A National Role Delineation Study of the Trauma Nurse ... · PDF fileA National Role...

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A National Role Delineation Study of the Trauma Nurse Executive Summary

Introduction

The purpose of this study was to identify the responsibilities of trauma nurses as a first step in the development of a job-related certification examination. The Board of Certification for Emergency Nursing (BCEN), with collaboration from the Society of Trauma Nurses (STN), requested the services of AMP to design and conduct a study that would provide the support necessary to develop specifications upon which a content valid certification examination could be built.

The title of this study includes the use of the term role delineation study. However, other equally appropriate terms could be used to describe this study, for example, job analysis or practice analysis. While role delineation is the term primarily used in this report, these other terms should be considered to be interchangeable in relation to this study.

The BCEN appointed a Role Delineation Study Advisory Committee (AC) to conduct the activities necessary to identify responsibilities of trauma nurses and develop Examination Specifications. The composition of the nine-member AC was reflective of the trauma nurse profession in all relevant respects, for example: geographic, professional area, level of responsibility, educational background, gender, and work setting. Without the AC's effort and expertise across the various specialty areas, this project would not have been accomplished.

Methodology

The AC considered various resource materials that could be useful in gaining an understanding of the responsibilities of trauma nurses, including job descriptions, journal articles, performance evaluation forms, and textbooks. Materials assembled prior to the first meeting of the AC included orientation materials, a draft of topics, tasks, rating scales, and demographic questions for role delineation study survey, and a timeline for conducting the study. Background information was provided regarding both the role delineation process and the role of the study to provide evidence in support of the validity of the examination results. Seven major tasks were initiated during the AC meeting held in April 2014. These steps included:

1. Defining the target practitioner 2. Developing a sampling plan 3. Identifying topics and tasks for the survey instrument 4. Identifying major domains 5. Determining the rating scales 6. Determining the relevant demographic variables of interest 7. Integrating demographics, rating scales, topics, and tasks into a survey instrument


Trauma Nurse Executive Summary

A summary of each activity follows.

1. Defining the target practitioner

For the purposes of this study, BCEN and the AC adopted the following target practitioner definition of a trauma nurse:

Trauma nurses are registered nurses who possess advanced critical thinking and highly developed skills in patient management, communication, and education. Trauma nursing relies on the ability to assess, analyze, intervene, and evaluate patients. Trauma nursing spans the continuum of care, from injury prevention through rehabilitation and reintegration into society.

2. Developing a sampling plan

The AC considered various methods of identifying individuals who consider themselves to be trauma nurses, or who would be knowledgeable about the duties of trauma nurses. It was determined that invitation e-mails containing a link to the online role delineation study survey would be distributed to trauma nurses through different trauma nurse professional organizations. These lists included STN members and state trauma system contacts, lists related to the STN Advanced Trauma Care for Nurses (ATCN) course, the Pediatric Trauma Society, the Eastern Association for the Surgery of Trauma, as well as personal contacts of the AC and other BCEN officials known to be involved in trauma nursing. A total of 5,288 invitations were sent, expected to be nearly the entire population of trauma nurses in the United States.

3. Identifying topics and tasks for the survey instrument

After discussion, the AC decided that the test specifications would be topic-based, and that the primary tasks underlying all content would be the steps of the nursing process: assessment, planning, intervention, and evaluation. Therefore, a linkage between the areas of knowledge (topics) would be established by the development of the survey in this manner.

The draft list was thoroughly discussed during the meeting held in April 2014. Topics and tasks representing individual job responsibilities were modified, added, and removed. All topics and tasks were verified as being appropriately linked to the associated domain. After the review of the draft list, the AC authorized development of the final survey. The final survey included 62 topics and 104 tasks.

4. Identifying major domains

The AC identified seven major domains of practice, under which topics were categorized into subcategories. The AC unanimously agreed on the linkage of each topic to the respective domain. The domains were as follows:

I. Clinical Practice: Head and neck II. Clinical Practice: Trunk III. Clinical Practice: Extremity and wound IV. Clinical Practice: Special Considerations V. Continuum of Care for Trauma VI. Professional Issues



5. Determining the rating scales

The AC discussed the advantages and disadvantages of various rating scales that could be used in responding to the topics and tasks. AMP suggested the use of a single significance scale. This single scale is intended to solicit judgments that combine the importance of a topic/task with the frequency with which it is addressed in practice, after first considering the extent to which it is necessary to the performance in practice. The significance scale adopted by the AC is shown below, and further instructions for respondents for use of the scale were included in the survey.

6. Determining the relevant demographic variables of interest

The AC identified 24 relevant and important demographic survey variables. Since this was a national study, it was important to identify the respondents' geographic regions of employment. Other demographic questions were written to assess characteristics of the representativeness of the respondents, including highest nursing degree, highest academic degree, courses completed, certification held, professional organization memberships, years of experience as an RN and a trauma nurse, organization, if work at trauma center, level of trauma center, unit/department, work setting, number of trauma nurses in the facility, primary role, time spent in bedside care, percent of patients that require trauma care (total and by age group), special population patients, incentives provided by the employer for certification, gender, age, and racial and ethnic background.

7. Integrating demographics, rating scales, topics, and tasks into a survey instrument

After the first meeting, all components of the survey (demographics, rating scales, topics, and tasks) were combined and designed into a draft survey instrument. As a pilot test, this draft was distributed to the AC and other individual content experts via an e-mail message, which included a link to the pilot survey. Following a review of the comments, the final survey was prepared and distributed via an e-mail invitation.

How significant is this topic/task to your nursing practice?

0 = Not necessary for my job (the knowledge or ability is not needed in my practice) 1 = Minimally significant (part of my job, but not too important) 2 = Significant (important knowledge or ability)

3 = Very significant (quite important knowledge or ability)



Results

The survey was accessible via the Internet through the response deadline of July 31, 2014. Of the 3,156 e-mail invitations distributed (among which 277 were undeliverable and 20 opted out the study), a total of 1,635 respondents accessed the survey, resulting in a raw response rate of 57%. After reducing the sample size for participants who completed 0% of the survey (no ratings provided for any tasks, n=205) and participants who completed less than 60% of the survey (n=102), a total of 1,328 responses were considered to be valid responses, for a corrected response rate of 42%, which is considered excellent for this type of study.

Demographic Information

Summaries of the percentage of respondents indicating each response to the demographic questions are shown in figures and tables that follow. Based on discussion of the demographic responses with the AC, the demographic data were as expected, and judged to be representative of the profession. In addition to ensuring that the respondent group was representative, it was important to evaluate whether responses were received in appropriate numbers from relevant subgroups. The AC determined that sufficient responses were received from relevant subgroups for subsequent analysis.

Figure 1. Respondent Distribution in the United States



Figure 2. Region

Northeast: CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VA, VT

Southeast: AL, AR, FL, GA, KY, LA, MS, NC, SC, TN, TX, WV

Midwest: IA, IL, IN, KS, MI, MN, MO, ND, NE, OH, OK, SD, WI

West: AK, AZ, CA, CO, HI, ID, MT, NM, NV, OR, UT, WA, WY

Figure 3. What is the highest degree in nursing you have completed?



Figure 4. What is the highest academic degree you have completed?

Table 1. Which of these courses have you completed?

(Select all that apply. Top 12 shown.)

N % of Cases*

ACLS 1,242 94.1 TNCC 1,119 84.8 PALS 1,042 78.9 ENPC 677 51.3 ATCN 547 41.4 ATLS 436 33.0 TOPIC 428 32.4 ABLS 375 28.4 PHTLS 273 20.7 TCAR 199 15.1 TPM 150 11.4 Optimal 142 10.8

*Note. Because respondents were allowed to choose more than one answer, percentages will not sum to 100%.

Table 2. Which of these national certifications do you currently hold? (Select all that apply. Top four shown.)

N % of Cases*

CEN 535 70.1 CCRN 229 30.0 CPEN 103 13.5 CFRN 75 9.8




Table 3. To which of these professional organizations do you belong? (Select all that apply. Top five shown.)

N % of Cases*

ENA 794 69.3 STN 734 64.1 AACN 339 29.6 ATS 199 17.4 TCAA 104 9.1


Figure 5. How many years have you been a registered nurse?

Figure 6. How many of your years in nursing have been spent providing trauma nursing care?



Figure 7. Which of the following best describes your organization?

Figure 8. Do you work in a trauma center? If so, what level is your trauma center?



Figure 9. Which of the following best describes the unit/department where you work?

Figure 10. Which of the following best describes the setting in which you work?



Figure 11. How many trauma nurses work in your facility?

Figure 12. Which of the following best describes your present primary role?



Figure 13. What is your gender?

Figure 14. What is your age?

Table 4. With which of the following racial/ethnic groups do you most closely identify?

Non-Hispanic Hispanic

N

% of Cases

N

% of Cases

America Indian or Alaska Native 29 2.2 10 .8 Asian 37 2.9 5 .4 Black or African American 33 2.5 8 .6 Native Hawaiian or Other Pacific Islander 17 1.3 2 .2 White 1128 87.0 101 7.8

Total 1244 90.8 126 9.2



Adequacy of the Instrument

Approximately 99% of those responding to the question shown in Figure 15, which appeared at the end of the survey, felt that the role delineation study survey at least adequately addressed the responsibilities of trauma nurses. Thirty-three survey respondents did not answer this question. Another aspect of the adequacy of the instrument relates to its reliability.

Figure 15. How well do you feel this survey covered Trauma Nursing Practice?

Reliability estimates of both the topic/task ratings and the raters (or respondents) were calculated. Topic/task reliability estimates show to what extent each scale "hangs together." A high topic/task reliability value may indicate that the scale represents a consistent collection of topics/tasks. Rater reliability estimates are more important and indicate the degree to which raters agree on the significance of an item. Overall, the calculated reliability estimates were around 0.90 or higher.

Topic and Task Ratings

Descriptive data for each of the 62 topics and 104 tasks were reviewed by the AC. Although relative ratings are interesting (e.g., when comparing topics, the topic/task with the higher mean rating could be said to be more significant to practice), it is important to consider the absolute meaning of the ratings. The reader should bear in mind that the response options (also known as anchors) for the significance scale were: 0) Not necessary for my job, 1) Minimally significant, 2) Significant, and 3) Very significant. The mean of the ratings shown in Table 5 is based on all ratings of significance and does not include the zero (i.e., Not necessary for my job) ratings. Therefore, the mean significance represents the level of significance judged by the respondents who believed that the topic/task was necessary to practice.

The topic mean significance ratings ranged from 1.81 (for topic 25: Surface and Burn Trauma: Radiological burns) to 2.80 (for topic 28: Shock: Hypovolemic). The mean rating of significance, calculated across all 62 topics, was 2.41, with a standard deviation of 0.23. The task mean significance ratings ranged from 2.00 (for task 45: Assist with or perform the following procedures: Diagnostic peritoneal aspiration/lavage) to 2.82 (for task 2: Assess, intervene and stabilize patients with immediate life-threatening conditions). The mean rating of significance, calculated across all 104 tasks, was 2.52, with a standard deviation of 0.16.



Table 5. Distribution of Mean Topic and Task Ratings

Topics Tasks Mean Rating N % N %

Greater than 2.49 21 33.9 62 59.6

1.50-2.49 41 66.1 42 40.4

Less than 1.49 0 0.0 0 0.0

Total 62 100.0 104 100.0

Ratings of Various Demographic Groups

The demographic questions were included in the survey to provide descriptive information about the respondents. For some demographic questions; however, it was important to ensure that individuals from different subgroups view the topics/tasks required of trauma nurses similarly, and that the ratings exceed a level of significance sufficient to warrant inclusion on a national examination. Means, standard deviations, and numbers of respondents providing ratings from each subgroup for the 62 topics were reviewed by the AC.

Examination Specifications

In developing the Examination Specifications, committee judgment must be used in interpreting the data gathered through the role delineation study. For purposes of this executive summary, the Examination Specifications will be defined as the confidential document that is used to guide the examination development process, and that includes sufficient detail to ensure the development of comparable examination forms. The Detailed Content Outline (DCO) can be defined as a subset of the Examination Specifications; it is a document that includes a detailed listing of content available in outline form for candidates and item writers. Every examination item must be linked to the DCO as a first step in meeting the Examination Specifications during the examination development process.

Of particular importance to a national certification examination program is that the Examination Specifications must appropriately reflect the responsibilities of all groups who will participate in the certification program. Therefore, it is important to ensure that neither the Examination Specifications nor the resulting examinations include topics/tasks that are not considered to be important responsibilities of the individuals for whom the examination is intended.

Decision rules were discussed and adopted by the AC to identify topics and tasks that would be eliminated from the DCO; therefore, not eligible for assessment. Applying these decision rules provides objectivity in ensuring that the resulting examination reflects the responsibilities of trauma nurses, as judged by a demographically representative group of trauma nurses. The first decision rule helped ensure the DCO would only reflect topics and tasks that were a part of practice; any that received a high percentage of respondents providing a “0” rating (Not necessary for my job) were eliminated. The second decision rule established a threshold for the mean significance rating for the overall respondent group, ensuring that what remained on the DCO was clearly significant to practice. Finally, ten different decision rules were adopted based on subgroup analyses, to ensure that the remaining topics and tasks were significant to practice throughout the United States, for different levels of education preparation and years of experience, as well as a variety of different characteristics related to the respondents’ work setting and role, based on their demographic responses.



In addition to applying decision rules, the AC reviewed the comments offered by the survey respondents, in particular, those comments that suggested that additional topics or tasks would be appropriate to practice. Following discussion, it was decided that no additional topics or tasks were needed to appropriately reflect practice or would be needed to contract a certification examination, but minor editorial changes were made in response to the comments. Application of the decision rules led to four topics and seven tasks eliminated from the DCO.

When developing the survey, the AC determined that each topic/task was clearly linked to the associated major knowledge area. During the meetings in September 2014, the AC reconfirmed that linkage. Item writers will be instructed to classify items according to a specific topic, and to ensure that the item is associated with the major area. When approving items, the examination committee will similarly confirm that linkage.

Development of Final Detailed Content Outline and Examination Specifications

The AC determined that the Examination Specifications would more effectively reflect trauma nursing practice if based on topics rather than tasks, and that the primary tasks underlying all content should be the four steps of the nursing process: assessment, planning, intervention, and evaluation. Therefore, the survey was designed with this linkage between the areas of knowledge (topics) and tasks in mind. After reviewing the survey results, the AC determined that a second dimension would be appropriate as a part of the Examination Specifications. The linkage between the knowledge required for practice and the tasks used in practice was verified and assured by the AC. Cognitive level requirements were also discussed as a possible second dimension. For example, a determination could be made as to whether each item would require recall of facts, application of information, or analysis of a situation.

The AC determined that clinical items would be classified as requiring assessment, analysis, intervention, or evaluation on the part of the candidate; whereas, the non-clinical items would be classified by cognitive level. It was noted in the discussion that frequently the process of assessment requires recall, the process of analysis or intervention often requires application of knowledge, and the highest cognitive process (analysis) is frequently inherent in the fourth step of the nursing process (evaluation).

The AC determined that the content on the DCO could be appropriately assessed by way of a total of 150 multiple-choice examination items to ensure appropriate coverage. Item writers will be advised that any knowledge area underlying a topic may be appropriate for assessment, and that the item should be directly related to the topic. After agreeing on the number of items on the examination, the AC discussed how these items should be distributed across the major areas. Based on the significance of the topic ratings, the breadth of content within each major knowledge domain, and suggestions of survey respondents, the AC expressed independent judgments about their recommendation for the distribution of items in the major content areas. Using the mean of their judgments as a starting point, the AC reached unanimous agreement regarding the number of items in each major area as shown in the DCO on the following pages. All forms of the Trauma Certified Registered Nurse (TCRN™) examination will match this DCO.



Trauma Nurse Examination Detailed Content Outline

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s

I. Clinical Practice: Head and Neck 29

A. Neurologic trauma 1. Traumatic brain injuries 2. Spinal injuries

B. Maxillofacial and neck trauma 1. Facial fractures 2. Ocular trauma 3. Neck trauma

II. Clinical Practice: Trunk 36

A. Thoracic trauma 1. Chest wall injuries 2. Pulmonary injuries 3. Cardiac injuries 4. Great vessel injuries

B. Abdominal trauma 1. Hollow organ injuries 2. Solid organ injuries 3. Diaphragmatic injuries 4. Retroperitoneal injuries

C. Genitourinary trauma D. Obstetrical trauma (pregnant patients)

III. Clinical Practice: Extremity and Wound 25

A. Musculoskeletal trauma 1. Vertebral injuries 2. Pelvic injuries 3. Compartment syndrome 4. Amputations 5. Extremity fractures 6. Soft-tissue injuries

B. Surface and burn trauma 1. Chemical burns 2. Electrical burns 3. Thermal burns 4. Inhalation injuries

IV. Clinical Practice: Special Considerations 22

A. Psychosocial issues related to trauma B. Shock

1. Hypovolemic 2. Obstructive (e.g., tamponade, tension pneumothorax) 3. Distributive (e.g., neurogenic, septic) 4. Cardiogenic

C. Systemic Inflammatory Response Syndrome (SIRS) and multiple organ dysfunction syndrome (MODS)



V. Continuum of Care for Trauma 21

A. Injury prevention B. Pre-hospital care C. Patient safety (e.g., fall prevention) D. Patient transfer

1. Intrafacility (within a facility, across departments) 2. Interfacility (from one facility to another)

E. Forensic issues 1. Evidence collection 2. Chain of custody

F. End-of-life issues 1. Organ/tissue donation 2. Advanced directives 3. Family presence 4. Palliative care

G. Rehabilitation (discharge planning)

VI. Professional Issues 17

A. Trauma quality management 1. Performance improvement 2. Outcomes follow-up and feedback (e.g., referring facilities, EMS) 3. Evidence-based practice 4. Research 5. Mortality/morbidity reviews

B. Staff safety (e.g., standard precautions, workplace violence) C. Disaster management (i.e., preparedness, mitigation, response, and recovery) D. Critical incident stress management E. Regulations and standards

1. HIPAA 2. EMTALA 3. Designation/verification (e.g., trauma center/trauma systems)

F. Education and outreach for interprofessional trauma teams, and the public G. Trauma registry (e.g., data collection) H. Ethical issues

Total Scored Items 150

For Categories I through IV, items will also be classified according to Nursing Process, distributed approximately as follows:

18% Assessment 31% Analysis 31% Implementation 20% Evaluation

For Categories V and VI, items will also be classified according to the Cognitive Level expected to be used by candidates, distributed approximately as follows:

21% Recall 61% Application 18% Analysis



Examination forms will include unscored pretest items (n=25), candidates will be allowed three hours of testing time.

Testable Tasks

I. Assessment 1. Establish mechanism of injury 2. Assess, intervene and stabilize patients with immediate life-threatening conditions 3. Assess pain 4. Assess for adverse drug and blood reactions 5. Obtain complete patient history 6. Obtain a complete physical evaluation 7. Use Glascow Coma Scale to evaluate patient status 8. Assist with Focused Abdominal Sonography for Trauma (FAST) examination 9. Calculate burn surface area

10. Assessment not otherwise specified

II. Analysis 1. Provide appropriate response to diagnostic test results 2. Prepare equipment that might be needed by the team 3. Identify the need for diagnostic tests 4. Determine the plan of care 5. Identify desired patient outcomes 6. Determine the need to transfer to a higher level of care 7. Determine the need for emotional or psychosocial support 8. Analysis not otherwise specified

III. Implementation 1. Incorporate age-specific needs for patient population served 2. Respond with decisiveness and clarity to unexpected events 3. Demonstrate knowledge of pharmacology 4. Assist with or perform the following procedures:

a. Chest tube insertion b. Arterial line insertion c. Central line insertion d. Compartment syndrome monitoring devices

i. Abdominal ii. Extremity

e. Doppler f. End-tidal CO2

g. Temperature control devices (e.g., warming and cooling) h. Pelvic stabilizer i. Immobilization devices j. Tourniquets

k. Surgical airway insertion l. Intraosseous needles

m. ICP monitoring devices n. Infusers:

i. Autotransfusion ii. Fluid iii. Blood and blood products

o. Needle decompression



p. Fluid resuscitation i. Burn fluid resuscitation ii. Hypertonic solution iii. Permissive hypotension iv. Massive transfusion protocol (MTP)

q. Pericardiocentesis r. Bedside open thoracotomy

5. Manage patients who have had the following procedures a. Chest tube b. Arterial lines c. Central lines d. Compartment syndrome monitoring devices:

i. Abdominal ii. Extremity

e. End-tidal CO2

f. Temperature control devices (e.g., warming and cooling) g. Pelvic stabilizer h. Immobilization devices i. Tourniquets j. Surgical airway

k. Intraosseous needles l. ICP monitoring devices

m. Infusers: i. Fluid ii. Blood and blood products

n. Needle decompression o. Fluid resuscitation:

i. Burn fluid resuscitation ii. Hypertonic solution iii. Permissive hypotension iv. Massive transfusion protocol (MTP)

p. Pericardiocentesis 6. Manage patients' pain relief by providing

a. pharmacologic interventions b. non-pharmacologic interventions

7. Manage patient sedation and analgesia 8. Manage tension pneumothorax 9. Manage burn resuscitation

10. Manage Increased abdominal pressure 11. Provide complex wound management (e.g. , ostomies, drains, wound VAC, open

abdomen) 12. Implementation not otherwise specified

IV. Evaluation 1. Evaluate patients’ response to interventions 2. Monitor patient status and report findings to the team 3. Adapt the plan of care as indicated 4. Evaluation not otherwise specified



V. Continuum of Care 1. Monitor or evaluate for opportunities for program or system improvement 2. Ensure proper placement of patients 3. Restore patient to optimal health 4. Collect, analyze, and use data:

a. to improve patient outcomes b. for benchmarking c. to decrease incidence of trauma

5. Coordinate the multidisciplinary plan of care 6. Continuum of Care not otherwise specified

VI. Professional Issues 1. Adhere to regulatory requirements related to:

a. Infectious diseases b. Hazardous materials c. Verification/designation d. Confidentiality

2. Follow standards of practice 3. Involve family in:

a. Patient care b. Teaching/discharging planning

4. Recognize need for social/protective service consults 5. Provide information to patient and family regarding community resources 6. Address language and cultural barriers 7. Participate in and promote lifelong learning related to new developments and clinical

advances 8. Act as an advocate (e.g., for patients, families, and colleagues) related to ethical,

legal, and psychosocial issues 9. Provide trauma patients and their families with psychosocial support

10. Assess methods continuously to improve patient outcomes 11. Assist in maintaining the performance improvement programs 12. Participate in multi-disciplinary rounds 13. Professional Issues not otherwise specified

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