Acute Care Nurse Practitioner:An Advanced Practice RoLe

for RN First AssistantsJANICE L SCHROEDER, RN, MSN, CRNFA, ARNP, ACNP

Perioperati\'e nurses and RN firstassistants (RNFAs) have long beenfamiliar with the advanced prac-

tice roles of the certified RN anesthetist(CRNA), certified nurse midwife (CNM),clinical nurse specialist (CNS) as clinicaleducator, and the family nurse practi-tioner (FNP) as a primary care provider.An advanced practice role that perioper-ative nurses and RNFAs may not be asfamiliar with is the acute care nursepractitioner (ACNP). Acute care nursepractitioners are educationally preparedto provide advanced nursing care topatients with complex acute, critical, andchronic illnesses. TTiis role is ideally suit-ed to perioperative nurses and RNFAswho want to take on an advanced prac-tice role but do not want to leave thehands-on, acute care setting of the peri-operative arena.

ADVANCED PRAcncE ROLES

AND SCOPE OF PRAcncE

The scope of practice defined by eachstate determines the type of patients thatNPs can treat, where they can practice,and under what circumstances they maydo so. In the past, some perioperativenurses and RNFAs may have been hesi-tant about pursuing an advanced prac-tice role, believing that the only nursepractitioner (NP) option was the FNPI ole. The FNP course of study and scopeof practice would likely take them out ofthe acute care setting they enjoy and aremost comfortable in and move theminto the outpatient primary care settingof a clinic or health department. FamilyNPs are trained for care of the familyunit from newborns and the postpartumwoman to older adults, and they areeducationally prepared to provide directpatient care aimed at health promotion.

health protection, and disease preven-tion.' Other NP specialties include

psychiatric,neonatal,pediatric,adult,gerontological,women's health, andacute care.An advanced practice opportunity for

perioperative nurses who are interestedin OR education, practice and policydevelopment, research, or managementis the clinical nurse specialist (CNS) role;employment in private practice for a sur-geon or other specialist also is an optionin some states. In defining the CNS role,the National Association of ClinicalNurse Specialists says that a CNS

independently provides theory andresearch-based care to clients in facili-tating attainment of health goals,works with nurses to advance nursing

ABSTRACTACUTE CARE NURSE PRACTITIONERS (ACNPs)are advanced practice RNs who are educationallyprepared to provide advanced nursing care topatients with complex acute, critical, and chronicillness.

THE EDUCATION of advanced practice nursesshould prepare them for the setting in which theypractice; ACNPs are well prepared for hospital andspecialty practice, particularly if they have experi-ence as RN first assistants (RNEAs).

THIS ARTICLE PROVIDES a brief overview of theACNP opportunity for RNFAs and the importanceof additional training for ACNPs without OR expe-rience who may be first assisting. AORN J 87 (June2008) 1205-1215. © AORN, Inc, 2008.

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practice to improve outcomes cost-effectively,and/or provides clinical expertise to affectsystem-wide changes in organizations toimprove programs ofcare.^

it is important to check the scope of practicefor CNSs in the state in which the nurse willpractice. In some states, the CNS is considered anadvanced RN practitioner (ARNP), but not inother states. States that do not recognize the CNSas an ARNP limit the CNS's scope of practice inareas of prescriptive authority, practice options,and reimbursement from Medicare and otherthird-party payers.' In addition, state legislaturespass regulations that change the scope of nursingpractice. For example, effectiveJuly 1,2007, the Nebraska StateLegislature signed into law anew definition of ARNP thatincludes CNSs, CRNAs, andCNMs. Before July 1,2007, inNebraska, "ARNP" referredonly to the NP roles. This leg-islative action also allows licen-sure for CNSs.'

Another advanced practicerole that perioperative nursesand RNFAs can pursue is theACNP role, which allows formore hands-on patient carethan the CNS role. Acute careNPs provide advanced nurs-ing care to patients with com-plex acute, critical, and chronicillnesses. Practice settingsinclude acute and subacutehospital departments such asthe intensive care, bum, emergency, trauma,dialysis, or medical-surgical units, as well asspecialty office and rehabilitative settings.Acute care NPs are often the mid-level providerof choice in specialty practice, such as pul-monology, cardiology, oncology, nephrology,neurology, and any of the surgical specialties.The ACNP scope of practice is determined byeach individual state's laws and is outlined inthe Nurse Practice Act.̂

Typically, both the CNS and ACNP practiceprimarily in acute care or specialty practice set-tings. Tlie perioperative CNS is educationally

prepared to focus specifically on the periopera-tive patient population through policy andpatient care protocols and ensuring that man-dated quality care initiatives are implemented.The perioperative ACNP is educationally pre-pared to make medical diagnoses collaborative-ly with a surgeon for individual patients, pre-scribe treatments for those medical diagnoses,and follow patients throughout their periopera-tive experience, including post-hospital dis-charge care.' A survey of 158 CNSs and 77ACNPs supports the scope of practice describedfor each role. The ACNP respondents indicatedthat individual patient care accounted for 74%of their practice time, whereas the CNS respon-

dents indicated that 26% oftheir practice time was spenton individual patient care."

The acute care nurse

practitioner role is an

advanced practice role

that allows for more

hands-on patient care

than the clinical nurse

specialist role.

DEVELOPMENT OFTHE ACNP ROLE

In the 1970s, the first ACNProle evolved from the pedi-atric NP role. A combinationof cutbacks in the number ofpediatric residents and in-creasing acuity and complexi-ty of surviving neonatal pa-tients prompted the develop-ment of the neonatal NP role.'A similar scenario then oc-curred in the adult population,and primary care NPs beganaccepting positions and addi-tional training for hospital-based practice.' The need foreducationally prepared ACNPs

became apparent, and the first graduate-level,adult ACNP programs emerged in tlie late1980s, with the first national certification exami-nation by the American Nurses CredentialingCenter being offered in 1995.̂

Also in 1995, AORN recognized and definedthe role of the perioperative advanced practicenurse with an official statement of practice ap-proved by the AORN House of Delegates.̂ Thisstatement was revised in 2006 to indicate that ahallmark of NP skill is autonomy and experhse inassessing, diagnosing, and prescribing pharmaco-logical and treatment modalities in the care of the

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surgical patient." This is a descriptive statementthat is not used as a form of credentialing ortitling by any state board of nursing, and it isapplicable to either a CNS or NR'

In 2003, the Accreditation Council for Grad-uate Medica! Education mandated restrictingresident physicians to working 80 hours perweek.'" Teaching institutions that traditionallyrelied on surgical residents for first assistantservices have begun using the surgically trainedNP or physician assistant (PA) to fill the void incare created by the decrease in resident hours."

As Medicare and other third-party reim-bursements continue to decline, demand forACNPs is increasing. Surgeons are faced withincreasing demands on their time and arelooking for ways to maximize their practiceresources without compromising patient careoutcomes.'- A surgeon functioning as a firstassistant is allowed to bill Medicare \6% of thesurgeon's Medicare allowable charge. AnARNP, CNS, or PA may bill 13.6% for the sameservice." Reimbursement from commercialinsurance for first assistant services is depend-ent on the individual company policy; somepayers allow 20"/> or 25% of the surgeon'sallowable fee. The ACNP as first assistant iscost-effective for the patient, insurance pro-vider, and surgeon. When the simplicity of asurgical procedure does not warrant an assis-tant, the ACNP's time and skills may be usedto monitor, assess, educate, and treat inpa-tients or outpatients, optimizing patient careand efficiency for the surgeon.

THE IMPACT OF NP CARE ON PATIENT OUTCOMESSeveral research studies have shown that in

addition to being cost-effective, the use of NPsand ACNPs in patient care leads to positivepatient outcomes. Brooten et al" analyzed 333interaction logs created by NPs during fiverandomized controlled trials that included• very low birth weight infants,• women who underwent unplanned cesare-

an birth,• women with a high-risk pregnancy,• women who underwent hysterectomy, and• older adults with cardiac medical and surgi-

cal diagnoses.Each group was monitored for total amount of

As Medicare and other third party

reimbursements continue to decline,

demand for acute care nurse

practitioners is increasing.

NP time, number of contacts per patient, andmean length of time per NP contact. Thegroups with greater mean NP time and con-tacts per patient had greater improvements inpatients' outcomes and greater health care costsavings.'^ Hysterectomy and cardiac surgicaldiagnoses were included in this study; it is rea-sonable to expect similar findings of improvedpatient outcomes and cost savings when anACNP is part of the team for other surgicalspecialties as well.

Researchers for the randomized controlledtrial Study of Nursing Intervention in Practiceassigned 339 consenhng patients scheduled forelective cardiac catheterizations to receive pre-procedure teaching and preparation by either anNP or a junior medical staff member." Tlie cardi-ologist's evaluation of patient preparation wasacceptable in both groups, with both groupshaving nearly equal scores: 983% in the NPgroup and 98.8 % in the junior medical staffmember group. No adverse events occurred inpatients in the NP group and adverse eventsoccurred for two of 161 patients (1.2%) in thejunior medical staff member group. Patient sat-isfaction questionnaires indicated greater satis-faction in the NP group (P = .04), and the medi-an duration of the preadmission visit was lowerin the NP group (ie, 165 minutes in the NPgroup versus 185 minutes in the junior medicalstaff member group). The researchers concludedthat an appropriately traiJied NP can safely pre-pare patients for diagnostic cardiac catheteriza-tion." This study indicates that ACNPs are wellsuited to provide preprocedure patient teaching.

In a 31-month study by Hoffman et al'" in ateaching institution, researchers compared

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patient outcomes in a subacute intensive careunit {ICU) as managed by two teams: anACNP and attending physician team and acritical care fellow or pulmonary fellow andattending physician team, The results showedthat the duration of mechanical ventilation,length of stay, readmission rates, and mortali-ty did not differ between the two manage-ment teams, indicating that an ACNP andattending physician team can safely managechronically critically ill patients. Both theACNP and the critical care/pulmonary fel-lows demonstrated similar efficiency profilesrelated to time spent in patient management.The ACNP spent 44% of the time on careactivities compared with 40% for the fellows.The researchers concluded that an ACNP/attending physician team can competentlyassume responsibility for the management ofchronically and critically ill patients.'" Theconcept of using ACNP/physician teams isapplicable to the care of surgical patients.

THE ACNP ROLE IN A SURGICAL PRACTICE

In addition to first assisting during surgery,preoperative and postoperative responsibilitiesof the ACNP in a surgical practice may include,but are not limited to,• taking histories and conducting physical

examinations,• working coilaboratively to manage in-

patients,• providing patient education,• performing postoperative discharge plan-

ning, and• teaching.Performing outpatient foUow-up care and minorprocedures (eg, inserting arterial lines, thoracos-tomy tubes, or chest tubes; performing woundrepair; excising skin lesions) and consultingwith referring physicians all may be part of acollaborative surgical practice.'̂ "" Although thetraining for all NPs includes the basic NP skillsof taking histories and conducting physicalexaminations, ACNP education also includes afocus on stabilizing acute problems, preventingand managing complications in the hospital set-ting, and providing comprehensive manage-ment of injury or iUness.̂ The ACNP who firstassists during surgery has a unique perspective

from which to manage the acute episode of thesurgical patient and work coilaboratively withthe surgeon, OR staff members, perioperativeCNS or educator, hospital surgical unit staffmembers, and office staff members to achievethe best possible outcomes for each patient.

An ACNP with an RNFA background isuniquely qualified to evaluate patients preop-eratively for potential intraoperative or post-operative complications. For example, anRNFA will know that electrolyte imbalancesmay precipitate cardiac dysrhythmias and thata hypertensive crisis or an unsafe level of anti-coagulation may warrant postponement of thesurgery. An ACNP without experience in theOR may lack some of the essential knowledgefor a first assistant. Awareness of physiologicalconditions that may impair wound healing,such as diabetes, chemotherapy, steroid use, ormalnutrition, will aid the ACNP and surgeonin proper wound closure techniques andchoice of antimicrobial therapy to avoid post-operative complications. Patient medications,age, nutrition status, body habitus, woundclassification, and intraoperative events all fac-tor into decisions regarding suture selection,drains, and length of time sutures or staplesshould remain in place. Preoperative medica-tion administration, intraoperative use ofantibiotics, and postoperative management areguided by evidence-based research and tai-lored to a patient's individual needs.

After surgery, daily rounding on patientsallows the ACNP to monitor patient progress,collaborate with the surgeon and staff mem-bers regarding best practice management, andidentify patient education needs. Continuity ofcare for the patients and a consistent personfor staff members to contact with patient con-cerns also is an important aspect of ACNPpatient rounds, particularly in a teaching facili-ty where surgical residents change frequently.

THE NEED FOR ADEQUATE TRAINING

Surgeons expect a competent first assistant tobe familiar with the steps of the surgical proce-dure and to be acutely knowledgeable regardingthe anatomic location of critical structures, phys-iologic consequences of tissue handling, andhow to anticipate these consequences without

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needing continual instruction or direction. Theability to identify and avoid damage to nervousand vascular structures, as well as knowingwhere electrosurgery or clamping can be safelyapplied, is only one difference between an OR-naive assistant and an experienced assistant.Experienced RNFAs know the conseciuences oftissue handling and are able to aiiticipate thesteps of the surgical procedure.'"

Rothrock and colleagues sought to deter-mine the pre-existing level of competence infundamental perioperative nursing careamong a cohort of 16 NPs enrolled in theDelaware County Community College'sRNFA program.'" A self-rating instrument tomeasure fundamental perioperative nursingcompetencies was used. Of the 16 NPs, nonehad RNFA experience, six had prior OR expe-rience, and 10 had no OR experience. The NPswith OR experience indicated they knewmany of the basic principles of perioperativecare but lacked confidence in• interpreting laboratory values and radiolog-

ic studies,• using various means of achieving hemosta-

sis in the surgical field,• identifying referral services, and• identifying fluid and electrolyte imbalances

and replacement therapies.''*Nurses in the NP group without OR experi-ence self-identified areas of deficiency in• establishing intraoperative nursing diag-

noses and patient outcomes;• developing an intraoperative plan of care,

including knowing instrumentation, sup-plies, and equipment needed;

• safe patient positioning for the surgicalintervention;

• creating and maintaining a sterile field;• anticipating requirements of the surgery;• performing counts to prevent the risk of

injury from a retained foreign body;• participating in use of surgical medications;• calculating blood loss;• monitoring and controlling the surgical

environment, including traffic patterns,electrical safety, thermoreguiation, andenvironmental sanitation;

• exercising safe judgment and decision-makingbased on past experience; and

• evaluating desired patient outcomes for theintraoperative period.'"

This survey showed that several self-identifiedgaps in knowledge and skill existed for theNPs surveyed before starting an RNFA pro-gram. This finding could raise issues of con-cern for patient safety if an ACNP accepts theresponsibility of first assisting without previ-ously obtaining adequate training.

Patient safety is of utmost concern in the surgi-cal setting. The Joint Commission now sets annu-al National Patient Safety Goals, one of which isreducing surgical site infections.̂ " If an ACNPpracticing in the role of first assistant is unfamil-iar with the essentials of creating and maintain-ing a sterile field or of environmental sanitationin the OR, as noted in the self-report analysis byRothrock,'" the risk of surgical site infectionwould increase rather than decrease. Safe patientpositioning also is a constant concern in the OR.The first assistant frequently assumes responsibil-ity for patient positioning before the surgeon'sarrival. Permanent nerve or vascular damage canoccur as a result of improper positioning or inad-equate protection of vulnerable areas.

These examples illustrate the importance ofadditional training for the OR-naive ACNP.From a medical-legal perspective, the ACNPwho accepts the responsibility of first assistingshould be able to demonstrate educationalpreparation and experience that qualifies him orher to function in the role of first assistant." Intoday's litigious society, additional credentialingas a graduate from an RNFA program adds tothe credibility that the ACNP is practicing with-in his or her scope of practice. When NPs prac-tice outside the scope of practice for whichthey have been trained and have experience,significant liability issues arise."

TRAINING FOR ACNPS

Certification for NPs specifically trained inacute care started in 1995.̂ As scope of practicelaws change with this relatively new ACNPoption, hospital administrators are looking moreclosely at the educational background and expe-rience of the NPs in their facilities. Competenciesguiding the educational preparation of theACNP are spelled out in the Acute Care NursePractitioner Competettcies developed by the

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TABLE 1

RNFA Programs'The following RN first assistant (IWFA) programs have met specific criteria and are accepted by theCompetency & Credentialing Institute (CCI) as acceptable programs for certified RN first assistant(CRNFA) eligibility. The program acceptance plan began in June 1998. Any formal RNFA programs takenbefore that date will be allowed for CRNFA eligibility.

None of the programs below are affiliated with CCI, so they may have separate eligibility requirementsfor enrollment. Please note that the following list is subject to change without notice. Web site addresseshave been provided where available.

The * denotes those programs that are affiliated with an accredited school of nursing. If you need moreinformation on their accreditation status, please contact the school directly.

Alabama^University of Alabama at Birmingham,School of Nursing(205)934-0610

California*School of Nursing, University of Californiaat Los Angeles-Extension(310) 825-7093http://-www.uclaextension.edu/index.cfm?href=/depa rtmentalpages/ii idex.cfm&departme} tt^/lieatthsci/index.cfni

Colorado*NIFA Distance Learning RNFAProgram,DenverAffiliated with Community College ofSouthern Nevada(800) 922-7747littp://wwu'. rnfa.net/

FloridaProfessional Assistants PRN, NaplesAffiliated with Southwest Florida Collegein Tampa(813)630-4401http://ioiow.swfc.edu/

*University of South Rorida,College of Nursing, Tampa(813) 974-4392/; t tp://wiinv.hsc.usf.edu/nocms/n ursing/index.html

IowaHawkeye Community College, Waterloo(319)296-2320x4457http://wiinv.hawkeyec.oltege.edu/futurestudents/progiwnsoffereddetail.asp ? ProgramNamelD=Registered%2ONurse%20First%20Assistant

Kansas*Elite School of Surgical First Assisting, Topeka(877) 224-0133E-mail: info@essfa.net

Maryland*Anne Anmdel Community College, Arnold(410) 777-7352http://unim.Kaacc.edu/default.cfm

Massachusetts"Northeastern University, SchtKil of Professional andContinuing Studies, Boston(617)373-5474http://ivww.spcs.neu.edu/professional/rnfa2

*Lawrence Memorial/Regis College, Medford(781)306-6684http://imow.lnnvgisnurse.org/

Michigan*O<ikwood Hospital Heritage Center, TaylorAffiliated with Wayne County Community College(313) 295-5400http://www. oakioood.org/Locations/locations_detail.as

National Panel for Acute Care Nurse PractitionerCompetencies.-^ All NPs are trained in a core setof competencies; additional training providedfor ACNPs includes assessment of tbe acutely illpatient, electrocardiogram and x-ray interpreta-tion, acute care respiratory support, arterial lineand chest tube insertions, hemodynamic moni-toring, and acute and critical care pharmacologi-

cal interventions, as well as additional training inthe clinical setting specific to a chosen practicearea. Additional skills mastered and proceduresperformed by the ACNP are influenced by thepatient population or specialty area in which theACNP is practicing, as well as individual abili-ties, motivations, and personality traits.'-'

Nurse practitioners without formal acute care

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RNFA

Missouri*St Charles Community College,St Peters(636) 922-8284http://www.stdias.edu/

*St Louis Communitv College(314)644-9272http://wwu'.stlcc.cdu/

New Mexico*Professional Nursing Seminars,Taos Ski ValleyAffiliated with Northern New MexicoCommunity College(505) 776-5989}iftp://wwu>.rnfirstassistant.coni/

New York*SUNY Upstate Medical University,College of Nursing, Syracuse(315) 464-4276http://unvuiiipAtnte.ciiu/con/

*University of BuffaloSchool of Nursing(716)829-2533littp://ntirsing.bufftilo.cdii/

*University of Rochester,School of Nursing/CommunityNursing Center(585) 273-5456httirj/wivw. edvan tagehealth.com/

TABLE 1

Programs (continued)'

North Carolina*Moses Cone Health System and North CarolinaAgricultumI & Technical State University, Greensboro(336) 832-2575http:/Auww.mosescone.com/careercenter.cfni?id=1365

Ohio*Columbus State Community' College(614)287-2487http://wunv.cscc.eiiu/

*Lakeland Community College, Kirtland(440) 525-7016http://iiRvio. lakeland.cc.oh.us/

*Loraiii County Community College, Elyria(800) 995-5222, ext. 7159http://www.lorainccc.edu/E-mail: psedlak@lorainccc.edu

Pennsylvania^Delaware County Community College, Media(610) 359-5286http:/Avww.dccc.edu/

*Luzerne County Community College, Nanticoke(570)740-0575http://itnvw.luzerne.edu/index.jsp

CanadaBritish Columbia Institute of Technology-SpecialtyNursing, Burnaby(800) 663-6542 - local 7079http://www.bcit.ca/health/mirsing/

7. RNFA programs. Compctcucij & Credentialing Institute. http://www.cc-institute.org/certj:rnf_prep_rnfa.aspx.Accessed January 8, 2008.

All web sites accessed January 8. 2008.

Adapted with permission fmm tite Competency & Credentialing institute, Denver, Colorado.

training who want to pursue an ACNP role canacquire clinical competence in several ways;• through preceptorships and mentoring by a

collaborating physician,• attending a formal post-master's ACNP

program,• attending conference sessior\s focusing on

acute care skills, or I

• obtaining certification through advancedcourse work such as the Society of CriticalCare Medicine's Fundamentals of CriticalCare Support course.̂ ^

Acute care NPs new to the surgical arena canacquire the basic skills of first assisting from oneof the RNFA programs that have iiicorporatedNP competencies into the curriculum (Table 1).

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Many RNFA programs have special considera-tions for advanced practice nurses regardingtheir admission policy. Some programs addressthe specific needs of the advanced practicenurse without OR experience by adding extraclinical and didactic time to the curriculum.-' Ifattending a formal RNFA program is not anoption for the ACNP, the perioperative CNS oreducator can teach the ACNP basic intraopera-tive skills to enhance patient safety before he orshe begins learning the first assistant role. Shortseminars in suturing also are available in someof the RNFA programs.

Perioperative nurses and RNFAs can accessNP graduate studies intended specifically forthe acute care setting from one of the manyACNP graduate programs across the nation.Kleinpell et af outlined contact information for70 schools offering the ACNP option to graduateand post-graduate students in their article "Edu-cational options for acute care nurse practitionerpractice." Some, but not all, graduate programsrequire critical care experience m an ICU oremergency room before accepting an applicantinto the ACNP track. Perioperative nurses andRNFAs without critical care experience may beable to obtain the minimum experience requiredfor admission by working part time in an ICUwhile attending graduate school.

AN IDEAL ROLE FOR RNFAS

The ACNP role developed out of a need foradvanced practice nursing care in the acute caresetting. Blending the roles of ACNP and RNFAoffers optimai benefits to patients and surgeonsby incorporatiiig the knowledge and skills ofboth roles into a collaborative surgical practice.As scope of practice laws are refined to reflect theexpected standard of care, however, it is becom-ing more important to ensure that ARNPs prac-tice within the scope of practice of their specialty.The introduction of ACNP graduate programsprovide RNFAs and perioperative nurses with anopportunity for advanced practice education thatprepares them to take on an advanced practicerole in an acute care setting. -

REFERENCES1. National Organization of Nurse Practitioner Fac-ulties. Nurse Practitioner Primary Care Competenciesin Specialty Areas: Adult, Family, Gerontological, Pedi-

atric, and Women's Health. Washington, DC: USDepartment of Health and Human Services, HeaithResources and Services Administration; April 2002.http://www.nonpf.com/finalaug2002.pdf. Ac-cessed January 1, 2008.2. Model rules and regulations for CNS title protec-tion and scope of practice. National Association ofClinical Nurse Specialists. March 9, 2004. http://www.nacns.org/model_language.pdf. AccessedJanuary 1,2008.3. Phillips SJ. A comprehensive look at the legisla-tive issues affecting advanced nursing practice.Nurse Pract. 2007;32(l):14-]7.4. Hravnak M, Kleinpell R, Magdic K, Guttendorf J.The acute care nurse practitioner. In: Hamric AB,Spross JA, Hanson CM, eds. Advanced Practice Nurs-iii;i: A}i lnte;:;rative Approach. 3rd ed. St Louis, MO:Elsevier/Saunders; 2005:475-514.5. Kieinpell RM, Perez DF, McLaughlin R. Educa-tional options for acute care nurse practitioner prac-tice. / Aw Aciid Nurse Pract. 2005;17(ll):460-471.6. Becker D, Kaplow R, Muenzen PM, Hartigan C.Activities performed by acute and critical careadvanced practice nurses: American Association ofCritical-Care Nurses Study of Practice. Am } CritCrtrc. 2006;15(2):130-148.7. Barber J, Burke M. Advanced practice nursing inmanaged care. In: Mezey MD, McGivern DO, eds.Nurses, Nurse Prnctitioiicrs: Evolution to AdvancedPractice. New York, NY: Springer Publishing Co;1999:203-218.8. Giordano BP. Dues increase, unlicensed assistivepersonnel, advanced practice top issues this yearAORN}. 1995;61{6):947-958.9. Position statement: Perioperative advanced prac-tice nurse. In: Stovdards, Recommended Practices, andGuidelines. Denver, CO: AORN; 2007:403. http://www.aorn.org/PracticeResources/AORNPositionStatements/Position_AdvancedPracticeNurse/.Accessed January 1, 2008.10. Common program requirements. iV. Residentduty hours in the learning and working environ-ment. Accreditation Council for Graduate MedicalEducation. February 2007. http://www.acgme.org/acWebsite/dutyHours/dh_ComlVogrRequirmentsDutyHours0707.pdf. Accessed January 4, 2008.11. Franko FP. Providers of first assisting services.AORN j . 2004;79(6):13n-1318.12. Burke M. Billing Medicare for the services ofNP's & PA'S. Physician's News Digest. April 2003.http://www.physiciansnews.com/business/403burke.html. Accessed January 1, 2008.13. Payment Changes Are Needed for Assistants-at-Siirgery. Washington, E)C: US General AccountingOffice; January 2004. ht:tp://www.gao.gov/new.items/dO497.pdf. Accessed January 1, 2008.14. Brooten D, Youngblut JM, Deatrick J, Naylor M,York R. Patient problems, advanced practice nurse(APN) interventions, time and contacts among fivepatient groups. / Nurs Scholarsh. 20a3;35(l):73-79.

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15. Stables RH, Booth J, Welstand J, Wright A,Ormerod OJ, Hodgson WR. A randomised con-trolled trial to compare a nurse practitioner to med-ictil staff in the preparation of patients for diagnos-tic airdiac catheterisation: the Study of NursingIntervention in Practice (SNIP). Eur j CardiovascNi/r_s, 2004;3{l):53-59.16. Hoffman LA, Tasota FJ, Zullo TG, ScharfenbergC, Donahoe MP Outcomes of care managed by anacute care nurse practitioner/attending physicianteam in a subacute medical intensive care unit. Am jCrit Care. 2005;14(2):12]-130.17. Fox VJ, Schira M, Wadlund D. The pioneer spir-it in perioperative advanced practice—two practiceexamples. AORN /. 2000;72{2):241-253.18. Zarnitz P, Malone E. Surgical nurse practition-ers as registered nurse first assists: the role, histori-cal perspectives, and educational training. Mil Med.2006;]71(9):875-878.19. Rothrock}. Competency assessment and compe-tence acquisition: the advanced practice nurse as RNsurgical first assistant. Topics in Ad'Otinced PracticeNursing ejournal [serial online]. March 21, 2005.http://www.medscape.com/viewarticle/499689.Accessed January 1, 2008.20. Facts about the 2007 National Patient SafetyGoals. The Joint Commission. June 2006. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_npsg_facts.htm. AccessedJanuary 7, 2008,

21. Herrick T. A new hurdle to leap: clinicians facecompetency and credentialing issue. CUn News.2005;9{3):1, 14-16.22. Klein TA, Scope of practice and the nurse practi-tioner: regulation, competency, expansion, and evo-lution. Topics in Advanced Practice Nursing ejournal[serial online]. June 15, 2005. http://www.medscape.com/viewprogram/4188_pnt. Accessed Janu-ary 1,2008,23. National Panel for Acute Care Nurse PractitionerCompetencies. Acute Care Nurse Practitioner Compe-tencies. Washington, DC: National Organization ofNurse Practitioner Faculties; November 2004, http://www,aacn.nche.edu/Education/pdf/ACNPcompsfina 12004,pdf. Accessed January 1, 2008.24. MelanderS, Kleinpell R, McLaughliti R. Ensur-ing clinical competency for NPs in acute care. NursePract. 2007;32(4): 19-20,25. RNFA programs. Competency & CredentialingInstitute. http:/'/www.cc-institute.org/cert_crnf_prep_rnfa.aspx. Accessed January 1, 2008.

Janice L. Schroeder, RN, MSN, CRNFA,ARNP, ACNP, is an acute care nurse prac-titioner and RN first assistant for a generalsurgeon at the Wichita Clinic Bethel,Newton, KS.

A Small Amount of Exerdse Increases Quality of Life

Exercising as [ittle as 10 to 30 minutes a day mayhelp women improve their quality of Life, accord-

ing to a March 13, 2008, news release from theAmerican Heart Association. A recent study exam-ined the role of exercise training in 430 sedentaryoverweight or obese postmenopausal women. Studyparticipants were randomly assigned to one of fourgroups. Three of the groups exercised at varyinglevels. The fourth group served as the controlgroup and did not exercise. Participants completeda survey before and after the study to measurequality of life and determine physical and mentalhealth. Survey scores were adjusted for ethnicity,age, employment status, smol<ing, anti-depressantuse, and marital status.

After six months of exercise, researchers foundimprovement in the following areas:• almost 7% in physical function and general health;• 16.6% in vitality;• 11.5% in performing work or other activities;• 11.6% in emotional health; and

• more than 5% in social functioning.At the beginning of the study, vitality and emo-tional scores among participants were lower thanfor the average US population. After six months,however, participants' vitality and emotional scoreswere higher than average. Individuals who partici-pated in the highest Levels of exercise saw thegreatest improvement, but women in the Lower Lev-eLs also saw improvement.

Though some women Lost weight during thecourse of the study, their seLf-reported improvementin quality of Life was not dependent on weight Loss.Researchers concluded that a positive associationdoes exist between exercise at any level and theeffect it has on one's quaLity of Life.

Overweight, obese women improve quality of life witti 10to 30 minutes of exercise [news release]. Colorado Springs,CO: American Heart Association; March 14, 2008. http://americanheart.mediaroom.com/index,php?s=43&item=364.Accessed March 14, 2008.

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