With the increased knowledge and skills necessary for the provision of com- prehensive care across settings and over time, CUSN DNP faculty developed a series of detailed, cognitively complex competencies that address the role of the advanced practice nurse in comprehensive care. These competencies form a subset of the CUSN DNP competencies and correspond to Essential 8 in the AACN framework. These specialized competencies, referred to as the Direct Care Competencies, provide direction for the curriculum in direct care and for the assessment of the student as a clinical expert in comprehensive care.
Each direct care competency is composed of several performance objectives, which are behaviors that are demonstrated in the provision of direct patient care. The performance objectives describe each competency using measurable behaviors. Students use the performance objectives to determine how to meet and to document attainment of the competency. Table 3.1 presents the direct care competencies and performance objectives. These competencies provide a framework for DNP residents and faculty to assess students’ ability to provide clinically complex, culturally sensitive, comprehensive care across settings and over time for patients in the context of family and community. Students dem- onstrate attainment of the direct care competencies through case presentations in class and by writing competency-based clinical case narratives. CUSN DNP graduates report that clinical case narrative writing is a transformational pro- fessional experience.
3.1 Doctor of the Nursing Practice Comprehensive Care Competencies and Performance Objectives for Direct Patient Care (Continued)
Domain (D) 1. Comprehensive Clinical Care Competency (C) 2
Evaluate population or geographically- based health risk utilizing principles of epidemiology, clinical prevention, environmental health, and biostatistics.
Competency (C) 3
Formulate differential diagnoses, and diagnostic strategies and therapeutic interventions with attention to scientifi c evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and effi cacy for patients who present with new conditions and those with ambiguous or incomplete data, complex illnesses, comorbid conditions, and multiple diagnoses in all clinical settings.
Competency (C) 4
Appraise acuity of patient condition, determine need to transfer patient to higher acuity setting, coordinate, and manage transfer to optimize patient outcomes.
Performance Objective (PO)
A.
A. Assess the patient/family at risk for a condition incorporating epidemiological principles and/or environmental factors that contribute to risk/incidence of disease.
B.
B. Assess the patient/family with a condition incorporating epidemiological principles and/
or environmental factors that contribute to risk/incidence of disease.
Performance Objective (PO)
A.
A. Formulate a differential diagnosis for a patient who presents with new undifferentiated signs and symptoms.
B.
B. Formulate a differential diagnosis for a patient who presents with ambiguous or incomplete data, complex illnesses, comorbid conditions, and potential multiple diagnoses.
C.
C. Discuss the rationale for the differential diagnosis.
D.
D. Discuss the rationale for the diagnostic evaluation with attention to scientifi c
evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and effi cacy.
E.
E. Discuss the rationale for the therapeutic intervention with attention to scientifi c evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and effi cacy.
Performance Objective (PO)
A.
A. Assess the acuity of patient status.
B.
B. Determine the most appropriate treatment setting based on level of acuity.
C.
C. Formulate a transfer plan.
D.
D. Implement plan to transfer the patient to a higher level of care utilizing written and oral communication.
E.
E. Coordinate care during transition to the higher acuity setting.
(continued)
Chapter 3 The DNP Clinical Competencies
33
3.1 (Continued)
Domain (D) 1. Comprehensive Clinical Care
Competency (C) 4 Performance Objective
Competency (C) 5
Evaluate and direct care during hospitalization, and design a comprehensive discharge plan for patients from an acute care setting.
Competency (C) 6
Direct comprehensive care for patient in a sub- acute setting to maximize quality of life and functional status.
F.
F. Co-manage care in person, or G.
G. Co-manage care though written and verbal instructions.
H.
H. Recommendations for patient disposition from the higher acuity location.
I.I. Coordination of post-discharge care.
Performance Objective (PO)
A.
A. Assess the acuity of patient’s condition and determine the most appropriate inpatient treatment setting based on level of acuity.
B.
B. Actively participate in the admission process to the appropriate inpatient treatment setting.
C.
C. Actively co-manage patient care during hospitalization.
D.
D. Formulate plan for ongoing care to be provided in a subacute setting, such as a long-term care facility, rehabilitation facility, or home or community setting.
E.
E. Coordinate ongoing comprehensive care to be provided in a subacute setting, such as a long-term care facility, rehabilitation facility, or home or community setting.
Performance Objective (PO)
A.
A. Assess the acuity of the patient’s condition to determine the need for subacute, long-term care.
B.
B. Determine the most appropriate subacute or chronic care treatment setting based on level of acuity, functional status, and availability of formal and informal caregiver resources.
C.
C. Coordinate ongoing comprehensive care provided in a subacute setting.
D.
D. Initiate referral to other health care professionals while maintaining primary responsibility for patient care in a subacute setting.
(continued)
3.1 Doctor of the Nursing Practice Comprehensive Care Competencies and Performance Objectives for Direct Patient Care (Continued)
Domain (D) 1. Comprehensive Clinical Care
Competency (C) 6 Performance Objective (PO)
Domain (D) 2. Interdisciplinary and Patient-Centered Communication Competency (C) 7
Facilitate and guide the process of palliative care and/or planning end-of-life care by discussing diagnoses and prognosis, clarifying and validating patient desires and priorities, and promoting informed choices and shared decision-making by patient, family and members of the health care team.
Competency (C) 1
Assemble a collaborative interdisciplinary network; refer and consult appropriately while maintaining primary responsibility for comprehensive patient care.
E.
E. Utilize consultant recommendations for decision-making while maintaining primary responsibility for care in a subacute setting.
Performance Objective (PO)
A.
A. Facilitate and guide the palliative care process by discussing diagnoses and prognosis, clarifying and validating patient desires and priorities, and promoting informed choices and shared decision-making by the patient, family, and members of the health care team.
B.
B. Facilitate and guide planning of end-of- life care by discussing diagnoses and prognosis, clarifying and validating patient desires and priorities, and promoting informed choices and shared decision- making by the patient, family, and members of the health care team.
Performance Objective (PO)
A.
A. Initiate referral to other health care professionals while maintaining primary responsibility for patient care.
B.
B. Accept referrals from other health care professions and communicate consultation fi ndings and recommendations to the referring provider and collaborative network.
C.
C. Utilize consultation recommendations for decision-making while maintaining primary responsibility for care.
D.
D. Evaluate outcomes of interventions.
(continued)
Chapter 3 The DNP Clinical Competencies
35
3.1 (Continued)
Domain (D) 2. Interdisciplinary and Patient-Centered Communication Competency (C) 1 Performance Objective (PO)
Domain (D) 3. Systems and Context of Care Competency (C) 2
Coordinate and manage the care of patients with chronic illness utilizing specialists, other disciplines, community resources, and family, while maintaining primary responsibility for direction of patient care and ensuring the seamless fl ow of information among providers as the focus of care transitions across ambulatory to acute, subacute settings, and community settings.
Competency (C) 1
Construct and evaluate outcomes of a culturally sensitive, individualized intervention that incorporates shared decision-making and addresses the specifi c needs of a patient in context of family and community.
E.
E. Provide ongoing patient follow-up and monitor outcomes of collaborative network interventions.
Performance Objective (PO)
A.
A. Coordinate care for a patient with chronic illness as the focus of care transitions across ambulatory, acute, subacute, and/or community settings.
B.
B. Co-manage care for a patient with chronic illness as the focus of care transitions across ambulatory, acute, subacute, and/or community settings.
C.
C. Coordinate care for a patient with chronic illness utilizing specialists, other disciplines, community resources, and family.
D.
D. Direct care for patient with chronic illness and ensure the seamless fl ow of information among providers as the focus of care transitions across settings.
E.
E. Co-manage care for a patient with chronic illness utilizing shared decision-making and teaching.
F.
F. Co-manage care for a patient with chronic pain as the focus of care transitions across ambulatory, acute, subacute, and/or community settings.
Performance Objective (PO)
A.
A. Assess culturally specifi c needs of patient in the context of family and community.
B.
B. Construct a culturally sensitive intervention to address the needs of the patient in the context of family and community.
C.
C. Evaluate outcomes of the intervention.
(continued)
References
American Association of Colleges of Nursing (AACN). (2006). The essentials of doctoral education for advanced nursing practice. Retrieved July 6, 2009, from http://www.aacn .nche.edu/DNP/pdf/Essentials.pdf
Council for the Advancement of Comprehensive Care (CACC). (2003). Competencies of a clinical nursing doctorate. New York: Columbia University School of Nursing.
Council for the Advancement of Comprehensive Care (CACC). (2006) Competencies of a clinical nursing doctorate. New York: Columbia University School of Nursing.
National Organization of Nurse Practitioner Faculties (NONPF). (2006). Practice doctorate nurse practitioner entry-level competencies. Retrieved from http://www.nonpf.com/nonpf2005/
PracticeDoctorateResourceCenter/CompetencyDraftFinalApril2006.pdf
3.1 Doctor of the Nursing Practice Comprehensive Care Competencies and Performance Objectives for Direct Patient Care (Continued)
Domain (D) 3. Systems and Context of Care
Competency (C) 2 Performance Objective (PO)
Evaluate gaps in health care access that compromise optimal patient outcomes, and apply current knowledge of the organization and fi nancing of health care systems to advocate for the patient and to ameliorate negative impact.
Competency (C) 3
Synthesize the principles of legal and ethical decision-making and analyze dilemmas that arise in patient care, interprofessional relationships, research, or practice management to improve outcomes.
A.
A. Identify gaps in access that compromise patient’s optimum care.
B.
B. Identify gaps in reimbursement that compromise patient’s optimum care.
C.
C. Demonstrate patient advocacy in the provision of continuous and comprehensive care.
D.
D. Apply current knowledge of the organization to ameliorate negative impact.
E.
E. Apply current knowledge of health care systems to ameliorate negative impact.
Performance Objective (PO)
A.
A. Synthesize ethical principles to address a complex practice dilemma.
B.
B. Apply ethical principles to resolve the dilemma.
C.
C. Synthesize legal principles to address a complex practice dilemma.
D.
D. Apply legal principles to resolve the dilemma.
37
Clinical Case
Narrative Writing
The Columbia University School of Nursing doctor of nursing practice (CUSN DNP) program is designed to provide advanced practice nurses (APNs) with the knowledge and skills necessary to provide fully accountable, evidence-based care for patients across clinical sites and over time. The purpose of this degree is consistent with the Institute of Medicine’s (IOM) defi nition of primary care as the “provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (IOM, 1996, p. 31). The DNP graduate is an expert clinician who views the patient in multiple contexts, interprets and analyzes health care choices, and engages the patient in a collaborative relationship.
The IOM report entitled Health Professions Education proposed reform- ing health professional education to enhance patient care, quality, and safety.
This included “competency-based education for clinicians prepared to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics”
(IOM, 2003, p. 3). The IOM called for well-defi ned clinical doctorates in direct care with standardized graduate competencies.
4
Janice Smolowitz Judy Honig Courtney ReinischThe publication Essentials of Doctoral Education for Advanced Nursing Prac- tice (AACN, 2006) recognized the direct care role for APNs. The DNP APN is described as a clinician with expanded responsibility and accountability in the care and management of individuals and families and is also educated to identify and improve provision of care for a particular population at the aggregate and systems level. The National Organization of Nurse Practitioner Faculties (NONPF) also recognized the direct care role for the APN DNP graduate and defi ned doc- toral competencies with emphasis on independent and interprofessional practice that requires advanced knowledge, skills, and abilities (NONPF, 2006).
AACN and NONPF, leaders in nursing education, have echoed the IOM’s recommendations and published guidelines and strong position papers in sup- port of doctoral education that prepares APNs with the necessary skills and competencies to provide comprehensive care. Schools of nursing must educate APN DNPs to address this need.