Research – Other

Emergency nurse practitioner practice analysis: Report and

implications of the findings
Diane O. Tyler, PhD, RN, FNP-C, FNP-BC, FAAN, FAANP, CAE (Director)1, Karen Sue Hoyt, PhD, RN, FNP-BC, ENP-C,
FAEN, FAANP, FAAN (Professor NP/DNP Programs)2, Dian Dowling Evans, PhD, FNP-BC, ENP-BC, FAANP
(Emergency Nurse Practitioner, Professor)3,4, Lorna Schumann, PhD, FNP-C, ACNS-BC, ACNP-C, ENP-C, CCRN-R,
FAAN, FAANP (Vice Chair)5, Elda Ramirez, PhD, RN, FNP-BC, ENP-C, FAAN, FAEN, FAANP (Professor, Clinical
Nursing & Director)6, Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP (Associate Professor &
Emergency Nurse Practitioner Specialty Coordinator)7, & Donna Agan, EdD (Data Scientist and Instructor)8

ABSTRACT
Background and purpose: A practice analysis of nurse practitioners (NPs) working in emergency care was undertaken
to define their job tasks and develop a specialty certification by examination.
Method: In phase I, clinical experts created a qualitative description of domains of practice, tasks performed,
knowledge required, and procedures performed by NPs in emergency care. Phase II involved validating the quali-
tative description through a national survey (N = 474) of emergency nurse practitioners (ENPs). Evidence from the
validation survey was used to create a test content outline for the ENP examination.
Findings and Conclusions: The delineation of ENP practice validated by the survey (Cronbach alpha = 0.86–0.94 across
rating scales) included 5 ENP practice domains: medical screening, medical decision-making/differential diagnoses,
patient management, patient disposition and professional, legal and ethical practices. There were 22 job tasks across
domains, 10 types of patient conditions/emergency types, 42 knowledge areas, and 68 procedures performed by ENPs.
These resulted in a test blueprint providing the foundation for the ENP certification examination content validity.
Implications for practice: Beyond certification, the practice analysis has the potential to further inform the scientific
basis of emergency specialty practice. Additional uses include refining professional scope and standards of practice,
job descriptions, performance appraisals, research, and policy development.
Key Words: Certification; emergency nurse practitioner; practice analysis; validation study.

Journal of the American Association of Nurse Practitioners 30 (2018) 560–569, © 2018 American Association of Nurse Practitioners
DOI# 10.1097/JXX.0000000000000118

In 2016, the American Academy of Nurse Practitioners
Certification Board (AANPCB) conducted a practice anal-
ysis to develop a new certification program for the ad-
vanced practice nursing specialty in emergency care
(American Academy of Nurse Practitioners Certification
Board, 2016). A practice analysis is the primary method-
ology and a process used by professional organizations
1
American Academy of Nurse Practitioners Certification Board, Austin,
Texas, 2University of San Diego, Hahn School of Nursing and Health
Science, Beyster Institute of Nursing Research, San Diego, California,
3 specifications to current emergency specialty practice.
Clinical, Nell Hodgson Woodruff School of Nursing, Emory University,
Atlanta, Georgia, 4Emory Healthcare, Emory University Hospital,
Atlanta, Georgia, 5American Academy of Nurse Practitioners
Certification Board, Austin, Texas, 6Emergency/Trauma Nurse
Practitioner Concentration, University of Texas Health Science Center
Houston, Houston, Texas, 7Vanderbilt University School of Nursing,
Nashville, Tennessee, 8University of San Diego, Hahn School of
Nursing and Health Science, Beyster Institute of Nursing Research,
San Diego, California
Received: 4 May 2018; accepted 31 July 2018
and credentialing agencies to establish content validity
for a certification program (Raymond, 2001, 2005). The
process involves delineating and validating the elements
of a job or profession. In the study reported here, we used
a set of structured processes to identify emergency nurse
practitioner (ENP) domains of practice, the tasks per-
formed, and the knowledge, skills, and abilities required to
perform job tasks (Sackett & Laczo, 2003) of NPs working in
emergency care. Ultimately, the practice analysis served as
a foundation for developing an examination by linking the
examination content outline (i.e., blueprint) and test
Purpose
This article describes the practice analysis methodology
and findings of the 2016 national practice analysis of
nurse practitioners working in emergency care settings.
The survey was conducted to validate the delineated key
elements of ENP practice and to create a content outline

560 October 2018 · Volume 30 · Number 10 Journal of the American Association of Nurse Practitioners
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and specifications for the ENP certification examination.
The background regarding need for ENP certification by
examination is presented. Additionally, implications for
use of the ENP practice analysis beyond the creation of
a certification examination are discussed.
Background
On AANPCB’s initiation of the ENP certification program, the
area of emergency specialty practice was well established.
There were multiple professional organizations as well as
defined emergency practice settings, job descriptions, ed-
ucational programs, specialty journals, competencies, na-
tional certifications, and research in the specialty. National
certification in emergency care by examination for regis-
tered nurses was available (Board of Certificataion for
Emergency Nursing, 2018); however, recognition of advanced
practice specialty competence through certification by ex-
amination for ENPs was not available.
The desire for ENP certification by examination in-
creased as the need for emergency care providers grew in
response to the rise in emergency care visits as noted in
the National Hospital Ambulatory Medical Care Survey
(NHAMCS) data (Rui & Kang, 2014). Between 2009 and 2014,
emergency department (ED) visits increased by 8.9%, from
129.8 million visits to 141.4 million visits (Centers for Dis-
ease Control, 2013; Rui & Kang, 2014).
The data also support that emergency care providers
must be prepared to treat patients of all acuities and ages
and that a majority of ED patients do not require critical
care services or admission. According to the 2010 NHAMCS
data, 11% of ED patients seen were triaged as emergent,
Emergency Severity Index (ESI) levels 1 and 2; 40% as
nonurgent, ESI levels 4 and 5; and 43% as ESI level 3.
Approximately, 6% of visits occurred in an emergency
service area that did not conduct triage. The age distri-
bution of ED patients revealed that 20% were younger
than 15 years, 16% were between 15 and 24 years, 28%
were between 25 and 44 years, 21% were between 45 and
64 years, and 15% were 65 years or older (Centers for
Disease Control, 2013).
Growth in the field of emergency care and in specialty
practice, especially among advanced practice nurses, was
also evident in information from professional nursing
organizations. For example, the Emergency Nurses Asso-
ciation (ENA), established in 1970, had a membership of
42,000 in 2016 that included several hundred advanced
practice nurses. Similarly in 2016, an American Associa-
tion of Nurse Practitioners national survey reported that,
of the 222,000 NPs within the United States, approxi-
mately 5% (13,320) reported working in urgent care and
emergency settings (American Association of Nurse
Practitioners, 2016). The growing number of NPs working
in emergency care led to the establishment of the
American Academy of Emergency Nurse Practitioners
(AAENP) in 2014, a professional specialty organization
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D. O. Tyler et al.
dedicated to advancing the role of NPs and their educa-
tion in emergency care. The AAENP began with 10
founding members and grew to more than 500 active
members by December 2016 (M. Marcum, AAENP Secre-
tary, written communication, January 2017). This rapid
growth in the ENP specialty prompted a need to develop
the scope and standards of practice for the ENP role and
a certification process to provide competency validation
for the profession.
Unexpected political issues among emergency
specialty-care providers and ensuing issues with state
regulators and employers further contributed to a need
for ENP specialty certification. For example, since the
enactment of the federal Emergency Medical Treatment
and Active Labor Act, mandating that all patients be seen
regardless of insurance status, ED census levels steadily
increased, and reimbursement for ED services declined
(Morganti, Bauhoff, Blanchard, Abir, Iyer, Smith, et al.,
2013). Reimbursement for ED services have been further
reduced by lobbying efforts from the insurance industry.
These efforts have resulted in out-of-network legislation
reducing insurer’s responsibility of payment for emer-
gency services and in some cases denial of payment for
ED services (American College of Emergency Physicians,
2017). These policies have led to a nationwide closure of
many hospitals offering ED services, adversely affecting
access to emergency care. Certification for ENPs may be
one method of increasing the number of qualified ED
providers able to generate a stronger and more unified
response to lobby regulators and insurers for equitable
reimbursement of emergency care services, thus ensur-
ing quality patient care (American Association of Nurse
Practitioners, 2016).
Credentialing in a specialty area affords NPs an
additional method by which they can demonstrate
competency. A total of 124 NPs across specialties became
certified through the portfolio process before it was
officially retired in November 2017 (oral communication
with Marianne Horahan, ANCC Director of Certification,
October 2017). With few NPs certified by portfolio,
encouragement from physician colleagues, and NPs
expressing interest in certification through board
examination, AAENP partnered with AANPCB to conduct
an ENP practice analysis in 2016 for the development of
an ENP certification examination. Launched in January
2017, a total of 344 ENPs successfully obtained ENP
certification by examination through July 2018.
Methods for development of the emergency nurse
practitioner certification examination
Design
A practice analysis was designed to obtain descriptive in-
formation about ENP specialty practice. The methodology
adhered to recommended practices within the testing
October 2018 · Volume 30 · Number 10 561
 Research – Other
industry and current certification accreditation standards
(National Commission for Certifying Agencies, 2016).
This work was implemented in two phases. In the first
phase, a task force of subject-matter experts created
a qualitative description of emergency care core ele-
ments that were delineated as domains of practice, tasks
performed, knowledge required, procedures performed,
and patient conditions seen in ENP practice. In the sec-
ond phase of the study, a survey of NPs in emergency
practice was conducted to obtain evidence for validating
the domains, job tasks, knowledge, patient conditions,
and procedures delineated in the initial phase.
Phase I: delineating emergency nurse
practitioner practice
The task force was comprised of clinical experts in
emergency practice (i.e., seven certified FNPs and one
emergency physician who was a formerly certified NP). In
addition to clinical expertise, task force members were
selected to represent diversity in practice settings and
geographic locations. Through a consensus-building
process, the task force delineated 5 domains of ENP
practice (i.e., medical screening, medical decision-
making/differential diagnoses, patient management,
patient disposition, and professional, legal and ethical
practices) with 23 associated tasks. Additionally, 42
knowledge areas, 68 procedures performed by ENPs, and
commonly seen patient conditions were identified for
inclusion in the ENP practice delineation.
Phase II: validating the delineation
Phase II used a survey to gather validation evidence re-
lated to the delineated elements of ENP practice. The
survey was constructed to validate the domains, job
tasks, knowledge areas, procedures, and patient con-
ditions contained in the delineation developed by the
ENP experts. Pilot testing of the survey was completed by
19 certified NPs from diverse practice settings and geo-
graphic areas who had emergency care expertise. Minor
revisions were made based on the pilot feedback.
The online survey included two unique rating scales
(i.e., frequency and harm scales) for the domains, tasks,
knowledge areas, and procedures; questions about types
of patients and conditions seen in emergency practice;
a background questionnaire; and a set of qualitative
questions regarding the completeness of the delineation.
Each element in the delineation was rated for how fre-
quently the ENP performed each task, used each
knowledge-based area, or performed each procedure.
Items were also rated according to how harmful the
results would be if an ENP performed the task or pro-
cedure incorrectly or was not in possession of the
knowledge base. From pilot testing feedback, the term
harmful, used in the validation rating scales, was revised
to include potential for harm and importance of having
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ENP practice analysis
knowledge, skills, abilities to perform tasks, and proce-
dures to prevent harm. Ratings on patient conditions seen
in emergency settings focused on types of chief complaints
(e.g., headache, chest pain, cough) and types of conditions
(e.g., respiratory, cardiovascular, gastrointestinal).
Sample
All AANPCB-certified FNPs who reported recent practice in
emergency care and interest in participating in the vali-
dation effort were invited to take the survey (N = 1,703).
The ENA also disseminated the survey link to 888 mem-
bers who were NPs. In addition, three large employers of
ENPs (i.e., CEP America, Northwell Health, and Team-
Health) agreed to distribute the survey link to their NP
employees practicing in emergency or urgent care. In
total, 474 surveys were completed.
Demographics. Survey responses were received from
all 50 states. Most (71%) worked full time in clinical
practice, defined as more than 30 hours per week. The
majority (88%) worked in hospital EDs and were distrib-
uted across urban (35%), suburban (30%), rural (34%), and
frontier/remote (1%) settings. Almost all (96%) were
educationally prepared and certified as family NPs. Most
(88%) received training in emergency care on-the-job or
through continuing education; less than 2% reported
emergency fellowship training. Respondents reported the
acuity of their patients as follows: primarily nonurgent/
primary care (44%), urgent care (41%), and emergent/
critical care (15%). Based on these sample demographics
and consistent with national NHAMCS ED data, the task
force considered the responses as representative of
emergency practice.
Findings
Reliability. Cronbach alpha reliability for the 6 rating
scales ranged from 0.86 to 0.95. All rating scales demon-
strated good reliability and well above the recommended
0.70 threshold (Nunnally & Bernstein, 1996).
Patient population and health conditions
Age. Thirty-nine percent of the respondents’ patients
were categorized as pediatric (newborn 2%, infant 6%,
child 11%, early adolescent 9%, and late adolescent 11%)
and 58% as adult-gerontology (adult 31%, geriatric 19%,
and elderly 8%). No population age was reported by 3% of
the respondents, and no information about patient
gender, race, or other demographic data were sought.
Chief complaints. The chief complaints of respondents’
patients were reported as a mean percentage and rep-
resented here in descending order of frequency: stomach
and abdominal pain (15%); fever, chest, cough, and back
symptoms (10% each); shortness of breath (9%); pain,
unspecified (8%); throat symptoms and trauma (7% each);
headache and vomiting (6% each). Two percent of
patients presented with other chief complaints.
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Other problems/conditions. In addition to chief com-
plaints, respondents reported the percentage of patients
seen with problems and conditions in system-based
categories. In descending order of frequency, these
problems and conditions were respiratory (15%),
gastrointestinal (14%), cardiovascular (12%),
musculoskeletal and head/eyes/ears/nose/throat (11%
each), dermatological/soft tissue, genitourinary and
trauma (8% each), neurologic and psychobehavioral (6%
each), and other (1%; Figure 1).
Domain ratings. The respondents were also asked the
amount of time spent in a typical day providing care as-
sociated with each of the five domains. The most time was
spent in patient management (30%), followed by medical
decision-making/differential diagnoses (25%), medical
screening (21%), patient disposition (14%), and
professional, legal, and ethical practices (10%). Mean
values for potential for harm were generated by assigning
numerical values to each response (1 = none, 2 = minimal,
3 = moderate, 4 = considerable). Potential for harm ratings
were similar among the domains (mean range: 3.3–3.7;
moderate to considerable harm) with the exception of
professional, legal, and ethical practices (mean: 2.8;
minimal to moderate harm).
Task ratings. Table 1 displays the mean (M) values for
frequency (1 = never, 2 = rarely, 3 = occasionally, 4 = fre-
quently, 5 = always) and the mean potential harm rating (1
= none, 2 = minimal, 3 = moderate, 4 = considerable) for
the 23 tasks performed by ENPs. Based on the mean rat-
ings, 22 of the 23 tasks were performed between fre-
quently and always by ENPs (M = 4.2–4.9). The remaining
task, stabilize critically ill patient, was performed between
Figure 1. Patient problems/emergencies/conditions.
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D. O. Tyler et al.
occasionally and frequently (M = 3.4). Potential harm
ratings ranged from a low of 2.4 (record essential ele-
ments of the patient care encounter to facilitate correct
coding and billing) to a high of 3.9 (stabilize critically ill
patient).
Knowledge area ratings. Mean frequency and potential
harm ratings for the 42 knowledge areas used by ENPs are
displayed in Table 2. Mean values for frequency were
generated by assigning numerical values to the response
options (1 = never, 2 = rarely, 3 = occasionally, 4 = fre-
quently, 5 = always). The average frequency ratings
ranged from a low of 2.3 (forensics) to a high of 4.9 (chief
complaint, signs and symptoms, focused physical exam-
ination, and medical decision-making). Potential for
harm ratings ranged from a low of 2.5 (biopsychosocial
principles/theories) to a high of 3.7 (medical decision-
making, diagnostic studies, and pharmacological
therapies).
Procedure ratings. Frequency and potential harm rat-
ings for 68 procedures used by ENPs were the same as the
other scales (Table 3). The frequency ratings for the pro-
cedures performed varied greatly. For example, surgical
airway (M = 1.3) was almost never performed; in compar-
ison, local anesthesia (M = 4.1) was administered fre-
quently. Perimortem C-section (M = 1.0) was virtually
never performed. Harm ratings ranged from a low of 2.8
(tooth stabilization) to a high of 3.9 (for intubation as well
as for cardiopulmonary, neonatal, and pediatric
resuscitation). The potential for harm was extremely high
for certain groupings of procedures, such as airway
techniques, resuscitation, cardiovascular, and thoracic (M
= 3.8).
Test specification determination. A test blueprint was
created to specify the percentage of domain items to
include in an examination. Respondents’ ratings of task
frequency and harm potential were averaged for each
domain and compared with their ratings of time spent in
each domain. The domain measures for frequency,
harm, and time were in close alignment and accepted by
the task force to determine the percentage of exami-
nation items for each domain, resulting in the test
specifications as follows: medical screening (20%),
medical decision-making/differential diagnosis
(27%), patient management (31%), patient
disposition (14%), and professional, legal, and ethical
practices (8%).
Weights for patient condition/type of emergency. As the
second dimension for ENP examination construction,
distribution of test questions across patient condition
and type of emergency were developed. For test weights,
the task force adopted the average percentage of
respondents’ patients presenting with each condition/
emergency (Figure 1). For example, the test content blue
print would have 15% respiratory conditions, 14%
gastrointerestinal, and so forth.
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 Research – Other ENP practice analysis

Table 1. Ratings for tasks performed by nurse practitioners

Frequency Harm

Domain 1: Medical screening

1.1. Perform an appropriately focused history and physical examination based on chief complaint 4.9 3.4

1.2. Establish patient acuity level 4.2 3.0

1.3. Stabilize critically ill patient 3.4 3.9

Domain 2: Medical decision-making/differential diagnoses

2.1. Develop a narrowed list of differential diagnoses based on the greatest likelihood of 4.8 3.3
occurrence

2.2. Prioritize the list of differential diagnoses, considering the potential diagnoses with the 4.8 3.4
greatest potential for morbidity or mortality

Domain 3: Patient management

3.1. Order and interpret diagnostic studies based on the pretest probability of disease and the 4.7 3.5
likelihood of test results altering management

3.2. Perform diagnostic and therapeutic procedures/skills as indicated 4.5 3.4

3.3. Select and prescribe appropriate pharmaceutical agents using current evidence-based 4.8 3.6
practice

3.4. Select other integrative therapeutic interventions 4.2 2.9

3.5. Collaborate and consult with other health care providers to optimize patient management 4.3 3.0

3.6. Evaluate effectiveness of therapies and treatments provided during observation 4.6 3.1

3.7. Reassess to identify potential complications or worsening of condition 4.7 3.5

3.8. Consider additional diagnoses and therapies for a patient who is under observation and 4.3 3.3
change treatment plan accordingly

3.9. Simultaneously manage multiple patients using situational awareness and task switching 4.8 3.5

Domain 4: Patient disposition

4.1. Determine appropriate and timely patient disposition including admission, discharge 4.8 3.3
(including follow-up plan), observation, or transfer as appropriate

4.2. Formulate a specific follow-up plan with appropriate resource utilization 4.7 3.0

4.3. Engage patient and/or surrogate to effectively implement a discharge plan 4.6 2.9

Domain 5: Professional, legal, and ethical practices

5.1. Record essential elements of the patient care encounter to facilitate correct coding and 4.8 2.4
billing

5.2. Integrate cultural competence into patient care 4.4 2.6

5.3. Identify needs of vulnerable populations and intervene appropriately 4.3 2.9

5.4. Manage patient presentation demonstrating knowledge of EMTALA regulations 4.6 3.1

5.5. Adhere to professional ethical standards in emergency care 4.9 3.2

Note: EMTALA = Emergency Medical Treatment and Active Labor Act.

Qualitative data (write in comments). Respondents were
invited to add comments to the demographic part of the
survey and after each rating scale. These qualitative
comments provided more information and captured
a fuller description of the sample and their practice.
Deliberations and task force recommendations. The task
force reviewed the frequency and potential for harm
ratings for each task, knowledge area, and procedure in
context of the evidence that supported inclusion in the
ENP test content outline. For tasks, thresholds for

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 D. O. Tyler et al.

Table 2. Ratings of knowledge areas used by emergency nurse practitioners

Frequency Harm

1. Medical screening examination 4.7 3.6

2. Patient safety/harm reduction 4.5 3.4

3. Staff safety 4.1 3.1

4. Crisis management 3.5 3.2

5. Disaster and mass casualty management 2.6 3.2

6. Emergency stabilization 3.8 3.8

7. Anatomy, physiology, and pathophysiology 4.8 3.6

8. Focused health history 4.8 3.5

9. Chief complaint 4.9 3.4

10. Sign and symptoms 4.9 3.6

11. Focused physical examination 4.9 3.6

12. Differential diagnosis 4.8 3.6

13. Medical decision-making 4.9 3.7

14. Definitive diagnosis 4.7 3.5

15. Diagnostic studies (electrocardiogram, radiology, body fluid) 4.6 3.7

16. Diagnostic/therapeutic procedures 4.5 3.6

17. Pharmacological therapies 4.6 3.7

18. Resuscitation 3.1 3.8

19. Observation and reassessment 4.5 3.5

20. Pain management 4.4 3.0

21. Sedation 2.8 3.6

22. Integrative therapies 3.5 2.8

inclusion were established at a mean of at least 2.5 on
both rating scales. All but one task qualified for inclusion.
Another task, record essential elements of the patient
care encounter, had a potential for harm rating below the
threshold (M = 2.4) but was retained because of its high
frequency rating (M = 4.8). For the knowledge areas, for-
ensics fell below the threshold on frequency (M = 2.3) but
exceeded the threshold on potential for harm (M = 2.8).
The task force judged that, because this was an emerging
area of focus, the knowledge should be retained in the
test content outline.
When the task force reviewed the ratings for proce-
dures, it became apparent that some procedures were
performed infrequently. Discussion ensued as to whether
the 2.5 threshold rating for frequency was appropriate
given that procedural interventions were a critical aspect
of providing emergency care. Although the need to
perform an emergency procedure occurred seldom in
actual practice, death was a potential consequence of
performing it incorrectly. Therefore, the task force de-
cided that potential for harm should be the sole criterion
for inclusion. All procedures exceeding the 2.5 threshold
on the potential-for-harm scale were retained in the test
content outline. The final ENP test blueprint can be
accessed on the AANPCB website (www.aanpcert.org).
Discussion and implications
The practice analysis yielded the necessary evidence to
create a valid test content outline (i.e., test blueprint)
upon which to build an examination for the ENP certi-
fication program. The tasks, knowledge areas, and pro-
cedures contained in the delineation of emergency
practice were examined in a national survey to verify
their eligibility for inclusion in the ENP test content
outline.
The survey validated five domains of ENP practice:
medical screening, medical decision-making/differential
diagnoses, patient management, patient disposition, and
professional, legal, and ethical practices with a total of 22
tasks across the five domains. The delineation also in-
cluded 10 types of patient conditions/emergency types,
42 knowledge areas, and 68 procedures performed by

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 Research – Other ENP practice analysis

Table 3. Ratings of procedures performed by emergency nurse practitioners

Frequency Harm

Airway techniques

1. Intubation 2.0 3.9

2. Airway adjuncts 2.5 3.8

3. Surgical airway 1.3 3.8

4. Mechanical ventilation 2.2 3.8

5. Noninvasive ventilatory management 2.7 3.7

6. Ventilatory monitoring 2.4 3.8

Resuscitation

7. Cardiopulmonary resuscitation 3.9 3.9

8. Neonatal resuscitation 3.9 3.9

9. Pediatric resuscitation 3.9 3.9

10. Postresuscitative care 3.8 3.8

11. Blood, fluid, and component therapy 3.8 3.8

12. Arterial catheter insertion 3.7 3.7

13. Central venous access 3.8 3.8

14. Intraosseous infusion 3.6 3.6

15. Defibrillation 3.8 3.8

Anesthesia and acute pain management

16. Local anesthesia 3.2 3.2

17. Regional nerve block 3.3 3.3

18. Procedural sedation and analgesia 3.7 3.7

Diagnostic and therapeutic procedures

Abdominal and gastrointestinal

19. Anoscopy 3.1 3.1

20. Excision of thrombosed hemorrhoid 3.2 3.2

21. Gastric lavage 3.2 3.2

22. Gastrostomy tube replacement 3.2 3.2

23. Nasogastric tube 3.1 3.1

24. Paracentesis 3.5 3.5

Cardiovascular and thoracic

25. Cardiac pacing 3.8 3.8

26. Cardioversion 3.8 3.8

27. Electrocardiogram interpretation 3.7 3.7

28. Pericardiocentesis 3.8 3.8

29. Thoracentesis 3.8 3.8

30. Needle/tube thoracostomy 3.8 3.8

(continued)

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Table 3. Ratings of procedures performed by emergency nurse practitioners, continued

Frequency Harm

Cutaneous

31. Escharotomy 3.3 3.3

32. Incision and drainage 3.1 3.1

33. Trephination, subungual 3.0 3.0

34. Wound closure techniques 3.1 3.1

35. Wound management 3.2 3.2

Head, ear, eye, nose, and throat

36. Control of epistaxis 3.1 3.1

37. Drainage of peritonsillar abscess 3.6 3.6

38. Laryngoscopy 3.5 3.5

39. Lateral canthotomy 3.4 3.4

40. Slit-lamp examination 2.9 2.9

41. Tonometry 3.0 3.0

42. Tooth stabilization 2.8 2.8

43. Corneal foreign body removal 3.3 3.3

44. Drainage of hematoma (auricular, septal) 3.2 3.2

Systemic infectious

45. Personal protection (equipment and techniques) 3.3 3.3

46. Universal precautions and exposure management 3.4 3.4

Musculoskeletal

47. Arthrocentesis 3.3 3.3

48. Compartment pressure measurement 3.4 3.4

49. Fracture/dislocation immobilization techniques 3.4 3.4

50. Fracture/dislocation reduction techniques 3.4 3.4

51. Spine immobilization techniques 3.7 3.7

52. Fasciotomy 3.6 3.6

Nervous system

53. Lumbar puncture 3.6 3.6

Obstetrics and gynecology

54. Delivery of newborn (including complications) 3.8 3.8

55. Perimortem C-section 3.7 3.7

56. Sexual assault examination 3.1 3.1

57. Bartholin cyst incision and drainage 3.0 3.0

Psychobehavioral

58. Psychiatric screening examination/medical 3.3 3.3

stabilization

59. Violent patient management/restraint 3.4 3.4

(continued)

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 Research – Other
Table 3. Ratings of procedures performed by emergency nurse practitioners, continued
Renal and urogenital
60. Bladder catheterization
61. Urethral catheter
62. Suprapubic catheter
63. Testicular torsion
Toxicologic
64. Decontamination
Other diagnostic and therapeutic procedures
65. Foreign body removal
66. Collection and handling of forensic material
67. Diagnostic ultrasound
68. Procedural ultrasound
ENPs. A test blueprint directly linked to the practice
analysis was subsequently used to guide item writing and
other components of examination development. In ad-
dition to providing the basis for constructing a specialty
certification examination for ENPs, the findings of the job
analysis provided a nationally representative view of
current advanced emergency practice.
Study strengths
An expert team of psychometricians led the practice
analysis and ensured fidelity to established practice
analysis and test specification development methodol-
ogies. The comprehensive survey was distributed to
a large sample; statistical analyses showed high re-
liability; and expert clinicians were involved throughout
the process. All these elements served to support validity
and generalizability of the findings.
Validity of the practice analysis was further substantiated
in that findings were consistent with the Centers for Disease
Control and NHAMCS ED census data (Centers for Disease
Control, 2013). For example, according to the National Center
for Health Statistics (Centers for Disease Control, 2013), only
7.9% of the 141.4 million visits to EDs annually resulted in
hospital admission; most patients were treated and
subsequently discharged. Other similarities with Centers for
Disease Control and Prevention data included the type of
patient visits, variety of chief complaints, acuity, and age of
ED patients. The significant number of newborns, infants,
and young children (19%) seen in emergency care
settings reported by this sample, as well as the high
volume of ambulatory visits, supported the need for
lifespan and primary care preparation for ENPs in
addition to having specialty knowledge and skills in
emergency care.
568 October 2018 · Volume 30 · Number 10
Ó 2018 American Association of Nurse Practitioners. Unauthorized reproduction of this article is prohibited.
ENP practice analysis
Frequency Harm
3.0 3.0
2.9 2.9
3.3 3.3
3.7 3.7
3.4 3.4
3.1 3.1
3.0 3.0
3.3 3.3
3.2 3.2
Participants had the opportunity to write-in comments
in the demographic portion of the survey and after each
rating scale allowing respondents to provide additional
information about their practice. Although many respond-
ents stated that they had nothing to add and the survey
content was complete, there were 94 write-in comments
regarding tasks, including procedures and skills such as
intubation and suturing. There were 23 write-in comments
for knowledge areas and 24 additional procedure-related
comments. The task force reviewed these comments and
determined that none of them differed from the content on
the survey. Some of the write-in comments described
nonclinical tasks and competencies (e.g., education of ED
staff, orienting new NPs, and being a preceptor) that were
not related to direct ENP patient care or specific to emer-
gency knowledge and skills. Therefore, the task force de-
cided the ENP delineation was valid and comprehensive.
Study limitations
Although the sample was sufficiently large and determined
by the task force to be representative of NP emergency
practice nationally, a response rate cannot be calculated.
Also unknown was whether the 4% of respondents who did
not list FNP as their primary certification were nurses or
certified in acute care, pediatrics, or adult gerontology. It was
recognized that non-NPs may have completed the survey as
4% of responders did not attest to a nursing degree.
Expanded use of the emergency nurse practitioner
practice analysis
In addition to providing essential data for development of
the ENP certification examination, the practice analysis
has other implications for the ENP specialty. This national
survey of NPs working in various emergency settings can
www.jaanp.com

serve as a basis for review and expansion of previously
established ENP competencies, such as those developed
by the ENA (Emergency Nurses Association, 2008; Emer-
gency Nurses Association NP Validation Work Team et al.,
2010). Although the process and elements of a job/
practice analysis differ from competency profiles, in-
formation obtained in a practice analysis can apply to
competency development in that competencies reflect
the integration of specialized knowledge, skills, and
abilities. A practice analysis describes the work per-
formed through a set of mutually exclusive performance
domains and the specific tasks performed within those
domains. Thus, specialized nursing knowledge and skills
needed to perform the job tasks are delineated sepa-
rately from the domains and tasks. This makes a practice
analysis particularly applicable for ENP-curricula build-
ing and evaluation. Furthermore, in addition to providing
content validity for a national specialty certification,
a review of clinical competencies, and curriculum de-
velopment, the findings from this ENP practice analysis
may prove useful in refining professional scope and
standards of practice, job descriptions, performance
appraisals, research, policy development, and enhancing
the scientific basis of the emergency specialty practice.
Lastly, the frequency for conducting job/practice analy-
ses is determined by changes occurring in the profession.
With the tremendous growth in emergency care settings,
patient visits and specialty educational programs, ENP
practice analyses are expected to be held on a five-year
cycle. The comparison of ENP practice from 2016 to 2021
will be interesting to analyze, as well as examine the fu-
ture impact on emergency education, competencies, and
practice standards.
Acknowledgements: The authors greatly appreciate Patri-
cia Muenzen and Carla Caro of ACT-ProExam for their
contributions in leading the Emergency Nurse Practitioner
(ENP) Practice Analysis project and writing the 2016 report.
The Executive summary of the 2016 ENP practice analysis
report is available on the American Academy of Nurse
Practitioners Certification Board (AANPCB) website (www.
aanpcert.org). The authors would also like to thank and
recognize the following members of the ENP Practice
Analysis Task Force: Teresa Amato (NY), Colleen Andreoni
(IL), Karen Sue Hoyt (CA), Kathleen Jordan (NC), Virginia
Mangolds (MA), Kathy Tackett-Morris (IA), Elda Ramirez
(TX), and Jennifer Wilbeck (TN). Finally, but important to
note, this project was a collaborative effort of AANPCB and
Journal of the American Association of Nurse Practitioners
Ó 2018 American Association of Nurse Practitioners. Unauthorized reproduction of this article is prohibited.
D. O. Tyler et al.
the American Academy of Emergency Nurse Practitioners.
Through the outstanding and highly productive leader-
ship of both organizations and under the direction of
Richard (Rick) Meadows, CEO of AANPCB, the ENP
certification program was created and launched within
a 12-month period.
Competing interests: The authors report no conflicts of
interest.
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