreed on a list of resources for developing questions for a certification examination and on a blueprint of domains, categories and items from which those questions should originate. Finally, the AC, with concurrence with a broad sample of CRNAs practicing NSPM, recommended a competency evaluation process be offered to those CRNAs who can demonstrate that they have completed an approved curriculum in NSPM, have an active NSPM practice, and hold credentials to practice NSPM at an accredited facility.
The AC members who believed it was inappropriate to include time and procedure requirements for the demonstration of an active practice may have a valid point. It is likely that mastery of clinical competency cannot be correlated with hours of clinical practice. A comprehensive study of pediatric nurse practitioner educational programs by Hawkins-Walsh, et al. (2011) revealed the complex nature of clinical experience and the difficulty of correlating the time spent in clinical practice with evidence of competency. Berg, Hawkins-Walsh, Gaylord, Lindeke, & Docherty, (2011) referenced well-respected authorities such as the IOM and the Pew Commission when reporting that there is little evidence to suggest that a required number of clinical hours translates into skills acquisition and competency. Although the AC suggested that there may be a more appropriate method to demonstrate active practice than requiring a minimum number of hours and procedures, they were unable to recommend a specific alternative. The AC felt that there should be an initial competency evaluation for certification followed by subsequent recertification periods. The initial competency evaluation should include completion of a written examination and demonstration of technical skills. The recommendation for recertification included 100 hours of continuing education specific to the practice of NSPM in the preceding five years and continued demonstration of active practice in NSPM. Retesting and reevaluation of technical skills for recertification in NSPM would also be consistent with the AC recommendations. The concept of competency has been expanded beyond fact-based knowledge to include patient-
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TABLE 5. Resource Material and Number of Times Cited by Advisory Committee #
Resource and First Author (if applicable)
1 1 2 2 2 1 2 1 1 1 1 1 1 1 2 1 1 1 1 1 3 1 1 1 1 1 1
Acupuncture: Trigger Points and Musculoskeletal Pain (Baldry) American Academy of Pain Management (www.AAPainManage.org) Atlas of Common Pain Syndromes (Waldman) Atlas of Image Guided Intervention in Regional Anesthesia and Pain Medicine (Rathmell) Atlas of Interventional Pain Management (Waldman) Atlas of Pain Injection Techniques (O’Connor) Atlas of Pain Management Injection Techniques (Waldman) Atlas of uncommon pain syndromes (Waldman) Bonica’s management of pain (Fishman) Cochrane Database (http://www.cochrane.org) Complications in regional anesthesia and pain medicine (Neal) Essentials of Pain Medicine and Regional Anesthesia (Benzon) Fast facts : chronic pain (Cepeda) Handbook of C-Arm Fluoroscopy Guided Spinal Injections (Wang) Imagine Guided Spine Intervention (Fenton) Imaging for Regional Anesthesia and Pain Management (Raj) Massachusetts General Hospital Handbook of Pain Management (Ballantyne) MDConsult (www.mdconsult.com) Neural Blockade: Pain Management (Cousins) Pain Management (Waldman) Pain Management: A practical Guide for Clinicians (Weiner) Pain Medicine: The requisites in Anesthesiology (Abram) Pain Physician (www.painphysicianjournal.com) Pharmacology and Therapeutics: Principles to Practice (Waldman) Physical diagnosis of pain: an atlas of signs and symptoms (Waldman) PubMed (www.pubmed.com) Textbook of Pain (Wall)
centered practice skills (Edler et al., 2009). Adding the evaluation of important technical skills to the competency evaluation was recommended by the AC. The incorporation of peer reviewed demonstrations of core technical skills using simulation may be a useful adjunct. The American Association of Nurse Anesthetists (AANA) offers an educational seminar in NSPM that includes ‘‘hands on’’ training with cadavers. Combining such a seminar with a competency evaluation of knowledge and skills would be an efficient use of time and manpower resources.
Development of a NSPM curriculum must be an evolving process and should include the characteristics of nursing philosophy. Nursing is an art and science that approaches patient care with theories that are uniquely different from any other health care profession (Selanders, 2010). CRNAs should look at all possible solutions to this complex and elusive issue of pain management and not be constrained by a single model. Including all aspects of the nursing metaparadigm; person, health, environment, and nursing, would set CRNA NSPM practice apart from others.
TABLE 6. Educational and Practice Prerequisites for the Target Group Initial
Subsequent Recertification
A
1
0
B
0
0
C
7
8
Choice
(a) Those who can demonstrate they have completed the curriculum content outlined by NBCRNA. (b) Those who have completed (1) and obtained 100 hours of approved continuing education credits in NSPM education in the last 5 years. (c) Those who have completed (1) and (2), and can demonstrate they have an active practice in NSPM.
Specialty Certification for Nurse Anesthetists
Certification of CRNAs in NSPM practice is a critical component of the vision of the NBCRNA (Thiemann, 2010). The recognition of a specialty area of practice is new to the profession and its members, and important to their efforts to have NSPM recognized by legislators, regulators, and policy makers as a specialty practice within the scope and education of CRNAs. Specialty certification is also consistent with the Consensus Model for APRN Regulation and its member organizations, one of which is the AANA (National Council of State Boards of Nursing, 2008).
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For those reasons, it is important to all CRNAs and to the profession, that the development of a competency evaluation and certification in NSPM be successful and sustainable. Without a valid competency evaluation tool, the specialty certification program is not likely to maintain credibility. An important part of the sustainability will be continued evaluation and validation of the tool, maintaining contemporary information going forward, and assuring fidelity to the overall organizational vision of competency, patient safety, and effective practice.
REFERENCES Akins, R. B., Tolson, H., & Cole, B. R. (2005). Stability of response characteristics of a Delphi panel: Application of bootstrap data expansion. BMC Medical Research Methodology, 5(1), 37. American Academy of Pain Management. ( 2007). Credentialing. Sonora, CA. Retrieved from http://www. aapainmanage.org/members/Credentialing.php. American Association of Nurse Anesthetists. (2005). Pain Management Position 2.1 Postition Statements (Vol. 2.11). Park Ridge IL. Retrieved from http://www.AANA.com. American Association of Nurse Anesthetists. ( 2009). Jack Neary Advanced Pain Management Seminar, Chicago, IL. Aron, D., & Pogach, L. (2008). Quality indicators for diabetes mellitus in the ambulatory setting: Using the Delphi method to inform performance measurement development. Quality & Safety in Health Care, 17(5), 315–317. Berg, M., Hawkins-Walsh, E., Gaylord, N., Lindeke, L., & Docherty, S. L. (2011). Emerging issues regarding pediatric nurse practitioner education in acute and primary are. Journal of Pediatric Health Care, 25(1), 62–66. Burns, B. (2009). Continuing competency: What’s ahead? Journal of Perinatal & Neonatal Nursing, 23(3). 218-227; quiz 228–219. Chornick, N. (2008). APRN licensure versus APRN certification: What is the difference? JONA’s Healthcare Law, Ethics, and Regulation, 10(4), 90–93. Council on Accreditation of Nurse Anesthesia Educational Programs. (2010). Standards for Accreditation of Nurse Anesthesia Educational Programs. Park Ridge, Illinois. Davis, D. A., Mazmanian, P. E., Fordis, M., Van Harrison, R., Thorpe, K. E., & Perrier, L. (2006). Accuracy of physician selfassessment compared with observed measures of competence: A systematic review. Journal of the American Medical Association, 296(9), 1094–1102. Edler, A. A., Fanning, R. G., Chen, M. I., Claure, R., Almazan, D., Struyk, B., & Seiden, S. C. (2009). Patient simulation: A literary synthesis of assessment tools in anesthesiology. Journal of Educational Evaluation for Health Professions, 6, 3. Hawkins-Walsh, E., Berg, M., Docherty, S., Lindeke, L., Gaylord, N., & Osborn, K. (2011). A national survey of the primary and acute Care pediatric nurse practitioner
educational preparation. Journal of Pediatric Health Care, 25(1), 5–15. Hsu, C., & Sandford, B. A. (2007). The Delphi technique: Making sense of consensus. Practical Assessment, Research & Evaluation. Retrieved August 10, 2013, from Http://pareonline.net/getvn.asp?v¼12&n¼10. Institute of Medicine (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press. 2001. Kak, N., Burkhalter, B., & Cooper, M. (2001). Measuring the competence of healthcare providers. U.S. Agency for International Development (USAID) Quality Assurance (QA) Project, Bethesda, MD. National Board of Certification and Recertification for Nurse Anesthetists. (2008). Advanced pain management for nurse anesthetists: A learning curriculum. Paper presented at the Radiology and Pain Specialty Workgroup, St. Petersburg, FL. National Board of Certification and Recertification for Nurse Anesthetists. (2010). NBCRNA: About us Retrieved March 17, 2010, from http://www.nbcrna.com/about-us/ Pages/default.aspx. National Council of State Boards of Nursing. (2008). APRN model act/rules and regulations, Retrieved from https:// www.ncsbn.org/APRN_leg_language_approved_8_08.pdf. Partin, B. (2009). Consensus model for APRN regulation. The Nurse Practitioner, 34(6), 8. Selanders, L. C. (2010). The power of environmental adaptation: Florence Nightingale’s original theory for nursing practice. Journal of Holistic Nursing, 28(1), 81–88. Swankin, D., LeBuhan, R. A., & Morrison, R. (2006). Implementing continuing competency requirements for health care pracitioners. Washington, D.C.: AARP Public Policy Institute. Thiemann, L. (2010). National Board of Certification and Recertification for Nurse Anesthetists Pain Management Practice Analysis: Draft Report. In Castle (Ed.). Chicago, IL Viera, A. J., & Garrett, J. M. (2005). Understanding interobserver agreement: The kappa statistic. Family Medicine, 37(5), 360–363. Williams, H. F., & Counts, C. S. (2013). Certification 101: The pathway to excellence. Nephrology Nursing Journal, 40(3), 197–208.
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From the *Duke University School of Nursing, Durham, North Carolina; † National Board of Certification and Recertification for Nurse Anesthetists, Chicago, Illinois; ‡Boone County Health Center, Albion, Nebraska. Address correspondence to Steven Wooden, DNP, CRNA, Boone County Health Center, 406 South 8th Street, Albion, NE 68620. E-mail: Steve@ stevewooden.com Received July 22, 2013; Revised August 15, 2013; Accepted August 16, 2013. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2013.08.002
ABSTRACT:
Certification is the outcome of the demonstration of knowledge and skills, which is an important link to licensing and credentialing. Considering the essential role that Certified Registered Nurse Anesthetists play in the practice of nonsurgical pain management, it is important that a certification process be developed that provides the necessary support to licensing and credentialing at the local, state, and federal levels. The goal of this project was to develop the foundational elements for a specialty certification in nonsurgical pain management. The Delphi method for the systematic solicitation and collation of information was used to query experts in the field of nonsurgical pain management regarding the elements necessary to establish such a specialty certification. Results of the query were compiled, analyzed, and compared to feedback about the elements from a sample of certified registered nurse anesthetists involved in nonsurgical pain management to assess reliability. The results provided identification of a target population for competency evaluation, tools for evaluation, resources for knowledge and skills testing, and a table of specifications for testing. A valid process to develop a specialty certification for nurse anesthetists with demonstration of knowledge and skills will help bridge the gap between continuing education and an actual demonstration that an individual practitioner possesses the necessary knowledge and skills to practice nonsurgical pain management. Ó 2013 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol -, No - (--), 2013: pp 1-9
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INTRODUCTION Certified registered nurse anesthetists (CRNAs) play an important role in the treatment of chronic pain. This group of professionals receives graduate level education in the provision of anesthesia care, including the framework for nonsurgical pain management (NSPM) (Council on Accreditation of Nurse Anesthesia Educational Programs, 2010). Throughout the United States, CRNAs are providing NSPM care and are frequently the only provider within the community with the knowledge and skills to provide such services (American Association of Nurse Anesthetists, 2005). Like many physicians, CRNAs obtained the knowledge and skills to provide these services through formal and informal education and training. Those NSPM services vary depending on the capability of the individual CRNA and the needs of the community. According to practice surveys by the American Association of Nurse Anesthetists and the National Board of Certification and Recertification for Nurse Anesthetists, those NSPM services provided by CRNAs range from the minimally complex interlaminar epidural steroid injection to a more comprehensive and complex service dealing with patient assessment, pharmacologic treatment, interventional strategies, imaging, and follow-up. Surveys also indicate that CRNAs work closely with physicians and other health care providers to address the NSPM needs of the patient. State legislators, regulators, and policy makers have a mandate to protect the health and safety of the public and, therefore, expect to be assured that health care professionals possess the knowledge and skills necessary for a particular scope of practice, such as NSPM, before licensing them. Licensing and certification are two different types of occupational credentials. A license is a governmental authorization to engage in a particular occupation or activity, and a certification declares that an individual has been found to meet certain competency standards established by a private agency for a particular occupation or activity. Certification is the outcome of demonstrating specific knowledge and skill set competencies identified as necessary to the profession and is a critically important link to licensing (Chornick, 2008). However, the specificity and scope of competency in the area of NSPM has not been well delineated, nor has a certification process been developed that would assist in setting a national standard for the knowledge and skills required to ensure safe and quality pain management care provided by CRNAs. The National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) has autonomous authority to carry out certification functions for the
CRNA community (National Board of Certification and Recertification for Nurse Anesthetists, 2010). A practice analysis conducted by the NBCRNA in 2007 indicated a need to describe and define CRNA practice in the area of pain management. Findings from the practice analysis supported competency evaluation and certification in the specialty area of NSPM (Thiemann, 2010). The concept of specialty certification is consistent with the National Council of State Boards of Nursing’s Consensus Model for APRN Regulation, which supports the development of specialty certification beyond the core role competencies and population foci (Partin, 2009). Competency evaluation in a specialty area of health care practice is not a new concept. It often takes the form of a certificate or additional credential beyond the general certification process. The process of evaluating competency in a specialty area is different from an initial certification in the profession with its focus on testing for knowledge and skills required by the novice-generalist nurse anesthetist. Certification in a specialty area validates that a practitioner has the knowledge and skills necessary for competent practice in the particular specialty beyond the minimal requirements for licensure. ‘‘Certification yields benefits to the individual nurse, the profession, and the public, including improved patient safety and a commitment to lifelong learning’’ (Williams & Counts, 2013). Continuing education requirements for CRNAs already exist, but there is no mechanism in place to assess the individual benefits of continuing education. A 2001 report from the Institute of Medicine (IOM) suggested that certification should include demonstration of competency because traditional methods of continuing education by themselves have not been shown to be effective indicators of competency (Institute of Medicine, 2001). The IOM report, and others (Burns, 2009; Swankin, LeBuhan, & Morrison, 2006), suggests that health care professionals should not rely solely on continuing education to maintain competency and that periodic demonstration of knowledge, skills, attitude, and judgment are critical to public safety. It is apparent that continuing education, without demonstration of acquired knowledge, does not assure that a health care provider is maintaining an adequate knowledge base for contemporary practice. Many continuing education programs rely on self-evaluation and self-determination of competency. Studies that assess the relationship between self-evaluation and measured competency found that there was little connection between the two and that the results of self-evaluation are often an inflated sense of knowledge and skills (Davis et al., 2006). To determine if an individual possesses fundamental knowledge, it is necessary to objectively
Specialty Certification for Nurse Anesthetists
assess their knowledge base. To determine that an individual has a needed skill set, it is necessary to objectively assess those skills. Designing and implementing a competency evaluation that tests fundamental knowledge of NSPM, followed by evaluation of the technical skill set necessary to practice NSPM, may help bridge the gap between continuing education and a more evident assurance that an individual practitioner possesses the necessary knowledge and skills to practice NSPM competently. The Quality Assurance Project of the U.S. Agency for International Development (USAID) stated that ‘‘Documenting competence is becoming essential, not optional, and is likely to become mandatory in the near future for initial and continuing licensure and certification, and perhaps even for employment’’ (Kak, Burkhalter, & Cooper, 2001). The USAID went on to say that written tests are a method to measure health care competence in applied knowledge. A specialty certification in NSPM would benefit the profession, would benefit CRNAs in this type of practice, and at a regulatory level, would strengthen the scope of practice rights of CRNAs to practice NSPM. More importantly, specialty certification will provide validation to the public that the nurse anesthesia practitioner providing their care has the necessary knowledge and skill set, which meets the national standard, to provide safe and competent diagnosis and treatment. The goal of this project was to develop the foundational elements for a specialty certification in nonsurgical pain management. The project objectives were to (1) identify the qualifications for competency and identify tools to assess the knowledge base and skill set to be used for certification, (2) identify sources for fundamental test items to evaluate competency, (3) develop a knowledge and skill set test blueprint to evaluate competency, and (4) identify the educational and practice prerequisites for the target group of CRNAs eligible to take a NSPM specialty certification exam.
MATERIALS AND METHODS Design Overview A literature review provided initial assumptions regarding potential NSPM certification assessment tools, test items, test blueprint, and target group. Sources of information for the initial assumptions included recommendations from a 2009 pain specialty workgroup, NSPM educational material, and other relevant material (American Academy of Pain Management, 2007; American Association of Nurse Anesthetists, 2009; National Board of Certification and Recertification for Nurse Anesthetists, 2008). The assumptions were
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used to initiate a discussion among an expert panel of CRNAs who practice NSPM concerning what qualifications should be required to be eligible for certification, how the required knowledge base and skill set to be certified in NSPM should be assessed, what test items should be included and the nature of the testing paradigm, and the test specifications. Repeated rounds of listing or ranking of the fundamental assumptions for each objective were performed by the expert panel until a consensus on the content was achieved. Finally, a sample of CRNAs were surveyed and asked to comment on the content to assess reliability of the expert panel recommendations. Materials Advisory Panel. To validate the literature-based assumptions for each objective of the project, an Advisory Committee (AC) was formed. To qualify, a prospective AC member must be highly trained and competent within the specialized area of knowledge, well known by the issue population, and respected (Hsu & Sandford, 2007). This AC could be made up of individuals who were teachers or publishers in the area of interest and should be representative of those in the specialty practice. There is no consensus or recommendation for the number of AC members required, but most experts agree that the number should allow for a diverse group in the field of interest, which can be obtained even with a relatively small group size (Akins, Tolson, & Cole, 2005). The NBCRNA was asked to provide the names and contact information of 6 to 10 CRNAs who practice NSPM from their practitioner database to create an AC that was both geographically diverse and represented different practice environments. This request resulted in a list of eight potential AC candidates. The candidates were contacted and provided information about the aims of the project, a consent form describing their responsibilities, and assurance of their anonymity as participants. All eight of the proposed candidates consented to participate in the project. The AC was composed of CRNAs from various geographic locations and with a variety of backgrounds, educational preparation, and experiences. The group included CRNAs from the East, West, North, South, and Midwest areas of the United States. They practiced in military, academic, urban, and rural settings. The Delphi Method. Once the AC was composed, the Delphi method was used to engage the committee in systematic evaluations to validate the literaturebased assumptions for each of the 4 project objectives. The Delphi method, developed in the 1950s by the Rand Corporation for use in U.S. military intelligence,
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was conceived as a judgment tool in which group experts evaluate the reliability and validity of subject matter. This empirical method makes use of structured group opinion and discussion to generate consensus, assess priorities, and quantify the judgments of experts (Aron & Pogach, 2008). The characteristics that make it an effective decision-making tool are anonymity, interaction with feedback, statistical group response, and expert input. It is considered effective as long as domination by individuals can be minimized, the feedback is controlled, and the information is compiled statistically to reduce group pressure for conformity (Hsu & Sandford, 2007).
Methods After internal review board approval of all methods and materials associated with this project and with the written consent of each AC member, the AC was presented with the fundamental assumptions for each objective of the project and asked to list or rank each item to validate its inclusion in the framework of the specialty certification. Objective 1. Delineate expected qualifications for competency in NSPM and identify tools to assess the knowledge base and skill set to be certified in the specialty. To delineate the expected qualifications a CRNA should possess to demonstrate competency in NSPM practice and identify potential assessment tools for NSPM certification, the AC was asked to consider a list of qualifications and mechanisms recovered from the literature that is used by health care professions to evaluate competency and award certification (Table 1). The AC members were asked to rank the item using a 3-point Likert scale based on whether or not the item should be accomplished by a CRNA practicing non-surgical pain management to be credentialed in that specialty area. The items were ranked as 1 ¼ agree, 2 ¼ somewhat agree, or 3 ¼ disagree. All items with a mean score equal to or greater than 2.0 were removed from the list. This threshold provided for a determination that an item was at least somewhat acceptable. If the variance for any item was 0.75 or greater, a determination was made regarding why the AC was so widely split on the item. Objective 2. Identify sources for fundamental test items to evaluate competency in NSPM practice. Each AC member was asked to provide a list of sources they used as common NSPM references for education and clinical practice. These sources were considered to represent primary resources in the development of testing tools for a competency evaluation.
TABLE 1. Identification of Assessment Tools Question: Which of the following do you feel should be completed by a CRNA practicing non-surgical pain management in order to be credentialed in that specialty area? Rank as: 1 ¼ agree, 2 ¼ somewhat agree, or 3 ¼ disagree Continuing education requirements Written exams Oral exams Peer Review and Quality Assessment Chart review Reference from other specialists Self-assessment Holding credentials at an accredited facility Demonstration of technical skills Clinical practice requirements (# of hrs and/or procedures) Completion of an established curricular content
Objective 3. Develop a knowledge and skill set test blueprint to evaluate competency in NSPM practice. An important step in developing a competency evaluation exemplar for NSPM was to construct an outline of critical performance domains that reflect the knowledge, skills, and abilities needed for competent and contemporary practice of NSPM. A table of proposed performance domains, with specific categories in each domain, and specific evaluation items in each category was constructed based on a set of performance domains validated and proffered by NBCRNA recertification practice analyses conducted in 2007 and 2009 (Thiemann, 2010). The evaluation items associated with each performance domain and category were generated using curriculum content from pain management courses available to CRNAs (Table 2). The percentage weight attached to each proposed performance domain was determined according to the time allocated to the curriculum content proposed by a pain specialty workgroup (National Board of Certification and Recertification for Nurse Anesthetists, 2008) (Table 3). The proposed knowledge and skill set blueprint was presented to the AC, and the members were asked to rank the appropriateness of each domain, each category, and each item using the same 3-point Likert scale and threshold criteria that was used to evaluate the qualifications and assessment tools in objective 1. The AC had an opportunity to add additional items during the first evaluation round. The committee was also asked if they agreed with the assigned percentage weight for each domain. Disagreement about the percentage weight of a particular domain that involved more than 20% of the AC would initiate further discussion until a consensus was achieved.
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TABLE 2. Table of Specification for Knowledge and Skills Evaluation (Weight of Test) Theoretical foundation of pain (8%) Clinical Practice Anatomy and physiology of the spine Factors influencing pain Cellular response to pain and treatment Practice Evaluation and Improvement Evidence based principles Opportunities for practice improvement Pain classifications Professional Responsibility Standards of care Sources of contemporary information Imaging and radiation safety (8%) Clinical Practice Evaluation of equipment Equipment safety Radiation safety Safe practices with imaging equipment Indications for advanced imaging Practice Evaluation and Improvement Patient Safety Provider and Staff Safety Professional Responsibility Statutory requirements Facility regulations Sources of contemporary information Assessment/diagnosis/integration/referral (26%) Clinical Practice Pathophysiology Physical Examination Health History Diagnostic studies Documentation Data interpretation Practice Evaluation and Improvement Evaluation of clinical judgment Consultation Care coordination Reporting Professional Responsibility Statutory requirements Facility regulations Pharmacological treatment (8%) Clinical Practice Pharmacology of pain Drugs for pain intervention Drug interactions Risks and benefits of drug therapy
Objective 4. Identify the educational and practice prerequisites for the target group of CRNAs eligible to take a NSPM specialty certification exam. Identifying the educational and practice prerequisites of the target group of CRNAs who should be eligible to take a NSPM certification exam was accomplished by asking the AC to respond to 2 questions. The first question required the AC to agree or disagree
Practice Evaluation and Improvement Patient safety Professional Responsibility Statutory requirements Safe drug practices Interventional pain strategies (34%) Clinical Practice Diagnosis of pain generators Targeted treatment of pain Global treatment of pain Development of care plan Implementation of care plan Consideration of patient’s health status Treating myofascial pain Trigger point pathology and treatment Imaging strategies Intervention for complications Practice Evaluation and Improvement Treatment goals Professional Responsibility Collaboration strategies Sources of contemporary information Comprehensive pain treatments (16%) Clinical Practice Informed Consent Protection of patient rights Patient monitoring Consideration of patient needs Post-procedure follow-up Multidisciplinary pain management Practice Evaluation and Improvement Outcome measurements Patient follow-up Professional Responsibility Multidimensional pain management Sources of contemporary information Skill Set Recognition of anatomical structure in various view planes Identification of anatomical components under fluoroscopy Proper and safe needle placement for various approaches in: Cervical region Thoracic region Lumbar region Sacrum
with a set of potential prerequisites including completion of specific pain management curriculum content, participation in continuing education, an active NSPM practice or a combination of these options. The second question asked the AC to agree or disagree on the appropriate number of NSPM practice hours and procedures recommended as one of the qualifiers for specialty certification. A baseline of 320 practice hours
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TABLE 3. Proposed Minimum Curriculum Content for NSPM Practice
Content Theoretical foundation of pain Imaging and radiation safety Assessment/diagnosis/integration/ referral Pharmacological treatments Interventional pain strategies Comprehensive pain treatments
Minimum Contact Hours (60 minutes ¼ 1 contact hour) 10 10 30 10 40 20
project. Descriptive statistics, including the mean, median, standard deviation, minimum, maximum, and valid numbers of responses as appropriate for each project objective, were determined after each round of questioning. Likert scale rankings were evaluated by calculating the mean, standard deviation, and median to determine the overall opinion and consistency of the AC members’ responses. Interrater reliability between the AC and CRNA survey sample group was assessed using the Kappa statistic (PASW v17.0.2). This statistic measures the agreement between two or more observers and evaluates the agreement scores against the level that would occur simply by chance (Viera & Garrett, 2005).
RESULTS per year and 10 procedures per week for 5 years was established as a starting point for this discussion. The threshold for determination of consensus by the AC was 80% agreement on a given prerequisite, number of practice hours, or number of procedures. If the 80% agreement criterion for a given option was not met during the first voting period, then the options that received more than a 20% agreement were sent back to the AC for an agree or disagree decision. During subsequent rounds, the AC members were asked to justify their responses. The final step in the process to examine the reliability of the AC consensus content contained in each of the four objectives was to survey an expanded group of CRNAs who practice NSPM to comment on the content. The sample survey group contained CRNAs in the NBCRNA database who self-identified as practicing NSPM (n ¼ 611). Of the 611 electronic surveys distributed, 155 were returned (25.36%). An 80% agreement threshold between the survey group and the AC group was used to confirm acceptance of the content. Reliability of the content was examined by testing interrater reliability between the AC and CRNA sample group and by comparing the ‘‘face validity’’ of the AC generated content with the competency evaluation and specialty certification recommendations from the 2007 NBCRNA practice analysis (Thiemann, 2010). Data Collection and Analysis Procedures Interaction between the primary investigator (S.W.) and the AC members occurred by phone and email between September and December of 2010. There was no group interaction by any communication mode and anonymity was thereby maintained. The 3-point Likert scale was chosen because intensity or direction of opinion was not important in this
Objective 1 Consideration of the expected qualifications for competency in NSPM and identification of tools to assess the knowledge base and skill set to be certified in the specialty required one round of deliberation by the AC and was responded to by all eight members. The AC identified continuing education, clinical practice requirements, completion of an established curriculum, and holding credentials at an accredited facility as expected competency qualifiers for eligibility for NSPM certification. The AC identified written examination, demonstration of technical skills, and peer review/quality assessment as acceptable assessment tools for specialty certification in NSPM (Table 4). Objective 2 Five members of the AC provided 27 references, which included books, journals, and web sites that they most frequently used for knowledge and technical skills information in their NSPM practice (Table 5). Objective 3 Each domain, category, and evaluation item on the draft knowledge and skill set blueprint to evaluate competency in NSPM practice was acceptable to the AC with a mean Likert score of between 1.0 and 1.25 (Table 2). There were no recommended additions to the blueprint and therefore no further discussions required to acquire consensus. Objective 4 Consensus on the educational and practice prerequisites for the target group of CRNAs eligible to take a NSPM specialty certification exam required three rounds of scoring. The final consensus was that the target group should have completed an established curriculum in NSPM, completed a required amount of
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TABLE 4. Qualification Requirements and Competency Assessment Tools 1
2
3
Variance
Mean
Qualifying Requirements
4 3 6 7 2
2 3 2 0 3
2 2 0 1 3
0.69 0.61 0.19 0.44 0.61
1.75 1.87 1.25 1.25 2.12
Continuing education requirements Holding credentials at an accredited facility Clinical practice requirements Completion of an established curricular content Reference from other specialists
1
2
3
Variance
Mean
Competency Assessment Tools
5 4 3 2 2 2
2 2 4 4 3 3
1 2 1 2 3 3
0.50 0.69 0.44 0.50 0.61 0.61
1.50 1.75 1.75 2.00 2.12 2.12
Written exams Peer Review and Quality Assessment Demonstration of technical skills Chart review Self-assessment Oral exams
Key to rankings: 1 ¼ Agree; 2 ¼ Somewhat appropriate; 3 ¼ Inappropriate.
continuing education in NSPM, and demonstrated that they have an active practice in NSPM (Table 6). The AC could not agree on the number of practice hours and procedures that should be required to be eligible to take the specialty certification exam. All but one of the eight AC members felt that the numbers offered as a starting point were too high, or that specific numbers would be difficult to confirm, or they would not be valid in determining active practice. Therefore, this effort did not result in a recommendation for the number of practice hours or procedures that would make a CRNA eligible to take a NSPM specialty certification examination. Analysis of the interrater reliability between the AC and CRNA survey sample demonstrated a significant level of agreement with a kappa ¼ 0.68.
DISCUSSION Recommendations resulting from the advisory committee input regarding specialty certification in NSPM included four specific competency qualifications for eligibility for certification and three assessment tools to evaluate those competencies. The AC agreed on a list of resources for developing questions for a certification examination and on a blueprint of domains, categories and items from which those questions should originate. Finally, the AC, with concurrence with a broad sample of CRNAs practicing NSPM, recommended a competency evaluation process be offered to those CRNAs who can demonstrate that they have completed an approved curriculum in NSPM, have an active NSPM practice, and hold credentials to practice NSPM at an accredited facility.
The AC members who believed it was inappropriate to include time and procedure requirements for the demonstration of an active practice may have a valid point. It is likely that mastery of clinical competency cannot be correlated with hours of clinical practice. A comprehensive study of pediatric nurse practitioner educational programs by Hawkins-Walsh, et al. (2011) revealed the complex nature of clinical experience and the difficulty of correlating the time spent in clinical practice with evidence of competency. Berg, Hawkins-Walsh, Gaylord, Lindeke, & Docherty, (2011) referenced well-respected authorities such as the IOM and the Pew Commission when reporting that there is little evidence to suggest that a required number of clinical hours translates into skills acquisition and competency. Although the AC suggested that there may be a more appropriate method to demonstrate active practice than requiring a minimum number of hours and procedures, they were unable to recommend a specific alternative. The AC felt that there should be an initial competency evaluation for certification followed by subsequent recertification periods. The initial competency evaluation should include completion of a written examination and demonstration of technical skills. The recommendation for recertification included 100 hours of continuing education specific to the practice of NSPM in the preceding five years and continued demonstration of active practice in NSPM. Retesting and reevaluation of technical skills for recertification in NSPM would also be consistent with the AC recommendations. The concept of competency has been expanded beyond fact-based knowledge to include patient-
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TABLE 5. Resource Material and Number of Times Cited by Advisory Committee #
Resource and First Author (if applicable)
1 1 2 2 2 1 2 1 1 1 1 1 1 1 2 1 1 1 1 1 3 1 1 1 1 1 1
Acupuncture: Trigger Points and Musculoskeletal Pain (Baldry) American Academy of Pain Management (www.AAPainManage.org) Atlas of Common Pain Syndromes (Waldman) Atlas of Image Guided Intervention in Regional Anesthesia and Pain Medicine (Rathmell) Atlas of Interventional Pain Management (Waldman) Atlas of Pain Injection Techniques (O’Connor) Atlas of Pain Management Injection Techniques (Waldman) Atlas of uncommon pain syndromes (Waldman) Bonica’s management of pain (Fishman) Cochrane Database (http://www.cochrane.org) Complications in regional anesthesia and pain medicine (Neal) Essentials of Pain Medicine and Regional Anesthesia (Benzon) Fast facts : chronic pain (Cepeda) Handbook of C-Arm Fluoroscopy Guided Spinal Injections (Wang) Imagine Guided Spine Intervention (Fenton) Imaging for Regional Anesthesia and Pain Management (Raj) Massachusetts General Hospital Handbook of Pain Management (Ballantyne) MDConsult (www.mdconsult.com) Neural Blockade: Pain Management (Cousins) Pain Management (Waldman) Pain Management: A practical Guide for Clinicians (Weiner) Pain Medicine: The requisites in Anesthesiology (Abram) Pain Physician (www.painphysicianjournal.com) Pharmacology and Therapeutics: Principles to Practice (Waldman) Physical diagnosis of pain: an atlas of signs and symptoms (Waldman) PubMed (www.pubmed.com) Textbook of Pain (Wall)
centered practice skills (Edler et al., 2009). Adding the evaluation of important technical skills to the competency evaluation was recommended by the AC. The incorporation of peer reviewed demonstrations of core technical skills using simulation may be a useful adjunct. The American Association of Nurse Anesthetists (AANA) offers an educational seminar in NSPM that includes ‘‘hands on’’ training with cadavers. Combining such a seminar with a competency evaluation of knowledge and skills would be an efficient use of time and manpower resources.
Development of a NSPM curriculum must be an evolving process and should include the characteristics of nursing philosophy. Nursing is an art and science that approaches patient care with theories that are uniquely different from any other health care profession (Selanders, 2010). CRNAs should look at all possible solutions to this complex and elusive issue of pain management and not be constrained by a single model. Including all aspects of the nursing metaparadigm; person, health, environment, and nursing, would set CRNA NSPM practice apart from others.
TABLE 6. Educational and Practice Prerequisites for the Target Group Initial
Subsequent Recertification
A
1
0
B
0
0
C
7
8
Choice
(a) Those who can demonstrate they have completed the curriculum content outlined by NBCRNA. (b) Those who have completed (1) and obtained 100 hours of approved continuing education credits in NSPM education in the last 5 years. (c) Those who have completed (1) and (2), and can demonstrate they have an active practice in NSPM.
Specialty Certification for Nurse Anesthetists
Certification of CRNAs in NSPM practice is a critical component of the vision of the NBCRNA (Thiemann, 2010). The recognition of a specialty area of practice is new to the profession and its members, and important to their efforts to have NSPM recognized by legislators, regulators, and policy makers as a specialty practice within the scope and education of CRNAs. Specialty certification is also consistent with the Consensus Model for APRN Regulation and its member organizations, one of which is the AANA (National Council of State Boards of Nursing, 2008).
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For those reasons, it is important to all CRNAs and to the profession, that the development of a competency evaluation and certification in NSPM be successful and sustainable. Without a valid competency evaluation tool, the specialty certification program is not likely to maintain credibility. An important part of the sustainability will be continued evaluation and validation of the tool, maintaining contemporary information going forward, and assuring fidelity to the overall organizational vision of competency, patient safety, and effective practice.
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educational preparation. Journal of Pediatric Health Care, 25(1), 5–15. Hsu, C., & Sandford, B. A. (2007). The Delphi technique: Making sense of consensus. Practical Assessment, Research & Evaluation. Retrieved August 10, 2013, from Http://pareonline.net/getvn.asp?v¼12&n¼10. Institute of Medicine (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, D.C.: National Academy Press. 2001. Kak, N., Burkhalter, B., & Cooper, M. (2001). Measuring the competence of healthcare providers. U.S. Agency for International Development (USAID) Quality Assurance (QA) Project, Bethesda, MD. National Board of Certification and Recertification for Nurse Anesthetists. (2008). Advanced pain management for nurse anesthetists: A learning curriculum. Paper presented at the Radiology and Pain Specialty Workgroup, St. Petersburg, FL. National Board of Certification and Recertification for Nurse Anesthetists. (2010). NBCRNA: About us Retrieved March 17, 2010, from http://www.nbcrna.com/about-us/ Pages/default.aspx. National Council of State Boards of Nursing. (2008). APRN model act/rules and regulations, Retrieved from https:// www.ncsbn.org/APRN_leg_language_approved_8_08.pdf. Partin, B. (2009). Consensus model for APRN regulation. The Nurse Practitioner, 34(6), 8. Selanders, L. C. (2010). The power of environmental adaptation: Florence Nightingale’s original theory for nursing practice. Journal of Holistic Nursing, 28(1), 81–88. Swankin, D., LeBuhan, R. A., & Morrison, R. (2006). Implementing continuing competency requirements for health care pracitioners. Washington, D.C.: AARP Public Policy Institute. Thiemann, L. (2010). National Board of Certification and Recertification for Nurse Anesthetists Pain Management Practice Analysis: Draft Report. In Castle (Ed.). Chicago, IL Viera, A. J., & Garrett, J. M. (2005). Understanding interobserver agreement: The kappa statistic. Family Medicine, 37(5), 360–363. Williams, H. F., & Counts, C. S. (2013). Certification 101: The pathway to excellence. Nephrology Nursing Journal, 40(3), 197–208.