MILITARY MEDICINE, 173, 8:759, 2008 Self-Assessment of Trum Competencies mong Army Fmily Nurse Prctitioners MAJ Brd E. Frnklin, ANC USA; MAJ Kte V. Crr, ANC USA; Dine L. Pdden, PhD ABSTRACT The objective of this descriptive study ws to determine whether Army fmily nurse prctitioners perceive themselves s competent in providing trum cre. Using n dpttion of trum competency outcomes from vrious trum courses, ll Army fmily nurse prctitioners were sked to evlute self-perceived level of trum competence nd self-perceived importnce of trum skills. Results (n 96) indicte generl greement tht ll skills identified in the questionnire were importnt in the mngement of trum ptient. The respondents considered themselves trined/somewht competent or higher in 50% of the skills identified. Mnn-Whitney U nlysis ws used to compre vrious groups within the smple. Significnt differences on self-perceived competency were noted with intensive cre/emergency room, Advnced Trum Life Support, nd deployment experience. Trum Nursing Core Course experience ws not significnt to self-perceived trum competency. Findings support the need for dditionl trum trining, such s Advnced Trum Life Support nd hnds-on trum experience. INTRODUCTION In September 2001, the U.S. militry entered worldwide mission ginst terrorism nd terror-sponsoring sttes. Since then, there hve been two mjor conflicts tht hve required the use of militry personnel on lrge scle, Opertion Enduring Freedom (OEF) nd Opertion Irqi Freedom (OIF). The mssive deployment of combt troops hs lso required the deployment of militry medicl personnel including physicins, nurses, medics, nd other llied helth personnel. Due to the demnds of theter cre nd support of our beneficiry popultion, there is shortge of physicin ssistnts (PAs) nd fmily medicine physicins (FPs), which re the usul medicl providers t level I nd II bttlion id sttions. (C. Pierce, personl communiction). Level I nd II bttlion id sttions re considered frontline medicl tretment res tht provide initil stbiliztion of combt wounded to sve life, limb, or eyesight. The Army hs used number of options to fill the shortge of providers t these levels tht includes the use of obstetric/ gynecologic, peditric, nd internl medicine providers. In ddition, there hs been documented use of physicin subspecilty providers such s peditric gstroenterologist nd neurologists t the bttlion id sttion level. As result of incresed opertionl tempo nd pprent shortge of FPs nd PAs, Army fmily nurse prctitioners (FNPs) hve been deploying in incresed numbers to support these missions. Historiclly, there hs been no wrtime mission for FNPs nd frequently they work s medicl/surgicl nurses or nurse dministrtors. 1 Current regultions hve been mended llowing uthorized substitution of FNPs for either the PA or FP physicins. At level II elements, FNPs cn substitute for PA only if the remining positions re Grdute School of Nursing, Uniformed Services University of the Helth Sciences, 4301 Jones Bridge Rod, Bethesd, MD 20814. This mnuscript ws received for review in My 2007. The revised mnuscript ws ccepted for publiction in My 2008. filled by either PAs or FP physicins. The regultion lso sttes tht FNPs substituting t level II must meet supplementl trum trining requirements before deploying s estblished by Chief, Helth Policy nd Service Division, Medicl Commnd (MEDCOM). 2 At present, there re 160 FNPs in the ctive Army Nurse Corps. Incresingly, these FNPs re being used t level II where they come in close contct with trum ptients. Currently, FNPs re prepred to prctice in expnded roles to deliver primry helth services to individuls, fmilies, nd communities. FNPs conduct comprehensive helth ssessments imed t helth promotion nd disese prevention. They lso dignose nd mnge common cute illness nd mnge chronic stble conditions, mking referrls s pproprite. Curriculum in FNP progrms includes theory, reserch, helth ssessment, pthophysiology, nd phrmcology. Other courses re included nd re gered towrd their primry role of helth promotion nd disese prevention. 3 FNP progrms typiclly do not include trum or emergency rottions but do cover cute conditions encountered in the infnt through geritric popultion. The FNP progrm s the Uniformed Services University of the Helth Sciences hs incorported trum component into their progrm in conjunction with the School of Medicine. The Uniformed Services University of the Helth Sciences FNP progrm is the only nurse prctitioner progrm the U.S. Army will fund currently. However, most current Army FNPs were trined t civilin institutions before the funding chnge. There re only hndful of cute cre nurse prctitioners in the Army Nurse Corps but re not recognized in the Army inventory s such. Acute cre nurse prctitioners, lthough trined in trum, do not hve the flexibility for the mjority of the helth cre delivered in the Deprtment of Defense. Of interest, 43% of ll nurse prctitioners working in the emergency room in the United Sttes re FNPs. MILITARY MEDICINE, Vol. 173, August 2008 759
Self-Assessment of Trum Competencies The literture provides vluble dt on the performnce of nurse prctitioners in the emergency room nd the relted ptient cre outcomes. 4 6 It lso demonstrtes tht nurse prctitioners re competent providers who cn provide level of cre comprble to tht of physicins on certin skills, if trined properly. 4 6 Nurse prctitioners re mnging minor trum nd, in some res, mjor or urgent emergency cses. 7 The literture lso sttes tht nurses will perform well with trum cses if there is ctive prticiption in Advnced Trum Life Support (ATLS), Advnced Trum Cre for Nursing (ATCN), nd Trum Nursing Core Course (TNCC), with continued reinforcement of lerned skills. 8 A gp exists in the literture on the incorportion of relevnt trum competence s it reltes to Army FNPs. Since ll Army FNPs cn potentilly be deployed t ny given time, it is impertive to evlute their self-perceived level of trum competence. The purpose of this study ws to determine whether Army FNPs perceive themselves s competent in providing trum cre. METHODS A convenience smple of ll Army FNPs ws invited to prticipte. Subjects were identified by the Humn Resource Commnd FNP brnch mnger s well s the FNP Consultnt to the Army Surgeon Generl. A cover letter explining the purpose of the reserch nd requesting the individuls consent to prticipte ws included in the online questionnire. There were 160 ctive Army FNPs t the time of the study. Demogrphic dt bout the subjects ws lso collected. It included informtion such s ge, gender, rnk, level of nursing experience, deployment experience, nd trum trining. Bsed on the review of literture, there re few tools vilble to evlute perceived trum competence. Of those discovered in the literture. none ws developed for deployment or the opertionl environment. A questionnire ws dpted bsed on the Tcticl Combt Csulty Course (TCCC), ATLS, nd ATCN competency evlution checklists. The 29 trum competencies identified were used to rte the self-perceived level of trum competence nd self-perceived importnce of the trum skills. The questionnire ws sent to 10 experts in the field of trum cre for content vlidity nd constructive feedbck. Eight of 10 questionnires were returned, for n 80% return rte. The experts rted ech element on its importnce to mnging trum ptient in the deployed setting on 5-point scle: 1, not importnt; 2, somewht importnt; 3, importnt; 4, very importnt; nd 5, essentil. The individul elements tht hd n verge score of 3 were removed from the questionnire. The remining 26 elements were ggregted into the 8 domins tht the questionnire covers. Two domins (orl nlgesi nd orl ntibiotics) were determined not to be vlid bsed on content vlidity from the trum experts nd were removed from the questionnire. One domin ws dded (neurologicl) bsed off the trum experts feedbck. Since this tool hd not been tested previously, relibility of self-perceived importnce of trum skills nd self-perceived level of competence ws conducted nd found to be cceptble with n of 0.76 nd 0.93, respectively. Self-Perceived Level of Importnce of Trum Skills The elements identified for inclusion were bsed on the need to mnge trum ptients. The 26 elements thought to be importnt in the mngement of trum ptient, s identified in ATLS/ATCN/TCCC covered the following 8 domins of trum cre: hemostsis, irwy, brething, circultion, neurologicl, intrmusculr therpy, frcture mngement, nd electronic monitoring. Respondents rnked ech skill on level of perceived importnce using Likert-type scle which included: 1, not importnt; 2, somewht importnt; 3, importnt; 4, very importnt; nd 5, essentil. Self-Perceived Level of Trum Competency of Trum Skills The self-perceived level of trum competency for ech trum skill identified from ATLS/ATCN/TCCC ws lso ssessed using questionnire. A Likert-type scle ws used which included: 1 not trined; 2 trined/not competent; 3 trined/somewht competent; 4 trined/competent; nd 5 trined/expert. RESULTS Of 160 ctive duty Army FNPs, 96 responded to the questionnire, resulting in response rte of 60%. Consistent with Army Nurse Corps demogrphics, most were femle (67%). The mjority of respondents were field grde officers (86%) with n verge of 10 yers of registered nursing nd 6 yers of FNP experience. A prepondernce of the subjects hd cute cre/inptient experience before FNP trining. The respondents minly work in fmily medicine t Army medicl ctivities (Tble I). Of the 96 respondents, 35 hve deployed (37%) in support of OIF/OEF. Thirty-one of those (89%) deployed to Irq. Sixty-three percent worked s FNP during deployment followed by 25% who worked s medicl/surgicl nurse. Army FNPs hve the opportunity to ttend wide vriety of trining depending on their duty section nd deployment opportunities. Over lmost 90% hve ttended Advnced Crdic Life Support (ACLS) nd over hlf hve ttended the Combt Csulty Cre Course, TNCC, nd Peditric Advnced Life Support (Tble II). The first im of this study ws to describe the perceived level of importnce of specific trum skills required to mnge trum ptients mong Army FNPs. Answers to the Likert-type scle provided by ll 96 respondents indicte generl greement tht ll skills re essentil, very importnt, or importnt in the mngement of trum ptient (Tble 760 MILITARY MEDICINE, Vol. 173, August 2008
Self-Assessment of Trum Competencies TABLE I. Demogrphics TABLE II. Trining Attended Scle Dt Rnge Men SD Age (yers) 27 43.1 5.9 Yers s RN 25 10.2 4.5 Yers s FNP 17.5 6.1 3.7 Nominl Dt No. % Gender Femle 32 67 Mle 64 33 Rnk CPT 14 14.6 MAJ 39 40.6 LTC 43 44.8 Bckground experience Medicl/surgery 34 35.4 ICU 23 24 ER 18 18.8 Peditrics 11 11.5 Ambultory cre 8 8.3 Obstetrics/gynecology 2 2.1 Msters loction USUHS 27 28.1 Other 69 71.9 Clinicl setting s FNP Fmily medicine 77 80.2 Troop medicl clinic 10 10.4 Internl medicine 2 2.1 Specilty clinic 1 1 Other 6 6.3 Fcility working t Medicl center 39 40.6 Medicl ctivities 57 59.4 Deployed (current or previous) to OIF/OEF Yes 35 36.5 No 61 63.5 III). Severl skills, however, were identified s not importnt by 1 to 3% of the respondents. Those skills were: intrvenous nlgesi, intrvenous ntibiotics, dministering blood products, Glsgow com scle, lert/verbl responsiveness/pin response/ unresponsive (AVPU ssessment), IM morphine/ntibiotics, splinting, trction splinting, electronic monitoring, nd obtining introsseous ccess. The second specific im of this study ws to describe the current level of perceived trum competence mong Army FNPs. Answers to the Likert-type scle rnged from not trined to the trined-expert level. The respondents reported wide rnge of trum competence (Tble IV). Of interest, there were respondents who indicted they hd never been trined on severl trum skills. Over hlf of ll respondents reported never being trined in the ppliction of HemCon (HemCon Medicl Technologies, Portlnd, Oregon)/Quick Clot (Z-Medic Corportion, Wllingford, Connecticut) (57%) nd nerly hlf on the insertion of chest tubes (43%) The other skills reported included: cricothyroidotomy (31%), needle thorcostomy (27%), treting open pneumothorx (27%), AVPU (27%), Course No. % ACLS Yes 83 86.5 No 13 13.5 Combt Csulty Cre Course Yes 56 58.3 No 40 41.7 TNCC Yes 52 54.2 No 44 45.8 Peditric Advnced Life Support Yes 50 52.1 No 46 47.9 ATLS Yes 27 28.1 No 69 71.9 TCCC Yes 7 7.3 No 89 92.7 ATCN Yes 1 1.0 No 95 99.0 Army Trum Trining Center Yes 2 2.1 No 94 97.9 trction splinting (21%), obtining introsseous ccess (20%), endotrchel intubtion (6%), splinting (6%), dministering blood products (4%), Glsgow Com Scle (3%), IV fluid resuscittion (1%), IV nlgesi (1%), nd IV ntibiotics (1%). Since the smple hd wide vrition in bckground experience nd yers of prctice, Mnn-Whitney U nlysis ws used to compre vrious groups nd perceived level of trum competence. The groups evluted included those who hd deployed nd not deployed, intensive cre unit (ICU)/emergency room (ER) experience versus other experience, those who hd ttended ATLS versus never ttended nd those who hd ttended TNCC versus never ttended. Significnce ws tested t p of 0.05. When ICU/ER experience ws compred to other experiences using the Mnn-Whitney U test, 18 of 26 skills were found to be sttisticlly significnt (Tble V). The Mnn-Whitney U test ws used to compre respondents who hd ttended ATLS nd those who hd not in reltion to self-perceived trum competence. Results were significnt in 5 of 26 skills. Those skills were treting open pneumothorx (p 0.05), strting IV (p 0.01), IV fluid resuscittion (p 0.0), IM morphine (p 0.0), nd IM ntibiotics (p 0.0) (Tble V). In compring those who hd deployed nd those who hd not deployed, only 2 of 26 skills were found to be significnt. Those skills were cricothyroidotomy (p 0.04) nd bgvlve msk (p 0.0) (Tble V). MILITARY MEDICINE, Vol. 173, August 2008 761
Self-Assessment of Trum Competencies TABLE III. Importnce of Trum Skills TABLE IV. Self-Perceived Competency in Trum Skills Men b SD Hemorrhge Apply tourniquet 3.64.67 Apply direct pressure 3.75.50 Apply HemCon/Quick Clot 3.04.98 Airwy/brething Chin lift/jw thrust 3.72.59 Oro/nsophryngel irwy 3.53.80 Cricothyroidotomy 3.22.94 Bg-vlve msk 3.73.57 Endotrchel intubtion 3.60.70 Brething Administer oxygen 3.73.57 Needle thorcostomy 3.30.80 Tret open pneumothorx 3.51.74 Chest tube 3.05.91 Circultion Assess for shock 3.91.33 Strt IV 3.83.43 Obtin introsseous ccess 2.96 1.08 IV fluid resuscittion 3.77.49 IV nlgesi 3.33.90 IV ntibiotics 3.16 1.06 Administer blood products 3.27 1.0 Neurologicl Glsgow Com Scle 3.29.87 AVPU 3.09 1.01 IM therpy IM morphine 3.14.98 IM ntibiotics 2.88 1.12 Frcture mngement Splinting 3.46.73 Trction splinting 2.94.90 Electronic monitoring 3.07 1.11 b Rnge, 0 4. The Mnn-Whitney U test ws lso used to compre those in the smple who hd ttended TNCC nd those who hd not in reltion to trum competence. None of the 26 skills were found to be significnt. DISCUSSION Since 60% of ll ctive duty Army FNPs responded to the questionnire, these results my be used to generlize bout the FNP group s whole. Army FNPs generlly strt their FNP trining when they re cptins nd hve 10 yers of registered nursing experience. Therefore, it ws not surprise tht mjority of the respondents were field grde officers (85%). An interesting finding ws tht such lrge portion of the FNPs hd previous ICU nd ER experience. Overll, the dt in this study clerly indicte tht ll trum skills identified re importnt in the mngement of trum ptient. Interestingly, severl of the skills were rted s not importnt in the mngement of trum ptient by smll minority of the smple (1 3%). It is not cler s to Men b SD Hemorrhge Apply tourniquet 2.89 0.95 Apply direct pressure 3.30 0.67 Apply HemCon/Quick Clot 1.01 1.32 Airwy/brething Chin lift/jw thrust 3.44 0.60 Oro/nsophryngel irwy 3.10 0.84 Cricothyroidotomy 1.18 1.08 Bg-vlve msk 3.38 0.68 Endotrchel intubtion 1.85 1.01 Brething Administer oxygen 3.67 0.52 Needle thorcostomy 1.47 1.21 Tret open pneumothorx 1.57 1.30 Chest tube 0.98 1.07 Circultion Assess for shock 3.21 0.78 Strt IV 3.44 0.71 Obtin introsseous ccess 1.72 1.23 IV fluid resuscittion 3.27 0.79 IV nlgesi 3.06 0.89 IV ntibiotics 3.20 0.88 Administer blood products 2.96 1.04 Neurologicl Glsgow Com Scle 2.82 0.96 AVPU 1.98 1.46 IM therpy IM morphine 3.34 0.77 IM ntibiotics 3.41 0.69 Frcture mngement Splinting 2.59 1.11 Trction splinting 1.77 1.27 Electronic monitoring 2.90 0.85 b Rnge, 0 4. why these respondents thought those prticulr skills were not importnt, since qulittive sttements were not collected s prt of the questionnire. The fct tht some skills were deemed not importnt might wrrnt further explortion. The second im of the study focused on perceived trum competence. Due to the vst differences in bckground experience nd trining, there ws significnt vrition in selfperceived trum competence. Clerly, those with ICU/ER experience thought themselves to be more competent in most of the trum skills identified, most likely relted to previous experience. With tht sid, it is possible to increse the competence level of the FNP by incresing the trining nd providing prcticl, rel-world trining nd ppliction in n ICU/ER setting. The results lso indicte tht ATLS is superior to TNCC in incresing trum competence. Dt to compre ATLS nd ATCN to trum competence were unvilble since only one subject hd ttended ATCN. A previous study indicted tht nurses who ttended both ATCN nd TNCC did well on 762 MILITARY MEDICINE, Vol. 173, August 2008
Self-Assessment of Trum Competencies TABLE V. Self-Perception of Competency in Trum Skills Self-Perceived Competence Mnn-Whitney U Results by Significnce Level Trum Skills Men SD Experience b Trining c Deployment d Hemorrhge Apply tourniquet 2.89 0.95 0.18 0.43 0.12 Apply direct pressure 3.30 0.67 0.02 * 0.81 0.07 Apply HemCon/Quick Clot 1.01 1.3 0.01 * 0.99 0.18 Airwy Chin lift/jw thrust 3.44 0.60 0.02 * 0.14 0.06 Oro/nsophryngel 3.10 0.84 0.00 * 0.15 0.95 Cricothyroidotomy 1.18 1.1 0.04 * 0.42 0.04 * Bg-vlve msk 3.38 0.68 0.05 * 0.17 0.01 * Endotrchel intubtion 1.85 1.0 0.03 * 0.16 0.92 Brething Administer oxygen 3.67 0.52 0.18 0.21 0.37 Needle thorcostomy 1.47 1.2 0.03 * 0.75 0.38 Tret open pneumothorx 1.57 1.3 0.01 * 0.05 * 0.08 Chest tube 0.98 1.1 0.01 * 0.74 0.08 Circultion Assess for shock 3.21 0.78 0.01 * 0.16 0.55 Strt IV 3.44 0.71 0.05 * 0.01 * 0.19 Obtin introsseous ccess 1.72 1.2 0.04 * 0.37 0.29 IV fluid resuscittion 3.27 0.79 0.01 * 0.00 * 0.61 IV nlgesi 3.10 0.89 0.23 0.38 0.89 IV ntibiotics 3.20 0.88 0.23 0.82 0.20 Administer blood products 2.96 1.0 0.08 0.25 0.20 Neurologicl Glsgow Com Scle 2.82 0.96 0.00 * 0.10 0.38 AVPU 1.98 1.5 0.03 * 0.44 0.18 IM therpy IM morphine 3.34 0.77 0.40 0.00 * 0.50 IM ntibiotics 3.41 0.69 0.10 0.00 * 0.77 Frcture mngement Splinting 2.59 1.1 0.20 0.30 0.86 Trction splinting 1.77 1.3 0.00 * 0.28 0.33 Electronic monitoring 2.90 0.85 0.01 * 0.17 0.12, p 0.05. b ICU/ER versus other; ICU/ER, n 41; other, n 55. c ATLS versus other; ATLS, n 27; other, n 69. d Deployed versus never deployed; deployed, n 35; no deployment, n 61. trum competence evlutions. 8 Since nurses cnnot ttend ATLS officilly, ttendnce t ATCN nd TNCC my be n cceptble substitute for ATLS. Our recommendtion is tht ll militry providers ttend the sme trum trining to ensure they re lerning the sme mteril. Deployment experience (previous or current) does not pper to chnge the self-perception of trum competence. This ws surprising finding since combt deployments usully hve more opportunities to see trum ptients. It is not cler how much trum, if ny, the 35 subjects who reported deployment time ctully experienced. Severl limittions were identified fter strting this study nd through dt nlysis. First nd foremost, this ws descriptive study on self-perception nd not ctul observed trum competence. This study ws logicl first step due to the limited mount of dt on FNPs nd trum competence. Another limittion identified ws tht only 37% reported deployment experience. Of those who did deploy, not ll worked s providers during their tours. The questionnire did not sk to identify only those deployments they took prt in s FNPs. Some respondents invribly hd deployment experience while either enlisted nd/or s registered nurse. Since the beginning of this study, AR 601-142 ws modified to llow FNP substitution for PAs t level II. It is certin tht more FNPs hve deployed in the provider role since the inception of this study. As of April 2008, 12 FNPs hve deployed to level II fcilities in Irq nd 11 report direct trum experience. Predeployment trining for FNPs hs lso been modified nd incorportes mny of the sme trining s other providers. Most providers now ttend the Tcticl Combt Medicl Course (TCMC), which ws in development stges t the initition of this study. Anecdotl reports from FNPs tht hve ttended the TCMC progrm nd deployed report incresed trum competence. MILITARY MEDICINE, Vol. 173, August 2008 763
Self-Assessment of Trum Competencies CONCLUSIONS Findings support the need for dditionl trum trining such s ATLS. Clinicl or hnds-on experience should be gered towrd the ICU nd ER settings where more trum procedures re performed. Further reserch in this re is needed becuse the numbers of FNPs who hve deployed hve incresed long with the trining ttended. Suggestions include repeting this study with only those FNPs who hve deployed s providers. Additionlly, study on pre- nd post-trum competency trining would provide useful informtion. Evluting the effect of the TCMC progrm on trum competence should lso be considered. The results of this study indicte tht with trining nd experience, FNPs perceive themselves s competent in trum mngement. ACKNOWLEDGMENTS We cknowledge Chui-Chieh Chen for his ssistnce in setting up the online questionnire with PHP Surveyor. We lso thnk LTC Lorrine Crney, FNP Consultnt to the U.S. Army Surgeon Generl, for inviting ll ctive FNPs to prticipte. Lstly, we thnk Lt Col Michelle Lvey nd MAJ Sndr McNughton for their ssistnce with the reserch process. REFERENCES 1. Drgis J, Horne T, Tillmn-Ortiz S, Scherr D, Yckel E: Expnding the role of the nurse prctitioner in the deployed setting. Milit Med 2006; 171: 770 3. 2. Hedqurters Deprtment of the Army: Personnel Procurement: Army Medicl Deprtment Professionl Filler System. Army Regultion 601-142. Wshington DC, Februry 2006. 3. Sherwood GD, Brown M, Fy V, Wrdell D: Defining nurse prctitioner scope of prctice: expnding primry cre services. J Advn Nurs Prct 1997; 1: 2. 4. Chng E, Dly J, Hwkins A, et l: An evlution of the nurse prctitioner role in mjor rurl emergency deprtment. J Advn Nurs 1999; 30: 260 8. 5. Skr M, Angus J, Perrin J, Nixon C, Nicholl J, Wrdrope J: Cre of minor injuries by emergency nurse prctitioners or junior doctors: rndomized control tril. Lncet 1999; 354: 1321 6. 6. Mson S, Fletcher A, McCormick S, Perrin J, Rigby J: Developing ssessment of the emergency nurse prctitioner competence- pilot study. J Advn Nurs 2005; 50: 425 32. 7. Christms B, Reynolds J, Hodges S, et l: Physicin extenders impct trum systems. J Trum Injury, Infect Crit Cre 2005; 58: 917 20. 8. Bird C, Kernohn G, Cotes V: Outcomes of dvnced trum life support trining: questioning the role of observer. Accident Emerg Nurs 2004; 12: 131 5. 764 MILITARY MEDICINE, Vol. 173, August 2008