Correction: We regret to report that an error was published in this article. The National Organization of Nurse Practitioner Faculties has indeed published core competencies for acute care nurse practitioner practice. They are in the following document: National Panel for Acute Care Competencies. Acute Care Nurse Practitioner Competencies.  Washington, D.C.: National Organization of Nurse Practitioner Faculties; 2004.

The past few years have featured an upsurge in the number and types of opportunities available for NPs. This increase in demand for NPs has resulted in specialization and subspecialization of the role.

Scope of practice is defined as the activities and services an individual health care provider is permitted to perform.¹This scope may be defined by state law, certification or by facility policy (or a combination of these). In the acute care role, an NP's daily duties may range from interpreting real-time data such as arterial blood gases to reading chest x-rays to placing chest tubes or arterial lines.^2,3An acute care NP should be deemed competent to perform such clinical procedures through a process that includes skill validation.

Setting Terms

Organizations such as the Joint Commission on the Accreditation of Healthcare Organizations and the Accreditation Association for Ambulatory Healthcare are focused on ensuring patient safety. One way they seek to achieve this in hospitals is through mandatory regulation of NP activities by an executive committee of medical staff.⁴This type of committee typically monitors NPs' credentials and privileges to ensure that they are practicing within their scope of practice. NPs further strengthen their scope via competencies.

The National Organization of Nurse Practitioner Faculties (NONPF) has published core primary care competencies for NPs in adult, family, gerontologic, pediatric and women's health practice.^5-7Some of these competencies include health promotion and protection, disease prevention, critical thinking, improvement of health outcomes, and evaluation of care. These core competencies overlap those possessed by acute care NPs. NONPF has not yet drafted core competencies for NPs in specialty roles, but acutely ill patients have comorbidities that the competencies for adult and family practice do not address. In my opinion, NPs working in acute care need standardization in their education to provide comprehensive care to patients in these settings.

The care delivered by NPs today may differ by setting. The focus of care differs when an NP is managing acute complex health conditions compared with conditions common in patients in an outpatient setting. It can be argued that a primary diagnosis or medical condition does not change across the continuum of care, but management of comorbidities, along with any acute change associated with a primary diagnosis, may alter treatment options.

Legal Issues

NPs who are not educated in an acute care program or who are not credentialed in an acute care setting may not be able to justify in a court of law that they are practicing within their scope of practice and clinical capabilities. In most states, standards of practice are so vague that the interpretation of practice scope varies according to who does the interpreting. As a result, nurse practitioners are placed at risk for jeopardizing their licenses. This was evident in a survey conducted in 2004, which found that although 8.5% of NPs were working in an acute care setting, only 4.5% of these were credentialed as acute care NPs.³Simply translated, this means that roughly 50% of NPs working in acute care are practicing without appropriate certification for this specialty.

Standardization Needed

These findings illustrate how NPs are increasingly working outside the accepted scope of practice based on their training and expertise. A possible explanation for this is that the role of the NP has never been standardized. NP scope of practice, competencies and validation need to be defined, standardized and validated. Proper credentialing prevents NPs from placing themselves at risk for lawsuits and ensures that they are not functioning outside their expected scope of practice.

On the flip side, an NP who has practiced in acute care for years and has never faced credentialing or competency issues puts patient safety and his or her own liability at risk. According to Nurses Service Organization (NSO), a liability insurer for NPs, "practice beyond scope" accounted for 6% of all claims filed in 2004.¹Thirty-two percent of claims made that year were related to charges of failure to meet minimal standards.¹Certification results also can be inconsistent for specific areas of practice. The National Council of State Boards of Nursing (NCSBN) states that "certification examinations . may be calibrated to a higher or lower level of difficulty . they may cover a too broad or too narrow scope of practice than would otherwise be appropriate for regulation. . A certification program covering a very narrow scope, such as a specific disease entity, would not necessarily validate that the [NP] is capable of practice consistent with the authority granted by the license. In other words, the [NP] may not be a safe practitioner for [patients] with a broad spectrum of health concerns."?⁶NCSBN has a valid point. But once certification is obtained, further validation should be obtained through competencies required by employers.

Uniform Scope Needed

In my opinion, NCSBN's document titled "Vision Paper: The Future Regulation of Advanced Practice Nursing" illustrates that issues such as scope of practice and standards of care can be adequately addressed.⁵The NCSBN proposes changes such as completing a broad-based educational preparation that crosses the lifespan, populations and setting, followed by a core licensure exam and a residency.⁵The NCSBN further envisions a uniform scope of practice that spans all states. This will alleviate confusion about scope of practice when NPs cross state borders. To view the NCSBN recommendations, visit www.ncsbn.org/170.htm.

As more NPs specialize in acute care, the monitoring of credentialing and standardization of competencies is necessary. By doing so, NPs will ensure that their patients receive optimal care from a competent, knowledgeable provider and at the same time decrease their risk for legal challenges.

References

1. Klein T. Scope of practice and the nurse practitioner: regulation, competency, expansion and evolution. Topics in Advanced Practice Nursing. Available at: http://medscape.com/viewarticle/506277. Accessed Nov. 3, 2008.

2. Kleinpell R, et al. Skills taught in acute care NP programs: national survey. Nurse Pract. 2006;31(2):7-13.

3. Melander S, McLaughlin R. Ensuring clinical competency for NPs in acute care. Nurse Pract. 2007;32(4):19-20.

4. Magdic K, et al. Credentialing for nurse practitioners: an update. AACN Clin Issues. 2005; 16(1):16-22.

5. National Council of State Boards of Nursing. Vision Paper: The Future Regulation of Advanced Practice Nursing. Available with member access at: https://www.nccnet.org/public/files/APRNVisionPaper.pdf. Accessed Nov. 3, 2008.

6. National Council of State Boards of Nursing. Regulation of advance practice nursing. Available with member access at: https://www.ncsbn.org/APRN_Position_Paper2002.pdf. Accessed Nov. 3, 2008.

7. National Organization of Nurse Practitioner Faculties. Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric, and Women's Health. Available at: www.nonpf.org/finalaug2002.pdf. Accessed Nov. 3, 2008.