Role Delineation Study - American Nurses Association

regarded as more critical than the frequency scale. Therefore, the scales were combined so thata particular value on the performance expectation scale would outweigh or outrank all values onthe consequence and frequency scales. This hierarchical scheme emphasized the work activitiesthat are required of newly certified specialists and have the greatest impact on public health orsafety. Thus this scheme was selected as the organizing mechanism for combining theresponses from the three survey scales into an overall measure of criticality.Data CollectionPilot Testing. Using the same procedures intended for administering the national datacollection, the survey was piloted in March and April 2013. Twenty-five ANCC-certified MedicalSurgical nurses were included in the selection of 125 ANCC-certified nurses randomly selectedfrom across the nation to take the pilot survey. Overall, 42 (34 percent) of the nurses invited totake the pilot survey responded (10 medical-surgical nurses).National Survey. In May and June 2013, the 1,500 ANCC-certified Medical-Surgicalnurses selected to take the national web-based survey were sent three notifications via theUnited States Postal Service: an alert letter, and two follow-up reminders. The alert letterexplained the purpose and importance of the study, the eligibility criteria of the study, and statedhow to access the survey via the internet. The letter indicated that the participant’s responseswould be kept confidential.The letter also notified that respondents completing the survey receive a 5 hour reductionof their continuing education requirement for their ANCC recertification.The first follow-up reminder letter was sent approximately two-weeks after the alert letter.It thanked recipients if they had already submitted their completed survey and encouraged themto do so if they had not already.The final follow-up reminder letter was sent out only to those who had not yet respondedto the survey and was sent out approximately two-weeks prior to the end of the survey.Data AnalysisThe three rating scales were combined into a single measure of overall criticality using ahierarchical method. As agreed by the initial study workgroup, the three rating scales werecombined into a single measure in such a manner that a particular value on the performanceexpectation scale would outweigh or outrank all values on the consequence and frequencyscales, and that a particular value on the consequence scale would outweigh or outrank all valueson the frequency scale.Table 3 displays how the values of the overall criticality rating were constructed accordingto all the possible survey response patterns that might be given to rate an individual work activityby its frequency, performance expectation, and consequence. For example, if a respondentindicated that a particular work activity was expected to be performed within the first six months ofwithin the specialty, could cause severe negative consequences if it was performed incorrectly,and is performed occasionally, the overall criticality rating for that response pattern would be 39.A score of 32 suggests that a work activity is generally expected to be performed within the firstsix months of certification within the specialty and have moderate negative consequences ifincorrectly performed. Therefore, work activities with scores of 32 or higher on the overallcriticality variable may be considered as highly critical. When a work activity was rated as neverexpected on the performance expectation scale, it would receive an overall criticality score of 1 asthe bottom row in Table 3 indicates.2013 Role Delineation Study: Medical-Surgical NursingNational Survey Results Copyright 2014 American Nurses Credentialing Center, All Rights Reserved7

Table 3. Construction of the Overall Criticality VariableSurvey Response OptionsPerformance ExpectationsConsequencesWithin the first 6 months ofcertification within the specialtySevere negativeconsequencesModerate negativeconsequencesMild negativeconsequencesNo negativeconsequencesAfter the first 6 months of certificationwithin the specialtySevere negativeconsequencesModerate negativeconsequencesMild ways11Frequently10Occasionally9Seldom8Never72013 Role Delineation Study: Medical-Surgical NursingNational Survey Results Copyright 2014 American Nurses Credentialing Center, All Rights Reserved8

Table 3. Construction of the Overall Criticality Variable (Continued)Survey Response OptionsPerformance ExpectationsAfter the first 6 months of certificationwithin the specialty (Continued)ConsequencesNo ver expected to perform thisactivity within the specialty12013 Role Delineation Study: Medical-Surgical NursingNational Survey Results Copyright 2014 American Nurses Credentialing Center, All Rights Reserved9

Survey ResultsThe total sample size of the national survey included 1,500 ANCC-certified MedicalSurgical nurses. A total of 432 completed surveys were returned. Thirty-six (36) respondentsindicated they were not currently practicing in Medical-Surgical nursing for an overall responserate of 28.80 percent and a usable response rate of 27.05 percent.Table 4 shows the percent of surveys per population returned in each geographic regioncompared to the number of ANCC-certified Medical-Surgical nurses selected within the region.Table 4. Number of Surveys Returned per Geographic RegionNumber Selected(Percent of total pop.)Number Returned(percent of total pop.)Northeast – NY, CT, MA, NJ, ME, PA, NH, VT, RI525 (35.00)136 (34.34)South – TN, MS, TX, FL, LA, AL, GA, AR, OK, VA, MD, SC, DC, NC, WV,DE, KY472 (31.47)127 (32.07)235 (15.67)66 (16.67)260 (17.33)65 (16.41)8 (0.53)2 (0.51)1,500 (100.00)396 (100.00)Geographic RegionMidwest – IA, NE, KS, OH, MO, MN, SD, ND, MI, IL, IN, WIWest – WA, AZ, CA, OR, CO, AK, ID, NM, UT, HI, NV, WY, MTOther – AE, AP, APOTotalDemographic InformationAppendix B details the Medical-Surgical nurses responses to 15 demographic questionswhich included inquiry on the respondent’s background and practice setting.Demographic BackgroundApproximately 95 percent of the respondents were female and 67 percent reported to bewhite. Approximately 68 percent of the overall sample fell into the age group of 45 to 64 years ofage.Approximately 44 percent of the Medical-Surgical nurses indicated that their entry-level(initial) education in Nursing was through an Associate Degree in Nursing program and 36percent indicated it was through a Baccalaureate in Nursing program. Forty five percent of theMedical-Surgical nurses indicated that they held a Baccalaureate in Nursing as their highestdegree in nursing. Approximately 27 percent indicated that they held an Associate Degree inNursing as their highest nursing degree and 16 percent of the respondents indicated that theyheld a Masters in Nursing.The average number of years of experience the Medical-Surgical nurses had as an RNwas 21.66 years. The respondents also reported on average 20.34 years of experience workingwithin the specialty.Fifty four percent of the respondents indicated working as a Staff Nurse (includingcommunity, clinic, in-patient/client, or other setting, 14 percent indicated working as a ChargeNurse, and almost 7 percent indicated working in management.2013 Role Delineation Study: Medical-Surgical NursingNational Survey Results Copyright 2014 American Nurses Credentialing Center, All Rights Reserved10

Practice SettingsApproximately 50 percent of the Medical-Surgical nurses indicated that they practiced incities with populations between 50,000 and 249,999. Towns with a population between 2,50049,999 had the second highest percent of respondents (18 percent) and Metropolitan areas witha population between 250,000 and 999,999 had the third highest percent of respondents (14percent).In terms of practice setting, approximately 50 percent of the Medical-Surgical nursesindicated that they practice in both Medical/Surgical, while 8 percent indicated practicing in aMedical Unit and 7 percent indicating practicing in a Surgical Unit. Fifty six percent of therespondents indicated they care for patients with Acute conditions while 26 percent indicatedcaring for patients with Chronic conditions. The Medical-Surgical nurses reported spending avast majority of their time treating Adult and Older Adult patients ages 18 years and older.Practice DescriptionsDescriptive statistics (means, standard deviations, and medians) for the three ratings ofall 65 work activities—performance expectation, consequence, and frequency—and mean overallcriticality are listed in Appendix C. The scales were highly reliable. Cronbach’s coefficient alphaestimates for the performance expectation, consequence, and frequency scales when applied toall the data were 0.9380, 0.9876, and 0.9597, respectively. (Cronbach's coefficient alpha, ameasure of internal stability, ranges in value between 0 and 1.)In Appendix D, the overall criticality statistics are presented in rank order of criticality.As indicated in Table 5, 15 work activities were rated by the 396 respondents as highly critical(with a mean overall criticality rank of 32 or above).Table 5. Number of Work Activities by Mean Overall Criticality Range and Population for Medical-Surgical NursingMean Overall Criticality ScoreNumber ofWorkActivities37.0 andaboveBetween32.0 and36.9Between27.0 and31.9Between22.0 and26.9Between17.0 and21.9Between12.0 and16.9Between7.0 and11.96.9 andunderTotalnumberabove32.01142883101015Table 6 and 7 displays the 20 highest-ranking and the 20 lowest-ranking work activitiesby mean overall criticality respectively. The grey shading in Table 6 highlights the only workactivity that received a criticality rating of 37 and above -- 21. Administer medications and othertreatments that are appropriate to the patient situation. Only one work activity received criticalityranking of less than 12. This work activity -- 62. Develop educational programs for groups -- ishighlighted in Table 7.2013 Role Delineation Study: Medical-Surgical NursingNational Survey Results Copyright 2014 American Nurses Credentialing Center, All Rights Reserved11

Table 6. Top 20 Work Activities Ranked by Mean Overall CriticalityWork Activity Number and Name21 Administer medications and other treatments that are appropriate to the patient situation.22 Respond proactively to changes in patient condition to prevent or minimize adverse patient outcomes.12 Document assessment findings.2 Obtain a current medication and treatment list.20 Reconcile medications and treatments across transitions of care.23 Document nursing interventions.4 Perform a physical assessment using age-appropriate, system-specific, evidence-based tools andtechniques.24 Evaluate patient’s response to interventions.32 Advocate for patient.17 Create a safe, therapeutic, developmentally appropriate environment conducive to care.6 Obtain diagnostic test results.28 Document patient’s response to interventions and changes to the plan of care.1 Obtain patient history using age-appropriate, system-specific, standardized/evidence-based tools.31 Maintain appropriate physical and emotional boundaries.11 Identify actual or potential risks to health and safety (e.g., interpersonal, environmental, lack of externalresources).16 Document plan of care and expected outcomes.10Identify barriers to effective communication (e.g., psychosocial, literacy, financial, cultural) and makeappropriate adaptations.33 Document pertinent aspects of nurse-patient interactions.13 Prioritize nursing diagnoses and/or problems.43 Document the education provided and its effectiveness.Overall 7.378.267.19Table 7. Bottom 20 Work Activities Ranked by Mean Overall CriticalityWork Activity Number and Name51 Use technologies to enhance nursing practice55 Coordinate patient safety initiatives.8 Synthesize available data and knowledge to identify patterns and variances.57 Identify and address legal, ethical, and regulatory situations and issues.3 Assess for use of complementary and alternative healthcare practices (e.g., therapeutic touch, herbalpreparations, acupuncture).53 Participate in key roles of quality improvement activities63 Collaborate with interdisciplinary team to identify community resources to assist and support patients inself-management.48 Serve as a clinical resource.59 Incorporate evidence on population-specific risk behaviors or factors when providing health informationand consumer education.56 Seek opportunities to advance professional nursing practice.49 Mentor colleagues for the advancement of nursing practice, the profession and quality health care.60 Participate in activities that promote partnerships between or among health care providers, employers andcommunities.64 Coordinate with community resources to provide strategies for health promotion and diseasemanagement.50 Serve as a clinical content expert for the design and enhancement of competencies, policies, procedures,processes, and systems that affect nursing care.61 Develop educational programs for individuals.54 Participate in key roles related to change management activities.58 Influence healthcare policy involving health care consumers and the profession.65 Participate in the development of new approaches for care delivery that promote population health.62 Develop educational programs for groups.51 Use technologies to enhance nursing practice2013 Role Delineation Study: Medical-Surgical NursingNational Survey Results Copyright 2014 American Nurses Credentialing Center, All Rights ReservedOverall 589.7223.9811.4811.109.7611.5812

Appendix AWork Activities Statements2013 Role Delineation Study: Medical-Surgical NursingNational Survey Results Copyright 2014 American Nurses Credentialing Center, All Rights Reserved

Domain 1: Assessment and Diagnosis1. Obtain patient history using age-appropriate, system-specific, standardized/evidence-based tools.2. Obtain a current medication and treatment list.3. Assess for use of complementary and alternative healthcare practices (e.g., therapeutic touch, herbal preparations,acupuncture).4. Perform a physical assessment using age-appropriate, system-specific, evidence-based tools and techniques.5. Perform a psychosocial assessment using age-appropriate, system-specific, evidence-based tools and techniques.6. Obtain diagnostic test results.7. Review findings provided by interdisciplinary team and external resources.8. Synthesize available data and knowledge to identify patterns and variances.9. Identify nursing diagnoses using a standardized classification system.10. Identify barriers to effective communication (e.g., psychosocial, literacy, financial, cultural) and make appropriate adaptations.11. Identify actual or potential risks to health and safety (e.g., interpersonal, environmental, lack of external resources).12. Document assessment findings.Domain 2: Planning and Outcomes Identification13. Prioritize nursing diagnoses and/or problems.14. Formulate expected outcomes with the patient, family, significant other, and interdisciplinary team to facilitate continuity acrossthe continuum of care.15. Develop an individualized, patient-centered age and developmentally appropriate plan of care.16. Document plan of care and expected outcomes.Domain 3: Implementation17. Create a safe, therapeutic, developmentally appropriate environment conducive to care.18. Implement age and developmentally appropriate evidence-based nursing interventions specific to the plan of care.19. Collaborate with the interdisciplinary team and external resources to coordinate the plan of care across the continuum.20. Reconcile medications and treatments across transitions of care.21. Administer medications and other treatments that are appropriate to the patient situation.22. Respond proactively to changes in patient condition to prevent or minimize adverse patient outcomes.23. Document nursing interventions.Domain 4: Evaluation24. Evaluate patient’s response to interventions.25. Evaluate the effectiveness of the interdisciplinary plan of care.26. Modify the plan of care in collaboration with patient, family, significant other, and interdisciplinary team based on ongoingassessment data.27. Disseminate results/changes in the plan of care to patient, family, significant other, and interdisciplinary team consistent withpatient preferences.28. Document patient’s response to interventions and changes to the plan of care.Domain 5: Nurse-Patient Relationship29.

Surgical nurses were included in the selection of 125 ANCC-certified nurses randomly selected from across the nation to take the pilot survey. Overall, 42 (34 percent) of the nurses invited to take the pilot survey responded (10 medical-surgical nurses). National Survey. In May and June 2013, the 1,500 ANCC-certified Medical-Surgical