Proposal for a New Graduate Nursing Program Concentration:

Critical Care Nurse Specialist

School of Nursing & Health Studies

August, 2002

Prepared by the Graduate Nursing Faculty: Janie Heath, ACNP and CCNS Program Coordinator Linda Briggs, CCNS Course Coordinator Mary Lou Siantz, Associate Dean

Introduction

Advances in the treatment of disease and in health care, in general, are occurring at a mind-boggling pace. The challenge for health care providers is to keep abreast of new information, as it becomes available, and incorporate it into meaningful and cost-effective improvements in practice. This charge is important for all disciplines and specialities, but has particular salience in critical care, which is traditionally Ahigh-tech@. Nurses are Afront-line@ providers in this rapidly changing, increasingly complex environment. In order to assist the beside nurse and other care providers in delivering state-of-the-art quality care, nursing experts need to have a constant presence in critical care units to advise, instruct, mentor, and participate in all phases of care. The expert in nursing is the clinical nurse specialist (CNS). According to the American Nurses Association (1996), a clinical nurse specialist is an expert in a particular specialty or subspecialty who functions in a number of expanded practice roles from direct patient care to organizational management. One of the primary roles is that of change agent. This is a critical and pivotal role in today=s health care environment.

While the CNS role is not new, recent changes in the arena of health care make this role more important than ever before. As mentioned earlier, the rapid pace of advances in knowledge require that all providers stay updated. In addition, the nursing shortage has created a need to redesign methods of care delivery to achieve maximum efficiency and quality. Further, the current mobility of the nursing workforce has created increased needs for unit-specific and specialty-specific education and orientation. In a fact sheet on the nursing shortage, the American Association of Critical Care Nurses (AACN) indicated that there is an acute shortage of experienced nurses especially in areas such as critical care that require more advanced training.

Nursing education has been slow to respond to these changes. Data from the National Sample Survey of Registered Nurses (1997) indicated that between the years 1992 and 1996, there was very little growth in the number of CNSs. Further, schools of nursing have reported that the proportion of CNS enrollments in master=s programs has consistently decreased (National Advisory Council on Nurse Education and Practice, 1999). Some of these trends may be partially explained by the growth of nurse practitioner programs during the same period and the elimination of many clinical nurse specialist positions during the early 1990s as part of hospital down-sizing and restructuring. However, the National Advisory Council (1999) was quick to point out that changes in health care make the CNS role even more vital for the future. The federal government considers the education of CNSs to be so important that it has designated funding for the development of these programs under 1992 legislation related to Title VIII Section 821 of the Public Health Services Act. Currently, there are indications from the health care industry that they are reinstating and increasing CNS positions. Nursing leaders are reporting that it is difficult to find qualified individuals to fill these jobs. Locally, several hospital administrators have voiced an interest in the creation of a critical

care clinical nurse specialist program. Interested organizations include Georgetown University Hospital and the Washington Hospital Center. In response to these issues, the School of Nursing & Health Studies (SNHS) is proposing the addition of a critical care clinical nurse specialist (CCNS) program as an option for graduate nursing studies.

Background Background

The CNS is one of several advanced practice roles identified by the American Nurses Association (ANA). The other roles include the nurse anesthetist, the nurse practitioner, and the nurse-midwife. All of these roles require graduate educational preparation at the master=s or doctoral level (ANA, 1996). Currently, SNHS offers programs for all of these roles except that of the CNS.

While the ANA (1996) acknowledges that the scope of practice for each of these roles is distinct, there is an overlap in the body of knowledge and skills required. The SNHS has sought to capitalize on this fact by creating a group of required core courses for all graduate nursing students. These core courses have been in existence for a number of years. Beyond this, the Family Nurse Practitioner (FNP) Program and the Acute Care Nurse Practitioner (ACNP) Program hold some joint sessions within their specialty courses to provide common content to both groups. The Critical Care Nurse Specialist (CCNS) Program would extend this concept in that CCNS students would attend the required core courses, as well as some joint sessions with the ACNP students. This plan provides for maximum efficiency and utilization of nursing faculty and guest lecturer expertise. It also allows for the development of collegiality between the different nursing groups. The CCNS clinical courses and the new AInnovative Teaching-Learning Strategies@ course will provide the remaining content necessary for current and anticipated CNS practice, and to satisfy eligibility requirements for the CCNS certification examination.

The need to identify the CCNS Program as separate and distinct from the ACNP Program grows out of differences in the scopes of practice and certification requirements from the American Nurses Credentialing Center (ANCC) and the American Association of Critical Care Nurses (AACN). Certification is becoming an increasingly important part of insuring quality in health care. In addition, more and more states are using certification as a criterion for advanced practice licensure. Currently, the ANCC does not offer critical care clinical nurse specialist certification, but is the only organization to offer ACNP certification. The American Association of Critical Care Nurses offers CCNS certification through the AACN Certification Corporation. Eligibility for the CCNS examination includes a master=s degree in nursing with evidence of CNS theory and clinical concentration. Five hundred hours of CNS-related clinical practice are required. Since transcripts

are the primary documents used by both organizations to determine examination eligibility, it is important to clearly distinguish which program the applicant completed. This can be accomplished by making the CCNS course of study a distinct program (concentration).

This distinction between ACNP and CCNS graduates has important legal implications. Since certification is becoming a major criterion for licensure, it is incumbent upon schools of nursing and certifying bodies to insure that only those individuals who have received the appropriate training and education become certified in a particular field of expertise. As mentioned previously, the scope of practice for the ACNP differs from that of the CCNS both from a theoretical and a legal standpoint. Not all states provide clinical nurse specialists with title protection. In addition, prescriptive authority for both CNSs and ACNPs varies from state to state. Therefore, it is important to insure that clinical nurse specialists do not take nurse practitioner examinations and vice versa.

Job Opportunities for the CCNS Job Opportunities for the CCNS

The job opportunities for CCNS graduates are expanding. Graduates of clinical specialist programs receive mailings from recruiters across the country on a regular basis. Local and national nursing publications are also replete with advertisements of positions (See samples in Appendix A). According to the National Sample Survey of Registered Nurses (1997) only 6.3% of the registered nurse population are advanced practice nurses. Of these 161,711 advanced practice nurses only 53,752 are CNSs and another 7,835 graduated with blended CNS/NP preparation. Currently there are only 262 certified Adult CCNSs. This low number is due in part to the newness of the examination and the flat growth rate in the CNS population overall. Certification is not currently mandatory, but as mentioned earlier, state boards are more frequently incorporating this as a criterion for advanced practice licensure. Magnet hospitals and other employers are also increasingly interested in employing certified nurses at all levels.

Goals and Objectives Goals and Objectives

The School of Nursing & Health Studies will respond to societal needs for safe, quality health care and the need for clinical nursing experts to oversee and provide that care by educating students to become critical care clinical nurse specialists (CCNSs). The objectives of the program are to:

Provide students with an in-depth understanding of the care of critically ill

patients and their families Assist students in gaining expertise within the three spheres of CCNS

influence: o Patient and family needs o Nursing needs o Systems needs

Prepare students to function as clinical experts, consultants, researchers, educators, nursing leaders and case managers upon graduation Prepare students who are eligible for national certification as clinical nurse

specialists (CCNS B AACN Certification Corporation)

Challenges Challenges

Competition

While there are at least four clinical specialist programs in the area (George Mason, Johns Hopkins, University of Maryland, and Marymount), only the University of Maryland and Marymount offer specialization in critical care. Marymount is a rather small school, which may be less attractive to candidates. Maryland=s program offers a blended nurse practitioner and clinical specialist role. For those individuals wishing to differentiate their practice, a program that specializes in the clinical specialist role may be more attractive. At the same time, the SNHS offers a specialized acute care nurse practitioner program. Students who are unsure of their career paths may elect part-time study and take the required core courses while deciding which program is more in line with their personal goals and desires.

Opportunities Opportunities

Since a number of local

hospitals have expressed a need for clinical nurse specialists and an interest in the proposed CCNS program, there may be opportunities for scholarships, grants, and donations. For example, Medstar=s interest in the CCNS program was instrumental in the development of the Excellence in Nursing Science and Practice Scholarship, which is a partnership between Georgetown University Hospital and the School of Nursing & Health Studies to encourage staff nurses to continue their education and to foster nursing

recruitment and retention. Interested hospitals may also be potential clinical sites for students and sources of jobs for graduates.

There may also be opportunities to obtain federal grant money for the development and growth of the CCNS program through Title VIII of the Public Health Services Act Section 821 or through the newly passed Nurse Reinvestment Act

Resources

Resources

Because faculty with training and expertise as critical care clinical nurse specialists are already employed by the SNHS, no additional faculty will be needed for the initiation of the program. As the program grows, additional faculty positions may need to be added to support the number of students enrolled. The dove-tailing of the FNP, ACNP, and CCNS programs to cover some common course content maximizes the utilization of existing faculty. Enrollment in required core courses is not expected to exceed capacity at this time. Additional sections for these courses may need to be added in the future if combined program enrollment increases significantly.

General Program Description and Rationale General Program Description and Rationale

The School of Nursing and Health Studies proposes to offer a Critical Care Clinical Nurse Specialist (CCNS) concentration as course of study to obtain a master=s of science degree. Further, the SNHS proposes that this concentration be offered as a traditional master=s of science program, a post-master=s certificate, and as direct entry into practice. This course of study is designed to prepare graduates who will be considered experts in critical care nursing and who will be eligible to take the Adult CCNS certification examination offered by AACN.

The SNHS is committed to this endeavor as a response to a documented need for additional advanced practice nurses, particularly in the area of critical care. The CCNS graduates will serve in important roles throughout the country working to improve patient outcomes and reduce healthcare costs (National Advisory Council on Nurse Education and Practice, 1999). Graduates will also serve as preceptors, advisors, and mentors for staff nurses to promote nursing

excellence in patient care and an improved perception of self-worth. These activities are crucial in national efforts to improve the quality of healthcare and to retain nurses in stressful, complex practice settings such as critical care.

PROGRAM REQUIREMENTS PROGRAM REQUIREMENTS

The requirements for the

CCNS graduate nursing program are designed to: Provide students with essential content recommended for all graduate

nursing programs Present theories pertinent to nursing and specifically to the role of the

critical care clinical nurse specialist Educate students to promote an in-depth understanding of the care of

critically ill patients and their families Enable student to obtain the necessary clinical experience to improve their

expertise and to satisfy practice requirements for the CCNS examination Assist students to gain skills necessary to provide the following:

o Organizational and systems analysis o Quality Improvement o Outcomes Research o Case Management o Continuing Education Programs o In-hospital staff education o Scholarly Presentations o Consultation o Role-modeling and mentoring

General Degree Requirements for the Master=s of Science in Nursing General Degree Requirements for the Master=s of Science in Nursing

Critical Care Clinical Nurse Specialist Concentration Critical Care Clinical Nurse Specialist Concentration

he CCNS graduate nursing program will incorporate existing core courses common to the ACNP, FNP and nurse mid-wifery programs. In addition,

there are three specialty clinical courses which address the disease processes, treatments and technologies outlined in the blueprint for the CCNS examination, as well as issues such as evidenced-based practice, and health care related information technology. These courses will also require the completion of a total of 500 clinical hours related to clinical nurse specialist activities. A course entitled AInnovative Teaching-learning Strategies for the Advance Practice Nurse: Theory & Practice@ will also be required. This course will encompass concepts and methods of designing and implementing educational programs. The total required program credits are 40 with an additional 3 to 6 credits required if the student elects the thesis option. Degree requirements are designed to be completed in 1 year of full-time, or up to three years of part-time study. Required Core Courses: (Currently existing courses required of all CCNS, ACNP, FNP, Nurse-Midwifery students Total Credits: 23)

nalytical Tools and Biostatistics (3 credits) B This course provides students with an overview of quantitative and qualitative methods useful in the collation, display, and analysis of data. The course provides a broad framework for understanding and applying commonly used data analysis techniques utilized in health care research.

cholarly Inquiry in Health Care (3 credits) B This course provides students with an intermediate profiency in research skills. The research literature in healthcare is used to illustrate and evaluate research principles.

rofessional Aspects in Advanced Practice (3 credits) B This course focused on advanced practice nursing roles. Emphasis is on philosophical inquiry, theory analysis, and the development of leadership skills for working with individuals and groups in advanced practice. Major theoretical perspectives from a variety of disciplines are explored as a foundation for advanced practice nursing.

ealth Systems and Policies in Transition (3 credits) B This course examines the complex political, economic and social forces that shape health care systems. It provides an introduction to general principles of health care organization, financing, and regulation. It then sets forth a dynamic comparison of various approaches to health care delivery systems in different parts of the world. Current policy initiatives are analyzed for their impact on cost, quality, access, and health of populations. Students develop beginning skills in the epidemiological approach to population-based health care systems.

dvanced Concepts in Physiology and Pathophysiology (3 credits) B This course presupposes a knowledge of human anatomy and physiology. Subjects are covered from a molecular, cellular, tissue, organ, and system perspective, and are then related to nursing practice. This course imparts concepts of pathophysiology which can be used by the student to further increase personal knowledge in the future. Emphasis is placed on acquiring skill in the use of scientific literature and conceptualizing information gained from many sources.

dvanced Concepts in Pharmacology (3 credits) B This course focuses on the pharmacologic concepts important to nurses. These concepts include receptor theory, receptor-effector coupling, dose-response relationships, mechanisms of action of important classes of drugs, pharmacokinetics and pharmacodynamics. Course content is geared toward providing the student with an understanding of pharmacology that can be applied to new drugs which may become available in the future.

dvanced Health Assessment (3 credits) B This advanced health assessment course covers content for students in advanced practice nursing specialties with a clinical component. Content includes theory and clinical practice in health history taking, risk appraisal, physical and mental evaluation, psychosocial assessment, and nutritional assessment, with an introduction to disease prevention. Health assessment skills are presented fro all age groups from the newborn through aged populations. Supervised practical experience is provided.

ioethics I for Health Care Professionals (1 credit) B This is an introductory exploration of medicine and nursing as moral endeavors B and of physicians and nurses as moral agents, of the professional-patient relationship; of the ethical significance of the concepts of health disease, and illness; and of the predominant theoretical frameworks for explaining and justifying solutions to problems in clinical ethics.

ioethics II for Health Care Professionals (1 credit) B This course presents methods for analyzing, working up, and resolving problems in clinical ethics. The history and contemporary status of thinking and practice with regard to the major problems in clinical ethics, e.g. truth-telling, communication, and confidentiality; competence, informed consent, and refusal of treatment; withholding and withdrawing treatment; assisted suicide and euthanasia;

genetic information, reproductive health care; justice and fairness are all discussed. Required Concentration Courses: (CCNS students. New courses approved by the Executive Faculty B SNHS; Total: 17 credits)

ritical Care Clinical Nurse Specialist I: Advanced Assessment of Acutely and Critically Ill Individuals (5 credits) B This course focuses on the integration of advanced assessment techniques and parameters with critical thinking to solve problems related to the care of patients with complex needs in acute and critical care settings. Additionally, an introduction to the CCNS role will be presented. Actualization of the theoretical components of the CCNS role as observed in the clinical setting will be discussed. Students will obtain practical experience in CCNS role activities under the guidance of experienced clinical nurse specialists (150 clinical hours). They will also have assignments and projects designed to assist them in gaining expertise in presenting, consulting, teaching, and writing for publication. This course will only be offered in the Fall as the first course in the Aclinical sequence@ of required concentration courses. Successful completion of this course with a grade of B or better is required for progression to the CCNS II.

ritical Care Clinical Nurse Specialist II: Research-based Interventions for Acute and Critically Ill Patients (5 credits) B This second level critical care course will only be offered in the Spring and focuses on the scientific basis of interventions to determine best practices in the care of complex, acutely ill individuals. The clinical practicum (200 clinical hours) provides opportunities to: participate as a member of a multi-disciplinary acute/critical care team; determine appropriate interventions; utilize critical care nurse specialist skills at the patient/family, staff, and systems levels to influence patient care; and to evaluate outcomes for the interventions and the patient. Successful completion of this course with a grade of AB@ or better is required to progress to the next course.

ritical Care Clinical Nurse Specialist III: Actualizing the Role (3 credits) B This course builds on the theories presented in the Professional Aspects of Advanced Practice course and on the Synergy Model developed by the American Association of Critical Care Nurses (AACN). Important aspects of the clinical nurse specialist role will be highlighted as well as methods and tools for the implementation of these various roles, including consultation, collaboration, and writing for publication. This final integration course is

offered only in the Summer (8 week session) and focuses on the student becoming an active participant in components of the CCNS role in the clinical setting. Leadership, financial, and organizational strategies will also be discussed. Students will perform a needs assessment and design an appropriate intervention in collaboration with his or her clinical preceptor for a problem observed in the clinical setting.

nnovative Teaching-Learning Strategies for the Advanced Practice Nurse: Theory & Practice (3 credits) B This course focuses on the concepts of designing and implementing educational programs for a variety of settings, from the bedside to major conferences. Topics will include determining learning needs, composing objectives, selecting appropriate educational methods, utilizing technology to enhance student learning, and applying to become a continuing education provider. This course will only be taught in the Spring. It will be offered to other graduate nursing students who are interested. The School of Medicine has indicated some interest in this course as well.

cholarly Project (1 credit) B During their final semester, students will work on a guided study intended to produce a scholarly product that reflects a synthesis and integration of core and specialty course content. The integration includes research, health care issues, roles, theory, and evidenced-based practice. Examples of scholarly projects include an analysis of the state of the science on a particular topic, creative approaches to practice, development of proposals for community-based projects, position paper on selected key issues, and research projects. Elective Courses:

natomy for Health Care Professionals (1 credit) B This course provides the student with an overview of the human body by exploration of the human dissected cadaver. The students will examine organ systems by region following a brief lecture on the topic. The lecture will focus on the relationship between form and function, while the lab will allow the student to relate his/her previous clinical knowledge to the 3-dimensional aspects of anatomy. This course is only offered in the Fall and is a companion to Advanced Concepts in Physiology and Pathophysiology. This course is a selling point for Georgetown=s advanced practice programs. Very few, if any, other schools provide NP and CNS students with this type of experience.

hesis Option (3 B 6 credits) B The thesis option is an alternative to the Scholarly Project. The student working independently with faculty guidance,

completes a thesis to meet specific professional and academic goals. Through this study, the student will demonstrate an in-depth knowledge of the research process.

ADMISSIONS REQUIREMENTS AND APPLICATION PROCESS

ADMISSIONS REQUIREMENTS AND APPLICATION PROCESS

ecause clinical nurse specialists are considered to be experts in their chosen areas of nursing, at least one year of clinical experience (critical care preferred) will be required prior to entry into the CCNS program. For direct entry students (previous baccalaureate degree), this year of experience will occur after completion of course work necessary to become eligible for the NCLEX examination and successful completion of the NCLEX. For all other students, a baccalaureate or higher degree in nursing from an NLN-accredited school is required.

ther criteria for admission include: A minimum undergraduate grade point average of 3.0 on a 4.0 scale

Graduate Record Examination (GRE) or Miller Analogies Test (MAT); the

test must have been taken within 5 years prior to application Completion of the Graduate School Admissions Application

Completion of a one to two page personal statement

Three letters of recommendation

Official transcripts from each undergraduate and graduate institution that

the applicant attended Satisfactory completion of an introductory three-credit statistical methods

course Registered nurse license

A pre-admission interview is recommended

TOEFL score of 550 (213 on computer-based tests) or better for

international students who have not received undergraduate or graduate degrees from accredited institutions of higher education in the United States

or from universities in other countries where English is the primary language of instruction. Application fee

References References

American Association of Critical Care Nurses (1999). Evaluating your knowledge for

CNS certification: Adult CCNS examination B a blueprint for study and sample

uestions. Alisa Viejo, CA: American Association of Critical Care Nurses. American Nurses Association (1996). Scope and standards of advanced practice

egistered nursing. Washington, D. C.: American Nurses Publishing. National Advisory Council on Nurse Education and Practice (1999). Federal report for the preparation of the clinical nurse specialist workforce through Title VIII. Report to the Secretary of Health and Human Services. Rockville, MD:

Division of Nursing Bureau of Health Professions, Health Resources and Services

Administration, United States Department of Heath and Human Services.

Retrieved from the internet 7/15/02: http://bhpr.hrsa.gov/dn/cnsrepex.htm

National Sample Survey of Registered Nurses: March 1996 (1997). Rockville, MD:

ivision of Nursing, Bureau of Health Professions, Health Resources and

ervices Administration.

Appendix A

CCNS Job Opportunities

Appendix B

Faculty Instructional Responsibilities

Clinical Nurse Specialist I (Fall) B team taught 1 section Clinical Nurse Specialist I (Fall) B team taught 1 section Linda Briggs

anie Heath

arol Rauen Clinical Nurse Specialist II (Spring) B team taught 1 section Clinical Nurse Specialist II (Spring) B team taught 1 section Linda Briggs

anie Heath

arol Rauen Clinical Nurse Specialist III (Summer) B team taught 1 section

inda Briggs

anie Heath

arol Rauen Innovative Teaching-Learning Strategies for the Advanced Practice Nurse: Theory and Practice (Spring) Innovative Teaching-Learning Strategies for the Advanced Practice Nurse: Theory and Practice (Spring) Carol Rauen Scholarly Project (Summer) Scholarly Project (Summer) Linda Briggs

anie Heath

arol Rauen Core Required Courses Core Required Courses No additional sections added

nstructors as previously designated

Appendix C

Sample Sequence of Classes Plan of Study (Masters Program B Full time): Fall Fall NURS 514 Analytical Tools & Biostatistics (3 cr) NURS 518 Bioethics of Healthcare Professionals ** (1 cr) NURS 528 Advanced Health Assessment (Fri & Sat for 4 weeks only) (3 cr) NURS 546 Physiology/Pathophysiology (3 cr) NURS 642 Critical Care Clinical Nurse Specialist I (5 cr) NURS 469 Gross Anatomy (elective) (1 cr) Total: 15-16 Spring Spring NURS 509 Scholarly Inquiry in Health Care (3 cr) NURS 518 Bioethics Healthcare Professsionals ** (1 cr) NURS 538 Professional Aspects (3 cr) NURS 544 Pharmacology (3 cr) NURS 640 Innovative Teaching-Learning Strategies: Theory & Practice (3 cr) NURS 644 Critical Care Clinical Nurse Specialist II (5 cr) Total: 18 Summer SummerNURS 548 Health Systems & Policy in Transition (3 cr) NURS 650 Critical Care Clinical Nurse Specialist III (3 cr) NURS 997 Scholarly Project (1 cr) Total: 7 Post-Masters Certificate Post-Masters Certificate Fall NURS 546 Physiology/Pathophysiology (if > 5 yrs since MS) NURS 528 Advanced Health Assessment NURS 469 Gross Anatomy (elective) NURS 640 Innovative Teaching-Learning Strategies: Theory & Practice NURS 642 Critical Care Clinical Nurse Specialist I Spring Spring NURS 544 Pharmacology

NURS 644 Critical Care Clinical Nurse Specialist II Summer Summer NURS 650 Critical Care Clinical Nurse Specialist III ** Pharmacology and Pathophysiology can be waived if graduate level courses were taken as part of previously earned graduate degree within the last 5 years.