Role Delineation Study for the American Society for Pain Management Nursing

Phase I: Initial Development and Evaluation 

In April 2008, the ANCC contracted Castle Worldwide, a full-service test development company, to conduct an RDS for the ANCC Pain Management certification examination. An RDS panel consisting of ten pain management nurses and ANCC staff was used in an advisory role throughout the study. The ten pain management nurses who served on the panel were academicians and practitioners who possessed different areas of expertise in pain management nursing. They represented a wide range of practice settings and came from various geographic regions across the United States.

In phase I, Castle Worldwide facilitated a meeting of the RDS panel to discuss the performance domains and tasks involved in pain management nursing and the knowledge required to perform the tasks, and to develop a survey of practice to be administered nationally to pain management nurses.

To begin the process, the panel discussed performance domains that exist in pain management nursing and agreed to organize practice into six domains:

After deciding on the performance domains, the panel delineated the tasks in each domain. This process produced a list of 70 task statements that were used in phase II to develop an online survey sent nationally to pain management nurses. The list of knowledge was validated in phase II also via a separate survey sent to independent reviewers with expertise in pain management nursing. Like the RDS panel, these reviewers represented academia and pain management practitioners from many different areas of specialization and diverse geographic areas.

Phase II: Validation Study—Questionnaire Design, Pilot Testing, and Distribution 

Castle Worldwide worked with ANCC to develop an online questionnaire that used the domains and tasks identified by the RDS panel. The questionnaire solicited biographic information to verify that the responses received were representative of the population of certified pain management nurses as a whole, and completion was done by appropriately qualified individuals. The questionnaire also solicited input on the Frequency, Performance Expectation, and Consequences of the task statements potentially performed by newly certified pain management nurses.

The questionnaire was pilot tested using a simple random sample of 75 current certificants in pain management. The subjects were invited by e-mail and post to participate. Respondents completing the questionnaire were offered a reduction of 5 contact-hours on the continuing education requirement for recertification with ANCC. Thirty-three completed surveys were returned, for a 44% response rate. The RDS panel reviewed the pilot study results to determine if it functioned as expected. Most demographic questions were adequate for the purpose of the survey; however, a few items were found to show unexpected results. Those few items were clarified in an attempt to obtain more useable information from the respondents.

The ANCC and Castle Worldwide examined the performance of the validity measures for the domain and task statements. No changes were necessary, and the RDS panel accepted the recommendation to make no changes to those survey items.

Once the questionnaire was finalized, it was distributed to 1,500 pain management nurses. This included the remaining 921 current pain management certificants and 579 additional nurses randomly selected from the American Society for Pain Management Nursing membership. As in the pilot study, those participants who completed the questionnaire received a reduction of 5 contact-hours on the continuing education requirement for recertification. The questionnaire was delivered to the respondents via e-mail and post. The online questionnaire was available for 3 weeks. Reminder e-mails and postcards were sent to those nurses who had not completed the questionnaire. The questionnaire had 585 usable returns, for a 39% response rate.

Results 

Over 95% of respondents reported that they were female, which is slightly more than the national nursing statistics of 92% (Buerhaus, 2009), and 93% indicated their race as white; 0.9% of respondents indicated that they were African American, Asian, or Hispanic (compared with national statistics showing 11% African American and 4% Hispanic). Other ethnicities reported were “other” and American Indian.

Thirty-three percent of the respondents reported a bachelor's degree in nursing as their highest degree awarded. There were 16.4% of respondents reporting an Associate degree and 11.6 % reported a diploma as the highest academic achievement. Nearly 9.5% of the respondents reported their highest degree as a Master of Science and, 2.4% of the respondents reported earning a Doctorate in Nursing as their highest degree.

Over 80% of the respondents indicated being certified in pain management nursing, and over one-half of the respondents reported holding other certifications as well. These certifications were from 53 different specialty areas. It is important to note that there was some overlap in the reporting. For example, geriatric nurse practitioner and gerontologic nurse certification was reported.

Over one-half of the respondents were between 50 and 59 years of age. According to recent projections, this age is predicted to be the average age in 2012 (Buerhaus, 2009). The mean time of nursing practice for the respondents was 24 years (range 1-53 y). The mean number of years working in pain management was 8.5 years (range 1-46 y).

Over one-half of the respondents spend 75%-100% of their time practicing in pain management. Table 1 shows the frequency and percent of respondents reporting practicing in various roles. Over 35% of the respondents indicated that they functioned as a staff nurse, 14% as a nurse practitioner, and 13% as a clinical nurse specialist. As shown in Table 2, 30% of the respondents indicated that they worked in an outpatient clinic, and over one-third of the respondents reported a practice setting that was not provided in the questionnaire. Those respondents who selected “other” were given the opportunity to describe their practice setting if they felt it was not described in the list (Table 2). Again, there was some overlap in those descriptions. For example, three nurses responded that they practice in the entire hospital, two respondents wrote that they practiced in an acute pain service, and two others reported working in an acute pain service team. In academia, the following was reported: academic setting (2), academic (1), and academic hospital (1).

Table 1. Responses to the Question: Which of the Following Best Describes Your Role?

	Category	n	%
	Staff Nurse	207	35.4
	Nurse Practitioner	82	14.0
	Clinical Nurse Specialist	76	13.0
	Clinical Coordinator/Case Management	52	8.9
	Other	48	8.2
	Education	46	7.9
	Case Manager	10	1.7
	Research	4	0.7
	Total	585	100.0

Table 2. Responses to the Question: Which of the Following Best Describes Your Practice Setting?

	Practice Setting	n	%
	Other	217	37.1
	Outpatient Clinic	181	30.9
	Surgical Unit	68	11.6
	Medical Unit	51	8.7
	Recovery Room	23	3.9
	Hospice	17	2.9
	Intensive Care Unit	9	1.5
	Home Care	7	1.2
	Long Term Care	7	1.2
	Emergency Department	2	0.3
	Labor and Delivery	2	0.3
	Blank	1	0.2
	Total	585	100.0

Part of the questionnaire requested that respondents rate performance expectation, consequence or the likelihood that the newly certified pain management nurse could cause harm, and frequency of how often the newly certified pain management nurse performs in each of the performance domains or tasks (the domains are listed in Table 3). The performance expectation was rated from 0 to 2. Zero indicates that the newly certified pain management nurse was not at all expected to perform the domain task. The response of 1 meant that within the first 6 months after certification the newly certified pain management nurse would be expected to perform the domain task. And a response of 2 indicated that after 6 months the newly certified pain management nurse would be expected to perform the domain task.

The consequence of the inability of the newly certified pain management nurse to perform duties or tasks in each performance domain was rated from 0 to 4: 0 = no harm; 1 = minimal harm; 2 = moderate harm; 3 = substantial harm; and 4 = extreme harm.

The frequency of how often the newly certified pain management nurse performs the duties or tasks in the performance domains was measured. and rated from 0 to 4. A rating of 0 indicated that the newly certified pain management nurse never performed the duty or task, 1 rarely, 2 sometimes, 3 often, and 4 repeatedly. The ratings from the survey were sufficiently high to validate the performance domains identified by the RDS panel. Table 3 shows the consequence, frequency, and performance expectation ratings for each domain. The first domain (assessment, monitoring, and evaluation of pain) received the highest average frequency rating. The second performance domain (pharmacologic pain management) received the highest mean rating on consequence, and the sixth performance domain (collaborative and organizational activity) had the lowest mean rating. The sixth domain, however, received the highest mean rating for performance expectation, which indicates that some of the tasks within this domain were too advanced for inclusion in the final blueprint of the examination.

Table 3. Performance Domain Ratings

	Performance Domain	Consequence			Frequency			Performance Expectation
		n	Mean	SD	n	Mean	SD	n	Mean	SD
	Assessment, monitoring, and evaluation of pain	583	1.94	1.189	585	3.70	0.619	584	1.03	0.188
	Pharmacologic pain management	585	2.65	1.291	584	3.33	0.980	585	1.12	0.432
	Nonpharmacologic pain management	585	1.25	0.940	585	3.14	0.879	584	1.07	0.297
	Therapeutic communication and counseling	585	1.44	0.991	585	3.16	0.938	584	1.17	0.415
	Patient and family teaching	584	1.71	1.116	583	3..54	0.714	584	1.04	0.204
	Collaborative and organizational activities	585	1.06	0.976	584	2.67	0.979	584	1.38	0.534
	Valid n	583			581			584

Consequence rated 0-4, frequency rated 0-4, and performance expectation rated 0-2.

Table 4 presents the task-level rating results for consequence, frequency, and performance expectation. A review of the task-level performance expectation ratings conducted by the RDS panel concluded that several tasks should be dropped from the final task list owing to a majority of respondents rating the task as 2, which indicated that they were considered to be more advanced than those expected to be performed by the newly certified pain management nurse. The nine tasks dropped from the final task list were 2.6, 2.7, 3.13, 3.14, 6.3, 6.5, 6.6, 6.7, and 6.9, which are indicated with asterisks in Table 4.

Table 4. Task Statement Ratings

	Domain and Task	Consequence			Frequency			Performance Expectation
		n	Mean	SD	n	Mean	SD	n	Mean	SD
	Domain 1: Assessment, monitoring, and evaluation of pain
	1.1 Assess characteristics of a patient's pain.	570	1.83	1.186	570	3.73	0.583	571	1.01	0.162
	1.2 Assess patient's perception of pain.	568	1.61	1.106	569	3.63	0.669	570	1.02	0.191
	1.3 Assess patient's ability to cope with pain.	568	1.67	1.063	566	3.49	0.747	569	1.07	0.293
	1.4 Utilize performance scales to assess activity status (e.g., Karnofsky Scale, Lansky Scale, Brief Pain Inventory).	568	1.25	1.014	567	2.77	1.237	570	1.11	0.504
	1.5 Obtain patient's previous experience with pain.	569	1.31	1.005	569	3.24	0.856	570	1.02	0.217
	1.6 Identify past interventions and response/outcomes to pain treatment.	569	1.50	1.081	569	3.32	0.803	570	1.04	0.251
	1.7 Perform focused physical exam related to pain.	569	1.79	1.183	569	2.88	1.195	570	1.15	0.552
	1.8 Utilize appropriate pain assessment scale (e.g., Neonatal Infant Pain Scale, Numerical Rating Scale, Checklist of Nonverbal Pain Indicators).	569	1.57	1.149	569	3.57	0.795	570	1.02	0.221
	1.9 Reassess the degree of pain relief received from an intervention.	569	1.85	1.157	569	3.72	0.604	570	1.01	0.151
	1.10 Reassess for side effects/adverse events after an intervention.	568	2.31	1.268	568	3.68	0.615	569	1.02	0.191
	1.11 Reassess the impact on the patient's physical and psychosocial functioning after an intervention.	569	1.74	1.091	569	3.35	0.818	569	1.08	0.318
	1.12 Identify expected pain management outcomes for a plan of care based on the comprehensive pain assessment.	569	1.48	1.014	569	3.08	0.903	569	1.22	0.457
	1.13 Assess for presence of tolerance and/or physical dependence for patients on chronic opioid therapy.	568	2.11	1.131	568	3.06	0.948	569	1.26	0.477
	1.14 Assess for negative social and emotional effects of chronic opioid therapy (e.g., depression, suicidal ideation, sexual dysfunction).	567	2.39	1.223	567	2.96	1.006	568	1.27	0.501
	1.15 Assess for history or presence of substance abuse or addictive disease.	569	2.27	1.169	569	3.02	0.977	570	1.21	0.467
	Domain 2: Pharmacologic pain management
	2.1 Implement pharmacologic interventions to reduce pain.	549	2.55	1.25	545	3.29	1.1	549	1.09	0.461
	2.2 Titrate analgesics based on patient assessment and reassessment within order or parameter limits.	548	2.61	1.264	547	3.21	1.13	548	1.11	0.479
	2.3 Assess and manage side effects of opioid analgesics (e.g., sedation, respiratory depression, constipation, nausea/vomiting, urinary retention)	547	2.71	1.241	548	3.52	0.814	547	1.05	0.289
	2.4 Manage functions of parenteral patient-controlled analgesia (PCA) infusion device (e.g., setup, programming, changing, troubleshooting).	548	2.84	1.314	547	3.00	1.193	548	1.06	0.421
	2.5 Manage functions of epidural device (e.g., setup, programming, changing, troubleshooting).	546	2.94	1.333	546	2.59	1.306	548	1.20	0.594
	∗2.6 Manage functions of intrathecal infusion device (e.g., setup, programming, changing, troubleshooting).	547	2.96	1.358	546	2.06	1.383	548	1.28	0.722
	∗2.7 Manage functions of peripheral nerve infusion devices.	546	2.43	1.345	546	1.94	1.428	548	1.16	0.738
	2.8 Assess neurologic function for patient receiving neuraxial analgesia (i.e., epidural, intrathecal).	546	2.72	1.292	547	2.60	1.243	548	1.15	0.517
	2.9 Monitor hemodynamic status for patients receiving neuraxial analgesia (i.e., epidural, intrathecal).	548	2.70	1.297	548	2.55	1.287	548	1.15	0.546
	2.10 Premedicate patient before any procedure or activity that may elicit pain.	547	2.11	1.167	547	2.93	1.084	548	1.00	0.320
	2.11 Manage patient receiving sedation to control pain.	547	2.64	1.265	546	2.54	1.243	548	1.15	0.528
	2.12 Monitor renal/hepatic lab studies for at-risk patients receiving opioid analgesics, nonopioid analgesics, and adjuvants.	547	2.31	1.199	547	2.67	1.160	547	1.14	0.515
	2.13 Assess for complications related to nonopioid/adjuvant analgesics (e.g., gastorintestinal bleeding, sedation).	547	2.45	1.189	547	3.04	0.939	547	1.06	0.324
	2.14 Monitor patient receiving chronic opioid analgesic therapy (e.g., medication usage, behaviors).	548	2.18	1.122	547	2.95	1.016	547	1.18	0.453
	2.15 Initiate bowel regimen when opioid therapy is begun.	547	1.86	1.040	546	3.20	1.026	548	0.98	0.260
	Domain 3: Nonpharmacologic pain management
	3.1 Promote sleep and rest to restore patient's energy.	536	1.30	0.951	534	3.12	0.931	539	1.02	0.269
	3.2 Manage environment to promote optimal comfort (e.g., temperature, noise, lighting).	536	1.01	0.873	534	3.08	1.006	538	0.97	0.239
	3.3 Support the patient's use of meditation to reduce pain.	537	1.22	1.056	535	2.88	1.115	538	1.03	0.324
	3.4 Demonstrate and encourage simple relaxation techniques (e.g., therapeutic breathing, progressive muscle relaxation) to reduce pain.	537	0.83	0.816	535	2.78	1.006	538	1.05	0.342
	3.5 Support the use of humor to reduce pain.	536	0.57	0.740	534	2.61	1.052	538	1.03	0.350
	3.6 Support the use of distraction to reduce pain.	536	0.64	0.766	534	2.78	0.998	538	1.01	0.269
	3.7 Apply heat or cold treatments to reduce pain.	536	1.11	0.799	533	2.86	0.959	537	0.99	0.216
	3.8 Apply external devices (e.g., splint, braces) to manage pain.	535	1.29	0.919	533	1.94	1.160	537	1.01	0.566
	3.9 Support the use of music to reduce pain.	535	0.50	0.705	533	2.27	1.060	538	1.01	0.386
	3.10 Support the use of massage to reduce pain.	534	0.81	0.755	532	2.17	0.996	537	1.02	0.416
	3.11 Support the use of complementary and alternative therapies (e.g., biofeedback, acupuncture, hypnosis, guided imagery).	536	0.84	0.782	534	2.10	1.063	538	1.15	0.544
	3.12 Promote healthy behaviors to reduce pain (e.g., weight reduction, smoking cessation, exercise).	536	1.02	0.96	534	2.71	1.069	537	1.01	0.326
	∗3.13 Manage noninvasive devices used in pain management (e.g., transcutaneous electrical nerve stimulation)	533	1.07	0.788	531	1.88	1.107	535	1.12	0.570
	∗3.14 Manage invasive devices used in pain management (e.g., spinal cord stimulation).	535	2.01	1.183	533	1.56	1.179	537	1.25	0.777
	3.15 Support the use of physical/occupational therapy strategies for pain control (e.g., aquatic therapy, paraffin therapy).	536	1.06	0.780	534	2.29	1.109	538	1.06	0.423
	3.16 Mobilize patient to reduce pain and prevent pain-related complications.	536	1.44	0.955	534	2.75	1.037	538	1.00	0.302
	Domain 4: Therapeutic communication and counseling
	4.1 Support patient and family in communicating pain.	530	1.28	1.074	529	3.42	0.829	531	1.03	0.255
	4.2 Collaborate with patient and family to identify treatment options and to discuss and prioritize the plan of care.	530	1.29	1.062	529	3.25	0.884	531	1.10	0.363
	4.3 Identify patient's effective coping strategies.	530	1.19	0.986	529	3.13	0.851	531	1.11	0.365
	4.4 Support patient and family in communicating emotions associated with pain.	530	1.16	0.974	529	3.04	0.892	531	1.11	0.363
	4.5 Counsel patient and family about potential emotional, developmental, or cognitive impairment as it relates to pain management.	529	1.27	0.986	528	2.73	1.009	531	1.26	0.513
	4.6 Support patient's spirituality in the context of pain.	530	0.95	0.939	529	2.61	1.053	531	1.08	0.402
	4.7 Counseling patient and family about consequences (e.g., psychological, financial, social, emotional, physical) of pain.	530	1.24	1.016	529	2.66	1.091	531	1.21	0.497
	Domain 5: Patient and family teaching
	5.1 Teach patients how and when to report pain.	528	1.54	1.242	527	3.66	0.650	529	0.99	0.130
	5.2 Teach patient about the pain as it relates to disease process.	528	1.31	1.122	527	3.31	0.830	529	1.10	0.343
	5.3 Educate the patient regarding the plan of care for pain management.	527	1.40	1.174	527	3.51	0.757	529	1.04	0.258
	5.4 Educate the patient on opioid safety (e.g., handling prescriptions, interactions, storage of medications).	526	2.16	1.299	526	3.41	0.823	529	1.04	0.290
	5.5 Educate on the safe and effective use of pharmacologic pain management modalities.	527	2.10	1.285	526	3.43	0.780	528	1.07	0.298
	5.6 Educate on the safe and effective use of nonpharmacologic pain management modalities.	527	1.29	0.976	527	3.17	0.847	529	1.06	0.313
	5.7 Educate the patient about potential side effects of pain medications.	527	2.10	1.265	527	3.57	0.691	529	1.01	0.208
	5.8 Educate patient and family about the benefits of controlled pain.	528	1.39	1.100	526	3.44	0.743	529	1.00	0.213
	Domain 6: Collaborative and organizational activities
	6.1 Advocate for patients with pain.	525	1.52	1.300	524	3.37	0.799	526	1.11	0.346
	6.2 Collaborate with other health care professionals within facility.	524	1.35	1.199	524	3.22	0.873	526	1.12	0.38
	∗6.3 Collaborate with other health care professionals outside facility.	524	1.11	1.075	524	2.26	1.071	526	1.29	0.567
	6.4 Utilize institutional/organizational, state, and federal standards of care in pain management.	523	1.50	1.255	523	3.11	1.022	525	1.15	0.419
	∗6.5 Collect outcome data for quality improvement and/or research.	523	0.80	0.943	523	2.19	1.109	525	1.45	0.627
	∗6.6 Advocate for evidence-based practice changes related to pain management.	523	1.11	1.161	522	2.50	1.052	525	1.42	0.555
	∗6.7 Develop policies and procedures related to pain management.	522	1.23	1.149	522	2.17	1.014	525	1.55	0.583
	6.8 Initiate referrals for patient services (e.g., community support, social services, pastoral care).	522	1.12	1.022	522	2.44	0.984	525	1.18	0.494
	∗6.9 Promote reintegration into work, family, school, and community for patients with pain.	522	1.08	0.992	522	2.21	1.118	525	1.25	0.587

∗ Task was dropped from the final task list, owing to a majority of respondents rating performance expectation of the task statement as 2, indicating that it was not expected to be performed by newly certified pain management nurses.

The reliability of each scale was assessed. Reliability refers to whether the test or survey is free from measurement error. A measure of the internal consistency intraclass correlation (Chronbach alpha) using the respondents ratings of consequence, frequency, and performance expectation was used. Adequate reliability ratings should be above 0.7. The reliability of the consequence ratings was 0.99. The reliability rating for the frequency was 0.97, and the performance expectation reliability was 0.95 scale. This shows that the measurement error is sufficiently small and that these ratings can be used in the computation of the test blueprint to determine how many questions should be in each domain.

Implications for Practice 

With revision of the RDS, those who decide to take the examination to become certified will be confident that the information tested is relevant to the practice of pain management nursing. Joining the ranks of >1,000 certificants is considered to be prestigious, especially for magnet-status employers. Certification is one measure of nursing excellence. It is an indicator of continuing education, leadership, professional growth, and safe practice.