THE DEVELOPMENT OF A GENERIC ' f
POSITION DESCRIPTION FOR AN -

ADVANCED PRACTICE NURSE INk A ' ‘

HOME HEALTH CARE ‘
BY. '

MICHELLE YATES LEE ; '~ I '

MICHEGAN STATE UNWERSITY
MASTER-0F SCIENCE -   -

' COLLECECF NURSING
1998

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THE DEVELOPMENT OF A GENERIC POSITION DESCRIPTION FOR AN
ADVANCED PRACTICE NURSE IN HOME HEALTH CARE

By

Michelle Yates Lee

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing

1998

ABSTRACT

THE DEVELOPMENT OF A GENERIC POSITION DESCRIPTION FOR AN
ADVANCED PRACTICE NURSE IN HOME HEALTH CARE

By

Michelle Yates Lee

As the health care dollars continue to escalate, many health care facilities are
examining ways to reduce costs. One trend is to move the location of service fi'om the
hospital to the home. Currently, advanced practice nurses are not utilized in home health
care. This project identifies the need for advanced practice nurses in home health care and
develops a generic position description for utilizing them in home health care. King’s
(1981) Theory of Goa] Attainment guides this project and the literature review provides
support for the development of a generic position description. Implications for its use
related to education, research, and practice are described. This position description
introduces a prototypical role which has the potential to be adopted by any home health

care agency and be modified to fit the specific needs of the agency.

Copyright by
MICHELLE YATES LEE
1998

This project is dedicated to my wonderful husband, John, and my terrific parents,
Jim and Barb Yates. Without their unfailing love, support, and prayers, this project would
have never been completed. I want to thank John for standing by my side and motivating

me through each step these last two years. My life would not be whole without him.

iv

ACKNOWLEDGMENTS

I would like to thank my Chairperson, Dr. Joan Wood, for her assistance and
encouragement. She kept me moving forward and always reminded me to focus on my
goal to complete this project at a designated time. She provided counsel and assistance
under a very tight time frame and was available day or night.

I would also like to thank Dr. Georgia Padonu and Catherine Lein for including me in
their busy schedules to serve on the committee. They provided advice and instruction

which enabled me to focus on exactly what I wanted to accomplish.

TABLE OF CONTENTS

LIST OF FIGURES ..................................................................................................... vii
INTRODUCTION ......................................................................................................... 1
STATEMENT OF THE PROBLEM .............................................................................. 3
PURPOSE ..................................................................................................................... 4
DEFINITION OF CONCEPTS ...................................................................................... 5
CONCEPTUAL FRAMEWORK .................................................................................... 8
CONCEPTUAL FRAMEWORK AS APPLIED TO APNS IN HHC ............................ 11
REVIEW OF LITERATURE ....................................................................................... 14
THE COMPONENTS OF A GENERIC POSITION DESCRIPTION .......................... 23
IMPLICATIONS ......................................................................................................... 28
SUNIMARY ................................................................................................................ 35
APPENDIX A - JOB DESCRIPTION FOR A LARGE BANK ................................... 36
APPENDIX B - JOB DESCRIPTION WORKSHEET ................................................ 38
APPENDIX C - SAWLE JOB DESCRIPTION,

BEXAR COUNTY HOSPITAL DISTRICT ..................................... 39
LIST OF REFERENCES ............................................................................................ 41

LIST OF FIGURES

Figure l - Schematic Diagram of King’s Theory of Goal Attainment ........................ 9

Figure 2 - Modified Schematic Diagram of King’s Theory of Goal Attainment
Including APNS in HHC ........................................................................ 12

Figure 3 - Generic Position Description for an APN in HHC .................................. 29

vii

INTRODUCTION

As health care dollars continue to escalate and consume a large percentage of the
gross national product, many health care facilities are examining ways to reduce costs
(Murray, 1996). Acute care facilities are no longer viewed as the center of the health care
network; the current trend is to keep patients out of the hospital and enhance their ability
to care for themselves in their homes (Murray, 1996). The move by health care providers
to alter the location of service fi'om the hospital institution to the home was initiated to
decrease costs, increase personal responsibility for health, and emphasize prevention of the
occurrence of illness (Perzynski, Zechman, Didion, Abby & Malone, 1996). With a
system of capitation, i.e., receiving a fixed sum of money per client regardless of the
amount or type of medical care received, it is more cost-effective to keep the client out of
the hospital and provide a subacute level of care which includes home health care (HHC)
(Murray, 1996). Such action meets the goal of health care reform, i.e., to reduce costs
and improve access to care (Ketter, 1994).

In general, the elderly receive most of the health care services in the United States
(Womack, 1997). Although they account for twelve percent of the entire population, they
fill fifty percent of available adult hospital beds and use seventy percent of available health
care services (Womack, 1997). Since the elderly are living longer and increasing in
number, the need for health care, including home health care, continues to grow
(Womack, 1997). Currently, only five percent of the elderly reside in long-term care
facilities while the majority of elderly live in the community. Approximately five million ill
and disabled older persons are cared for in the home setting (Hess, 1991). More than

1

eighty percent of individuals over the age of eighty-five have at least one chronic disease,
and most of the advanced aged population have multiple health problems (Hess, 1991).

Since the introduction in 1983 of the prospective pricing system (diagnosis-related
groups) for hospital reimbursement under Medicare, home health care has been the fastest
growing segment of the Medicare program and has promoted greater hospital
diversification (Rakich, Longest, & Darr, 1992). Medicare Ins effectively created an
industry of post-hospital care, especially with the hospital policy to discharge patients
“quicker and sicker” (Kahn, 1990). The Health Care Financing Administration (HCFA),
which administers Medicare, is the largest payor for home health care services and covers
fifty percent of the nursing visits (Altman & Walden, 1993; Branch & Goldberg, 1993).

Advanced practice nurses (APNS) are independent health care providers who can
provide continuous and comprehensive care while making client referrals and collaborating
with other health professionals (American Nurses Association, 1987). APNs provide
services to individuals, families, and groups, emphasize health promotion and disease
prevention, as well as diagnose and manage acute and chronic diseases (Berger, et al.,
1996).

APNS in HHC may strengthen the potential of clients to achieve their goals by
maximizing the capacity of the client to fitnction as independently as possible. Thus, the
client should be able to remain at home and nursing home placement be delayed. APNS
are able to facilitate case management, provide more timely and sophisticated

interventions, and upgrade other nurses’ awareness (Ebersole & Enloe, 1983).

STATEMENT OF THE PROBLEM

As efforts are made to cut costs in health care, clients are being quickly discharged
from acute care hospitals to their home environments. Frequently, these clients have
minimal education related to their illness, medications, diet, activities to promote
independence, and ways to decrease the risk for exacerbations or limit readmissions to the
hospital. As clients are discharged earlier from the hospital, HHC costs have risen. This
is due to the fact that more visits are needed to assess and/or teach large amounts of
information in the home. This situation is further complicated because of the increased
acuity levels of clients living at home (Kane, Finch, Blewett, Chen, Burns, & Moskowitz,
1996).

With managed care driving the market, and the presence of Medicare and Medicaid
in the managed care structure, HHC must meet the sometimes conflicting goals of
containing costs and maintaining or improving quality of health care delivered. APNS can
play a significant part in cost eflectiveness, since they have the potential to detect
complications quickly and intervene immediately. They have advanced knowledge and
skills in assessment and diagnosis, pharmacology, health promotion, and disease
prevention, and have access to health care professionals and referral systems which may
expedite services.

Presently, registered nurses (RN 5) in HHC provide therapeutic care, patient
education, and case management as well as collecting and analyzing client health data
(Murray, 1996). They document for reimbursement, adapt equipment and procedures to
the home environment, maintain competence in working with complex technology,

supervise all aspects of care and are autonomous (Leighton, Davis, & Anderson, 1990).

Thobaben (1993) surveyed home health nurses for key stressors on the job. The following
areas were consistently mentioned: astronomic paperwork, increased patient responsibility
without adequate backup, demanding or dissatisfied patient/families, difficulty
communicating with other professional care givers, uncertainty about patient needs, safety,
and fiequent schedule changes. An APN in HHC could provide on—site as well as in home
support to the RN, i.e., function as a “backup” and communicate with other professional
care givers on behalf of the client.

To date, APNS have been minimally involved in HHC possibly due to limited
research supporting the idea, issues with reimbursement, or an unrecognized need for their
contributions. Forthcoming changes in reimbursement and fitrther limitation of acute care
services should promote the utilization of APNS in HHC settings. Thus, there will be an
increased interest by these organizations to employ them. Development of a position
description which describes the APN’s qualifications and duties is essential to meet this
emerging need.

PURPOSE
The purpose of this project is to develop a generic position description for the APN in
HHC. APNs in HHC should improve the attainment of clients’ goals by maintaining high
levels of functioning, independence, and increased quality of life. A position description
includes responsibilities, requirement qualifications, such as education, work experience,
and personal characteristics, supervision, equipment, and accuracy of the APN in HHC

(Pell, 1995).

DEFINITION OF CONCEPTS

The major concepts related to this project are generic position description, advanced
practice nurse, home health care, and client/family.
Generic Position Description

Pell (1995) states a position description is a written description of the responsibilities

that fall within a job and includes the skills and requirements to perform a job effectively.
French (1994) defines a position description as a written summary about one’s job which
usually is one or two pages long and includes the basic associated tasks. It frequently
includes a section describing the qualifications needed to perform the job. Menard’s
(1987) definition includes a summary (fitnction and scope), duties (typical and periodic),
supervision (received and given), education (required and preferred), experience (required
and preferred), equipment (required), and accuracy. She states that the position
description can be used as a method for evaluation. The position description for this
project is defined as a descriptive framework outlining qualifications, and duties or specific
fitnctions. This definition was chosen in order to obtain the essential detailed information
while promoting thoroughness and ease in understanding.
Advanced Practice Nurse

In 1992, the American Nurses Association (ANA) Congress of Nursing Practice
approved the following definition:

Nurses in advanced clinical practice have a graduate degree in nursing. They

conduct comprehensive health assessments, demonstrate a high level of autonomy,

and possess expert skills in the diagnosis and treatment of complex problems.

They formulate clinical decisions to manage acute and chronic illness and promote

wellness. Nurses in advanced practice integrate education, research, management,
leadership and consultation into their clinical role and fimction in collegial
relationships with nursing peers, physicians, professionals, and others who
influence the health environment.

An APN can be identified as a nurse practitioner (NP), a certified registered nurse
anesthetist (CRNA), a certified nurse midwife (CMW), or a clinical nurse specialist
(CNS). Crucial skills required of all APNS have been analyzed and a common core of
abilities is included in all APN educational programs (Ray & Hardin, 1995). The primary
difference between the CNS and the NP is the ability of the NP to have prescriptive
privileges in more jurisdictions and the ability to bill clients directly (Kerstein, Rijswijk, &
Beitz, 1998).

The APN has several role characteristics that are utilized during practice. McFadden
and Miller (1994) list clinical expert, consultant, educator, and researcher as roles that
APNS encompass in direct and indirect practice. The clinical expert formulates diagnoses
and provides direct primry care to promote self-care abilities, maintains health, and
prevents complications. The consultant provides advice to others related to their area of
expertise. The researcher investigates clinical problems and tests theories, and the
educator applies the theories and learning methods to teach clients to meet their health
educational needs. Page and Arena (1994) suggest that the educator role is the primary
role for APNS in practice. Strunk (1995) states the central fimction of an APN is to
facilitate delivery of optimum patient care and that change is an integral part of this
fitnction. She notes that change agent abilities are necessary in all four main role

components including expert clinician, educator, administrator, and researcher.

For this project, an APN is defined as a CNS or NP who has a Master’s degree in
nursing and is able to perform complete histories and physical exams, diagnose and treat
clients autonomously and focus on health promotion/disease prevention. The APN is a
critical decision maker who allocates resources in a cost effective manner related to
quality health care.

Hom_e Health Care

HHC refers to an organized plan of health services delivered in the home setting
(Miller & Keane, 1983). These services are provided by an agency or organization and
include skilled nursing services and other therapeutic services, such as physical, speech, or
occupational therapy, medical social services, and home health aide services. Vivian
(1996) states there are five major purposes of home health care: (a) maintaining patients
at home, (b) patient assessment, (c) arranging for additional support services, ((1)
educating patients, and (e) addressing patients’ psychosocial needs.

According to Keating and Kelman (1988), HHC nursing refers to “specialized nursing
services in the home health care setting. The client system includes the person with a
diagnosed health problem(s) who requires skilled nursing care with assistance from
significant others in the home setting.” For this project, Miller & Keane’s (1983)
definition of HHC has been used since it gives a complete description of the setting.
m

“Client” is used in its broadest sense; it refers to an individual, a family, a geographic
unit or a population (group of individuals) who share common values, needs, or problems
(Zwanziger, et al., 1996). In HHC, the client is typically referred by a primary care

provider (PCP) or a hospital based physician who gives specific orders which enable the

HHC agency nurse or therapist to make the first visit. In order to be eligible for HHC

under Medicare, the client must be homebound, wish to remain at home, and have a

significant acute or chronic illness requiring intermittent, skilled, medical care or therapy

(Rakich, Longest, & Darr, 1992). This complete definition is used for this project.
CONCEPTUAL FRAMEWORK

King’s (1981) Theory of Goal Attainment describes humans as Open systems
interacting with the environment. This theory identifies three interacting systems which
encompass the scope of person and environment, i.e., personal, interpersonal, and social;
each of these interacting systems is comprised of concepts. The personal system refers to
the individual and includes the concepts of perception, self, growth and development,
body image, space, and time. The interpersonal system involves two or more persons
interacting. Concepts involved in understanding this system include human interactions,
communication, transaction, role, and stress (See Figure l). The social system refers to
groups of people with common interests, goals, values, behaviors, and agreed-upon roles
and practices. Its concepts are organization, authority, power, status, and decision making
(King, 1981).

King (1992) has depicted five essential elements of systems which include goals,
structure, functions, resources and decision making. The personal and interpersonal
systems of the nurse and client form the structure. The function of the nurse/client
interaction, i.e., nurse/individual, nurse/family, or nurse/group interaction, promotes
the goal of client health. The resources are the nurse and the client. Decisions made

by the client involve communication and transaction with the nurse. The nurse

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10

and the client mutually make decisions regarding the use of their resources (Woods,
1994)

King (1981) states that energy is transformed between the internal and external
environment of human beings. She proposes that satisfaction in the performance of daily
living depends on harmony and balance in each person’s environment. She describes the
focus of nursing as the interaction of humans with their environment which leads to a state
of health.

King (1981) describes the phases necessary for successful nurse-client relationships as
action, reaction, interaction, perception, and transaction. During the action phase, the
nurse and client meet for the first time and evaluate the initial meeting. Perceptual
congruency between client and nurse facilitates future encounters. Based on the reaction
between them, interaction occurs when problems are mutually identified and appropriate
goals are defined. Perceptual congruency is also essential during interaction. If there is a
disturbance resulting in incongruence during action or interaction, goal attainment, which
is the essence of transaction, may be inhibited.

King’s (1981) Goal Attainment Theory combines some factors fiom the classification
system and the process of human interaction (See Figure 1). Both the client and nurse
develop perceptions throughout the process. They communicate with each other, which
creates action. Actions result in reactions. If there is a disturbance, goals need to be
reevaluated and redefined. At this point, means for goal achievement are explored and
agreed upon, transactions are made, and goal attainment results (Marriner-Tomey, 1994).
Therefore, in the nurse-client dyad, transactions occur and goals are attained if there is

accuracy of mutual perceptions.

11

CONCEPTUAL FRAMEWORK AS APPLIED TO APNS IN HHC

Imogene King’s (1981) Theory of Goal Attainment can be modified for APNs in
HHC. There is an ongoing interaction between the stafl’ nurse and the client in HHC (See
Figure 2). The staff nurse and the client identify specific client focused goals; the nurse
then teaches and instructs on diseases, medications, and diet(s) in order to attain the goals.
This, in turn, promotes attainment of the three general goals for all HHC clients, which are
maintaining the highest possible level of functioning, promoting independence in self-care,
and enhancing quality of life.

The stafl' nurse in HHC interacts with the client through teaching or direct care and
reacts and modifies the goals until they are attained. The time fiame varies from one week
to several years. As long as the client’s goals are not fulfilled to promote health and
prevent disease, there is a need for the nurse to continue to interact with that client. In
HHC, the client’s home environment is unique; therefore, the nurse needs to modify the
interactions to fit within that environment and its boundaries.

Vivian (1996) suggests that a collaborative model is most appropriate in home health
care when clients are recognized as necessary partners in discussions of care and
compliance. Further, when clients are encouraged to actively participate in compliance
decisions, they may be more committed to those decisions and achieve their goals. In
order to fulfill each client’s goals, the nurse must be educated over a broad spectrum of
diseases, medications, and diets, as well as specific practices which promote health and
prevent new diseases. King’s (1981) Theory of Goal Attainment provides an appropriate

fiamework for Vivian’s suggested collaborative model.

12

 

   

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The stafi~ nurse in HHC is frequently presented with client situations which could
profit from the support of an APN. The APN has highly developed specialized skills and
expertise to conduct comprehensive health assessments, diagnose, and manage acute and
chronic diseases. Whereas a skilled nurse needs to wait for the PCP to call with new
orders, an APN could independently change a treatment plan. Therefore, the client could
be treated quickly before any serious exacerbations occurred.

The staff nurse and APN partnership benefits both client and the staff nurse (See Figure
2). The APN observes and reacts to problems or potential problems and often consults
more easily with allied professional health care workers. The APN also assists the staff
nurse by providing education on specific topics and techniques both on an individual level
as well as group inservices. Presently in HHC, a staff nurse-client dyad exists. However,
the proposed modified model includes a staff nurse-APN dyad, a client-APN dyad, and a
stafi‘ nurse-APN-client triad. This triad enables communication which creates action;
action results in reaction. All develop perceptions throughout the process, and if there is a
disturbance, goals need to be reevaluated and redefined. Transactions are made when the
activities to achieve the goals are explored and agreed upon; then goal attaimnent results.
As the APN implements his/her specialized skills (See Figure 2), the objective to attain the
client’s goal of restored health is strengthened.

While a position description which clearly describes the responsibilities of an APN
working in HHC is currently not available, it should enhance the relationships of the staff
nurse, APN, and client. All three working together could reach the same intended goal,
ie., restoration of health through maintaining the highest possible level of fitnctioning,

promoting independence in self-care, and enhancing quality of life.

14

REVIEW OF LITERATURE
A review of literature includes the following categories: the APN in HHC, King’s

Theory related to HHC, reimbursement issues, and the elements of a generic position
description
The APN in HHC

Minimal information was located during the review of literature about APNS and their
role in HHC. This appears to be a new concept; therefore, this review examines two
target areas, APNS and HHC.

To date, APNS have been minimally utilized in home care; however, many
opportunities exist for APNS to contribute significantly to the care of persons receiving
health care in their homes (Beuscher, 1994). Early hospital dismissal requires that staff
nurses be highly knowledgeable about technology, including oxygen concentrators,
nebulizers, tube feeding machines, and hospital beds. They also need to be competent
educators and decision makers (Neal, 1995).

HHC visits by APNS facilitate access to a higher level of care. Because many clients
have chronic conditions warranting continued monitoring of treatment typically done in
acute care facilities, home visits by APNS may decrease costs (Snyder & Mirr, 1995).

HHC is more a general practice and embraces concepts fi'om mental health nursing,
parent-child nursing, community health nursing, gerontologic nursing, and
medical-surgical nursing (Murray, 1996). Womack (1997) states APNS have educational
preparation in all of these aspects and could play a vital role in HHC.

Zwanziger, et al. (1996) examined the potential of expanding the APN role to the

community. These authors as well as Nursing’s Agenda for Health Care Reform (1992)

15

support the need for community-based APNS. These sources suggest that the APN could
(a) enhance consumer access to services by presenting primary health care in
community-based settings, (b) be a cost-effective care provider, (c) address vulnerable
populations, (d) reduce health care costs by caring for chronic illness within the home, and
(e) provide long-term care.

Stringer, Spatz, and Donahue (1994) examined the use of an APN in the delivery of
prenatal care in the home as an alternative type of health care delivery. This included
matemal-fetal physical assessment, weight, diet, uterine growth, urine assay, blood
pressure and deep tendon reflexes, activity, fetal activity, auscultation of fetal heart tones,
nonstress test and acoustic stimulation, biophysical profile testing, cervical examination,
uterine activity, self-palpation, and home monitoring. This study resulted in the provision
of safe, quality, satisfying care and demonstrated that home prenatal care provided by an
APN responded to the complex needs of medically and socially high-risk pregnant women.
Although cost was not a specific focus of this study, the authors suggested that the use of
an APN in the home may prove to be cost-effective.

When care is delivered in the home, interventions and teaching need to be modified to
fit the home environment. A typical client could be one who is discharged fi'om the
hospital after having surgery, after an exacerbation of a disease, or after developing a
wound. The PCP may initiate HHC afier seeing a client at the oflice and recognizing the
need for fi'equent assessments. In general, the client would be homebound, making it
difficult to leave the home and then only for infrequent selected activities. The stafi’ nurse
would need to teach post-0p restrictions, recommendations to decrease the risk of another

exacerbation, or perform wound care. The staff nurse would also assist the client to

16

understand his/her medications, set up the medication schedule and alter the home
environment to fit the client’s needs. Quality home health care allows for earlier discharge
from the hospital and may prevent hospital readmittance at a considerable savings. This
may be done by recognizing problems early on and educating clients about the
signs/symptoms of an impending problem. The APN can collaborate easily with the staff
nurse as well as other health professionals and community resources available to the client.
An APN could benefit the HHC agency; for example, the APN could quickly assess if an
exacerbation develops, change the plan of care, prescribe antibiotics to treat infections, or
change wound care. Without an APN in HHC, the staff nurse would have to call the PCP
and wait to receive new orders by phone or schedule the client to go to the PCP’s office
to be assessed.

Zimmer, Groth-Juncker, and McCusker (1985) assessed a team approach to home
care. The team consisted of a physician (internist), an NP or APN, and a medical social
worker who had weekly team conferences to assure coordination of patient care. The
results indicated the team’s clients (n=85) had fewer hospitalizations, fewer nursing home
admissions, and fewer outpatient visits than the control group (n=82). They used more
in-home services as measured in weighted cost figures including home health aide visits,
lab technician visits, staff nurse visits, physician and APN home visits, and medical social
worker visits. The overall cost of the team approach was lower than the traditional
approach to care received by clients in the control group; however, the difference was not
statistically significant. This study was done thirteen years ago, but opened the possibility

that the employment of APNS in I-HIC could contribute to decreased health care costs.

17

Womack (1997) states the background and orientation to nursing, acquired through
education and experience, enables the APN to treat not only physical symptoms, but to
evaluate psychosocial, spiritual, and environmental needs. Health care of older adults is
complex because symptoms of illness tend to be more subtle and less predictable than in a
younger population. The elderly are more likely to experience mental changes rather than
physical complaints in response to medications and physiological disturbances. Often, by
the time physiological disturbances are noticed, the problem has progressed to an
advanced stage and complications have developed (Miller, 1995). The goals for managing
chronic disease in the elderly are: (a) to maintain the highest level of function, (b) to
promote independence in self-care, and (c) to enhance quality of life (Matteson, 1997).

Womack (1997) gave an example of the vital role an APN can play in long-term care.
She states that at a nursing home, a stafi’ nurse may notify the APN about-a client’s change
in condition. The APN may order laboratory tests stat and rearrange his/her workload to
make an immediate visit. Depending on the laboratory findings, treatment will follow.
This early intervention results in fewer clients developing complications and needing
hospitalization. This intervention may also increase satisfaction of the client, family, and
nursing home staff.

Ebersole and Enloe (1983) identify how a geriatric NP or APN is vital to HHC and
Hospice. They state that a geriatric NP facilitates better case management, provides more
timely and sophisticated interventions, and is able to train all the stafi‘ nurses about special
aspects of aging. Beuscher (1991) believes that the APN can give comprehensive
assessments, direct care, provide family support and counseling, coordinate community

resom'ces, provide consultation and staff education, thus improving home care delivery.

18

Kerstein, Rijswijk, and Beitz (1998) explain how an APN wound specialist working in
HHC can demonstrate quality and effective wound-care delivery in a cost-efiective
fashion. The APN wound specialist could access the patient before discharge fiom the
hospital, continue to provide care in the home, and have direct communication with the
responsible staff nurse. The idea of an APN in the area of wound care is currently being
studied to assess the effect of continuity and quality of optimal client care (Kerstein,
Rijswijk, & Beitz, 1998).

Although little research has been done about APNS in HHC, the studies explored
provide positive data in support of employment of APNs in HHC. The APN may benefit
the staff nurse by acting as a consultant and as an educator while providing timely
interventions to the client.

K__y_1g' ’s Theory of Goal Attainment Related to HHC

No literature was found specifically relating King’s (1981) Theory of Goal Attainment
to HHC. Woods (1994), however, applies King’s (1981) Theory of Goal Attainment to a
group of elderly clients experiencing chronic ailments and acknowledges its value as a
theoretical guide for practice. The theory was applied to a group setting and its value in
caring for clients’ experiencing chronic health problems was demonstrated. Sowell and
Lowenstein (1994) linked the theory to quality of care in community-based health settings.
They concluded that King’s (1981) Theory of Goal Attaimnent can provide a framework
for the definition and delivery of quality care in community-based health services. King
emphasized interaction, communication, and mutual goal setting; all are consistent with
quality care. Goal attainment that helps clients reach their maximum potential can readily

be expanded to all service transitions. This is especially important in a health care

19

environment that seeks to integrate the physical, spiritual, and psychosocial components of
care as well as promote more comprehensive services at the community level (Sowell &
Lowenstein, 1994).
Reimbursement Issues

Reimbursement for HHC comes from Medicare, Medicaid, and third party payors. All
three provide specific guidelines regarding the type, frequency, and duration of services.
In order for Medicare to cover 100% of services, two main components must be present.
First, the nurse or therapist must provide a skill to the client; and second, the client must
be homebound (exceptions are for PCP appointments or irregular appointments like going
to the beauty salon every month). Medicaid and third party payors follow Medicare
guidelines, but some insurances only cover 80% per visit or up to a desigmted number of
days per year. Since most insurances only cover a certain number of visits, the nurse or
therapist must call an insurance company case manager to obtain approval for additional
visits. Home care services are structured around the medical acute model of care, in order
to receive reimbursement. Services must end when the client’s care is no longer
reimbursable, even if health care needs remain (Gerber, 1994).

Currently there are no Medicare, Medicaid, or third party payor regulations specific

to APNs in HHC. Medicaid only pays for pediatric and family NPs. As of 1998,
Medicare directly reimburses NPs only in federally designated rural areas, but legislation is
pending that would require Medicare to reimburse NPs in all areas (Summary of Health
Care Financing Administration Program Memorandum, 1998). A growing number of
commercial insurers have begun to cover care provided by NPs or APNS because the

insurers have gained an understanding of their cost effectiveness (Olmsted & Demint,

20

1997). Indirect reimbursement through a physician is one possibility where the APN
would see clients without the physician on-site and overseeing, but billing would be done
with the cooperating physician’s Medicare number.
Position Description

An initial step for this project was to determine if a position description for an APN in
HHC had already been developed. The Michigan Home Health Association (Anne,
persoml communication, November 14, 1997) did not have records indicating that APNS
were already working in HHC or have any information about a generic position
description. However, she did provide the names of the five largest HHC agencies in
Michigan, including Visiting Nurses of Southwest Michigan, Munson Home Health,
Detroit Beaumont Home Care, Amicare Homecare, and Luce, Mackinac, Angler, and
Schoolcrafi (LMAS). Each agency was contacted and information about the employment
of APNS, their roles and responsibilities, e. g. working in the field visiting clients or in
management, was requested (Kristina, Sue, Debbie, Mike, & George, respectively,
personal communication, January 26, 1998). Various titles used for the APN, such as NP
or CNS, were used to broaden the identity of an APN during these contacts. All agency
representatives stated they did not have an APN routinely visiting clients; they stated they
employed master’s prepared nurses in management. The Amicare Homecare
representative reported they had one pediatric CNS who mainly worked in the corporate
ofice and assisted with education by creating handouts for the RNs. Therefore, no
position descriptions for APNS in HHC were identified from these sources.

Given that there were no position descriptions to analyze fi'om these sources and

none were identified in the literature, a review of the literature related to the basic

21

elements and composition of a position description was conducted. French (1994) states
that a position description should include job duties and job requirements. This article
provided an example of a job description for a large bank (See Appendix A). Job duties
include what needs to be compiled and what needs to be prepared. Job requirements are
narrowed into sub categories for easier viewing and understanding. These sub categories
include education, experience, resourcefuhress, responsibility, contacts, supervision,
mental effort, physical effort, and job conditions. No additional information was given
about each category or sub category.

According to French (1994), there are many purposes for position descriptions. They
are helpfitl throughout the recruiting and selection process as well as when orienting and
training new employees; they can provide an overview of the activities that need to be
carried out; they can be used for the development of performance standards and
establishing measurable terms about job performance. In addition, position descriptions
provide basic information needed for job evaluation and also can clarify mutual
expectations. Finally, position descriptions can be used to think through and develop the
avenues for transfer and promotion that lead to advancement in the organization.

The need for position descriptions that accurately reflect job content is clear in light of
the weight given to job descriptions by applicants and recruiters. Some applicants make
themselves available for interviews according to how the job is described in an
advertisement. Recruiters may not have detailed knowledge of the actual job, so they
follow the position description. Inaccurate position descriptions can reduce the
efl‘ectiveness of training or result in the development of unrealistic performance standards

(French, 1994).

22

Rolfe and Phillips (1997) developed a position description for APNS working with
dementia clients. They divide it into three categories: service, healthcare professionals,
and patients/families. Under the service category, they explain service development,
liaison and collaboration with other services. The healthcare professional category include
education and stafi‘ development. The patients/ families category include outreach, early
intervention, open access, autonomous practice, expert/specialist service, health education,
and counseling. This description was written in paragraph format throughout the article;
there was no visual counterpart so it was dificult to see a relationship between the text
and a product.

Pell (1995) created a job description worksheet (See Appendix B) to be used as a
guide. His worksheet displays the essential components recommended for inclusion, i.e.,
duties, skills, responsibilities, equipment, and leadership. Pell (1995) and Rolfe and
Phillips (1997) did not identify additional information about the categories, the order of
the categories, or the need for specifics.

Menard (1987) outlined specific categories to be utilized in a position description.
The categories are the summary, education, experience, duties (roles/responsibilities),
supervision, equipment, and accuracy. A sample job description for a CNS fi'om Bexar
County Hospital District (See Appendix C) was developed using these categories. The
description is thorough, neatly organized, and easy to read.

In general, this literature review reveals that there is minimal information about APNs
in HHC, that there is support for an APN role in HHC, and that there is a need for the
development of a clearly articulated generic position description for an APN in HHC.

This description needs to identify the APN as an integral part of the triad (RN, APN and

23

client) who work together to mutually identify and achieve an acceptable goal; King’s
(1981) Theory of Goal Attainment is an appropriate theory to guide this process. Such a
relationship could enable more complete, holistic care to the clients at a cost which might
prove to be a savings over the current experience. This project addresses the APN‘s
position description in HHC as an enhancement to the current model used in the HHC
setting.

THE COMPONENTS OF A GENERIC POSITION DESCRIPTION

Several formats of position descriptions were previously identified. Most formats
were very general and short (French, 1994, Rolfe & Phillips, 1997, & Pell, 1995). The
description provides an overview of the activities that need to be carried out. Since there
are several potential uses for a position description (French, 1994), the need for position
descriptions to accurately reflect the actual content of a position is very important.

For this project, the following categories, outlined by Menard (1987), are utilized.
The categories include the summary, education, experience, responsibilities (duties),
accountability (supervision), equipment, and accuracy. These are consistent with the
definition for the position description selected for this project (See Pg. 5) and were
selected so the description would be thorough and precise. This format was selected since
it is easy to read and neatly organized. A generic position description needs to be
applicable to an APN at any home health care, but can be revised by a specific home health
care agency in order to reflect its specific needs.

Since King’s (1981) Theory of Goal Attainment was modified to include the APN in
HHC, the specific goals to be attained, and the categories of the position description, this

project reflects incorporation of these aspects. The actions/interactions/transactions

24

between the APN, staff nurse, and client are reflected in the responsibilities section of the
description.
Content/Format/Organization

The position description is divided into several categories to make it easier to read and
understand. Each category identifies specific information that needs to be addressed to
make the position description accurate and complete. The format which has been selected
models Appendix C, the Sample Job Description at Bexar County Hospital District, in
most areas. The information is written in sentences for ease of reading, except in the
responsibilities category. The summary is not divided into function and scope; a
paragraph format is considered to be adequate, thorough, and easy to understand.
Jab—Tm

Position descriptions usually have a label, called a “job title” (French, 1994). The title
is short and alerts the reader to the position of interest. For this project the title is
Advanced Practice Nurse in Home Health Care.
Sum—mar!

The summary identifies the general responsrhilities of the APN and the location where
the duties are fulfilled (Menard, 1987). The summary includes the responsibilities that are
consistent with the agency’s standards of practice. This category is usually one paragraph
in length. For this project, the summary states that the APN is responsible for providing
quality nursing care through previous knowledge and skills of HHC nursing, continuing
professional education, setting standards, and conducting research in nursing practice.
The APN mutually identifies goals with the staff nurse, client, and primary care provider.

The APN is an expert and serves as a guide to other health professionals in assisting with

25

the identification of problems or barriers and development of solutions. The APN
provides nursing services consistent with agency standards. Activities include direct client
care, assessment and therapeutic interventions, consultation, staff education, community
education, and liaison with other health care providers.

Resmnsibilities

This section provides the role expectations for the position (Menard, 1987).
McFadden and Miller (1994) focus on four roles for the APN in direct and indirect
practice including clinical expert, consultant, educator, and researcher. These roles can be
applied to the HHC setting and are included. The bulk of the position description content
is in this section and explicitly describes everything the APN may do in HHC.

This section is divided into typical and periodic responsibilities and is identified by
numbering each duty for clarity. One proposed typical duty, providing client care services
that address the holistic health needs of the client and family, includes performing
advanced physical and family health assessments at the home and docmnenting
information according to agency guidelines. A second duty utilizes the nursing process; it
includes forming nursing diagnoses, creating intervention plans, mutually establishing
goals, and monitoring and evaluating goal progression. Third, the APN writes
prescriptions and adjusts medication dosages in collaboration with the physician, orders
diagnostic tests, interprets them and adjusts the treatments accordingly. Fourth, the APN
acts as a consultant to agency personnel and assists in identifying learning experiences and
education resources with the agency. The APN also develops protocols and/or inservices

for the agency.

26

The APN also has periodic responsibilities. For example, the APN may teach agency
personnel about issues related to clinical specialty areas including assessments, nursing
diagnoses, and interventions. Second, the APN can demonstrate leadership and serve as a
role model/preceptor for agency personnel as well as APN students. The APN can
participate in and encourage interdisciplinary meetings, teamwork, and collaborate within
the agency and the community. The APN may participate in research projects, integrate
findings; he/she may provide education to the community, payors, providers, and
consumers regarding services provided by the APN in HHC and the advantages of those
services for the client, family, physician, payor, and community.

Accountabm' '

This section identifies who supervises the APN in this position. For this project, the
category is not divided into received and given, as in Appendix C, since supervision will be
determined by each specific agency. The agency’s organizational chart should provide
information regarding the APN’s supervision.

Education

According to the American Nurses Association (1992), the APN is a nurse in
advanced clinical practice who has a graduate degree in nursing. This category includes
the need for the APN to maintain continuing education requirements, also. This category
is divided into required and preferred education. For this project the APN is required to
have a Master’s degree in nursing and a current state NP specialty certification license.
The APN must also maintain continuing education requirements as outlined by the state
and employing agency. It is preferred that the APN have a certificate in a specialty area

related to a disease or a HHC issue.

27

Emrience

HHC is a general practice including components fiom mental health nursing,
parent-child nursing, community health nursing, gerontologic nursing, and medical surgical
nursing (Murray, 1996). Therefore, the APN needs experience across the life span. In
HHC, the APN could deliver prenatal care (Stringer, Spatz, & Donahue, 1994), newborn
care, adolescent care, middle age and elderly care. The agency may revise this section to
make it appropriate for an adult or geriatric NP which would not include child care. Since
HHC is a unique environment and has specific guidelines for practice (Rakich, Longest, &
Darr, 1992), it is important that the APN has had prior experience in HHC.

This section is divided into required and preferred experience. In the example by
Menard (1987) in Appendix C, the education and experience categories are exactly alike,
however, in this project, more detail needs to be included about experience. Therefore,
required experience includes having comprehensive knowledge, skills and abilities related
to family nursing care along the life span continuum and preferred experience includes
previous experience as a primary care APN and previous employment in a HHC setting.
Equip ment

Since clients are discharged to their home quickly, HHC personnel need training in
technology, including oxygen concentrators, nebulizers, tube feeding machines, and
hospital beds (Neal, 1995). The APN needs to know how to work the equipment and why
the equipment is needed in order to administer the optimum care to the HHC clients. This
means for this position description, the APN is expected to have a thorough knowledge of

all equipment and instruments used in HHC.

28

Accuracy

This section explains how precise the APN needs to be in order to fulfill the work
expectations; for this project the APN is required to be efficient and accurate in all phases
of work and to facilitate timely and appropriate written and verbal communication with
the agency and community.

Afier identifying each section and what needs to be included, the description has been
titled a Generic Position Description for an Advanced Practice Nurse in Home Health
Care (See Figure 3). This position description is the project’s product.

IMPLICATIONS

The implications of the development of the generic position description are numerous.
This section explores different ways the position description can be applied to practice,
education, and research.

Implications for Advan_ced Pragic_e

Developing a position description for an APN in HHC opens up a new career option.
Since APNS are not highly utilized in HHC at the present time, the possrhilities are
limitless. A HHC agency could benefit fi'om an APN working with the client, family, and
agency personnel to reach the client’s goals. The APN could detect problems early and
treat accordingly and quickly. Home visits by an APN could decrease health care cost
since a client’s problem would be assessed, diagnosed, and treated quickly thus eliminating
unnecessary emergency room visits.

Physicians could also benefit by collaborating with an APN working in HHC.
Presently, the staff nurse has to call the physician each time the laboratory results change

or the client takes a new “over the counter” medication or there is a change in client

29

Figure 3

GENERIC POSITION DESCRIPTION FOR AN ADVANCED PRACTICE

Job Title:

SUMMARY

NURSE IN HOME HEALTH CARE
Advanced Practice Nurse in Home Health Care

The APN is responsible for providing quality nursing care through
previous knowledge and skills of HHC nursing, continuing
professional education, setting standards, and conducting research
in nursing practice. The APN is an expert and serves as a guide to
other health professionals to assist with identifying problems or
barriers and developing solutions. The APN mutually identifies
goals with the staff nurse, client, and primary care provider. The
APN provides nursing services consistent with agency standards.
Activities include direct client care, assessment and therapeutic
interventions, consultation, staff education, community education,
and liaison activities with other health care providers.

RESPONSIBILITIES

Typical

Periodic

1) Provides client care services that address the holistic health needs
of the client and family, including advanced physical and family
health assessments and documenting information according to
agency guidelines.

2) Utilizes the nursing process by forming nursing diagnoses and
intervention plans, mutually establishing goals, and monitoring
and evaluating goal progression.

3) Writes prescriptions and adjusts dosages in collaboration with

physicians.

4) Orders diagnostic tests, interprets, and adjusts treatments

accordingly.

5) Acts as a consultant to agency personnel and assists in identifying
learning experiences and education resources with the agency.

6) Develops protocols and/or inservices for the agency.

1) Teaches agency personnel about issues related to clinical
specialty areas, including assessments, nursing diagnoses, and
interventions.

2) Assumes leadership and serves as a role model/preceptor for
agency personnel as well as APN students.

3) Participates in and encourages interdisciplinary meetings,
teamwork, and collaboration within the agency and the
community.

4) Participates in research projects and integrates findings.

30

5) Provides education to the community, as well as payors,
providers, and consumers regarding services provided by the
APN in HHC and the advantages of those services for the client,
family, physician, payor, and community.

ACCOUNTABILITY The APN is supervised according to the agency’s organizational

chart.

EDUCATION

Required The APN (NP or CNS) must have a Master’s degree in nursing
and have a current state NP specialty certification license. The
APN must maintain continuing education requirements as
outlined by the state and the employing agency.

Preferred The APN has a certificate in a specialty area related to a disease
or HHC issue.

EXPERIENCE

Required The APN must have comprehensive knowledge, skills and
abilities related to nursing care along the life span continuum.

Preferred The APN has experience as a primary care APN and previous
experience in HHC.

EQUIPMENT

Required The APN has thorough knowledge of all equipment and
instruments used in HHC.

ACCURACY The APN is required to be efiicient and accurate in all phases of

work and to facilitate timely and appropriate written and verbal
communication with the agency and community.

31

status. Consequently, the physician is taking a large amount of time out of the day to
return calls to the staff nurse. If an APN worked at the HHC agency, the lines of
authority might change, and the stafi‘ nurse could report to the APN and the APN could
change orders or make a home visit to monitor closely. This would free up the physician’s
time to see the ofice, clinic or hospitalized clients.

The staff nurses could also benefit from having an APN at the HHC since the APN
would be available every day as a consultant, educator, mentor, and counselor. The APN
could collaborate with the stafl" nurse and physician to assist the client to reach their goals;
the APN could be an essential link between the community, staff nurse, physician, and
client.

Creative approaches need to be developed by the HHC agency in order to recruit the
APN to practice in HHC. A pamphlet could be written emphasizing the need for APNS in
HHC. The state home health organization could assist APNS in looking for a home health
position by maintaining a revolving registry of HHC agencies interested in APNS.
Graduate programs could make HHC an option for a clinical site, which could attract
APNS to this working environment.

Each HHC agency could describe their specific needs for an APN before the agency
begins its recruitment process. These needs should match the APN’s skills. Agreements
between the HHC agency and physician(s) would need to be developed related to the
APN’s practice.

HHC could be a new area for APN practice with benefits to all levels of health care,
while emphasizing the client’s goal of independence. This generic position description

could be the beginning of the APN as an accepted valued member of the HHC team

32

Implications for Education

Since HHC is a new area for APN practice, the clients, staff nurses, physicians, and
payors need to be informed of the benefits of an APN in HHC. First, the clients and
families utilizing HHC need to know the differences between a staff nurse, an APN, and a
physician, in the areas of their education and scope of practice. This could be done by
developing a pamphlet describing the various health care providers in HHC for the client
to read, or the staff nurse or APN could educate the client at the initial visit. The state
home health organization could develop a summary of the benefits of APNs in HHC and
promote the concept in newsletters to HHC agencies or focus on the partnership at
seminars.

Upon employment of an APN, the staff nurses and other employees of the HHC
agency would need to know the APN’s roles and responsibilities as well as the benefits the
agency could receive from an APN. The employed APN may conduct inservice programs,
prepare handouts, develop protocols, and assist in the development of policies and
procedures for the agency. For the agency to promote the APN, all the employees must
understand the APN roles, responsrhilities, and benefits to the stafi’ and agency.

Assuming that the APN in HHC will communicate with health care providers in the
hospital and community, the hospital personnel and physician offices need advisement
about an APN working in HHC. The discharge planning coordinators in particular need
to know about the role of an APN in HHC. These coordinators decide where the client is
to be placed after discharge, whether in a nursing home, assisted living, or home with or

without support.

33

The physicians must be informed as to how an APN could be utilized in HHC and how
it would benefit them. This is a strategic objective since the APN works in collaboration
with physicians. The APN would share the physicians’ clients and order tests, write
prescriptions, etc.; therefore, the physicians need to have a good understanding of the
APN’s potential role and contributions. While informing the physicians, the APN must
emphasize how the physician could benefit from this partnership. The physicians and the
APN would need to develop a trusting relationship. This could begin by an APN working
in the physician’s practice for a short time, allowing the physician to observe the APN; a
trusting relationship develops over time. The HHC agency could participate in physician’s
education by having a the APN or a spokesperson visit each office and meet with the
oflice manager, explain the role of the APN in HHC and the benefits to the physician(s).
Although potentially time consuming, it could prove to be the best approach. Another
approach which could prove more cost efi‘ective would be to send each office a brochure
or video introducing the APN, or hold an open house sponsored by the HHC agency to
inform physician(s).

Medicare, Medicaid, and third party payors would also need to be instructed about the
duties of an APN working in HHC, especially if the APN is to be reimbursed directly. The
efl‘ectiveness of the APNS teaching as a cost saving measure along the care continuum
should be emphasized. Political involvement would be needed in order to have this issue
addressed. The support of the American Nurses Association or Michigan Nurses
Association would need to be sought.

As previously described, graduate programs could inform the students about the

possibility of the APN working in HHC and could make HHC an option for a clinical site.

34

This generic position description could be available for the students to examine when
considering practice location options. Therefore, many educational possibilities need to be
addressed.
I_r_nph'cation§ for Resear_ch

After developing this generic position description, research needs to be done to
determine if the basic components are complete and if they reflect the significant
desired/required duties of the APN in HHC. To begin, the description could be shared
with the five largest agencies in Michigan which were previously identified in this review.
They could be asked to evaluate the description. If adapted by agencies, their collective
experience with this generic position description could be evaluated. It could take several
years until a suflicient number of APNS are working in HHC and have adapted the
proposed description. It would be important that the APN actually implement the
components of this description including home visits and clinical management of clients,
rather than work in management, in order to evaluate the description effectively.

This project suggests a change in the current HHC model due to the recommended
inclusion of the APN. This proposed prototypical role of APNS in HHC suggests the
significance of collaboration with PCPs, the need to consider the staff nurse-APN ratio,
the impact of APN utilization on reimbursement and cost saving techniques, and the
identification of a typical client load for the APN.

This scholarly project could be rewritten as an article for an NP journal and describe
the development of the generic position description and how an APN could be employed
in HHC. This could assist in educating other APNs all over the country who might be

interested in a career in HHC but had not thought of this practice setting and role. The

35

article could assist APNs in acquainting the HHC agency and physicians about the benefits
of employing an APN.

Once APNs are employed in this role, data needs to be collected which documents
the outcomes of an APN working in HHC. In order to gain support of the HHC agency
and physicians, research which describes the relationship between employment of an APN
working in HHC and positive client outcomes could be pursued. These outcomes could
include decreased number of emergency room visits or admissions to the hospital,
decreased number of exacerbations of diseases, decreased calls to PCPs’ offices, and
increased client independence and optimal functioning. Other areas to examine could
include the number of APN visits per client in HHC and its relationship to the number of
emergency room visits or hospital admissions. Specific assessment tools would need to be
developed in order to evaluate these outcomes.

Since HHC is expanding so quickly and an APN in HHC is a new concept, filture
research possibilities are unlimited. Research is a very important part of developing a new
idea, such as an APN in HHC, since it could provide the empirical evidence needed. This
would make it easier for others to realize the benefits, but it will take several years for
research to be done on the outcomes.

SUMMARY

APNs could play a vital role in HHC. This project identified the benefits of APNS in
HHC and was based upon King’s (1981) Theory of Goal Attainment. The product,
Generic Position Description for an APN in HHC, acknowledges the APN as a
collaborator with the stafl’ nurse in assisting the client to reach his/her goals. This generic

position description has many implications for practice, education, and research.

APPENDICES

APPENDIX A

36

APPENDIX A

JOB DESCRIPTION FOR A LARGE BANK

Job Title Research Assistant Branch
Job Number 3135-1 Division ECONOMIC RESEARCH
Salary Grade 9 Department
Date Section
JOB DUTIES

Compiles industrial and economic data by: obtaining current and comparative statistics
relative to trends in production, commerce, employment, etc., from
newspapers, periodicals, publications of government agencies, trade
associations, and other standard sources; maintaining a set of statistical records
for the department concerning industries and areas of the region; selecting and
classifying for the department library pertinent articles fi'om the
above-mentioned sources; digesting suitable material on national and regional
economic developments; plotting acquired statistics and developing informative
graphs, tables, and charts; preparing special statistical and other reports.

Also computes department’s own seasonally adjusted employment data serves.
Fumishes various industrial and economic data to bank and other oficials.

Prepares the Weekly Business Briefs by gathering and assembling data and writing
original copy to provide a digest of regional and national business news for the
Bank’s stafi”, officers, and customers. Uses own judgment in selecting articles
of significance. Submits material for final approval.

Also researches and prepares section for the Summary of Regional Industries.
Researches and prepares local business section for the Metropolitan Real
Estate Research Report. Prepares statistical data for charts and tables in the
quarterly and annual issues of the Surmnary. Prepares statistical data and
writes a section of local home price trends for the Metropolitan Real Estate
Research Report. Prepares special reports on various subjects as requested.

Assists in maintaining research library; assists Economist in developing new
statistical series and ideas for charts; assists other staff members with
miscellaneous functions.

The Research Assistant, under general supervision, is engaged primarily in the
acquiring of pertinent, factual data relative to varied industries, their trends
and any other significant details. In large part this material provides the basis

37

for analysis, opinions, and recommendations by the Economist, although some
of the analysis is included in the duties of the Research Assistant.

Education

Experience

Resourcefulness

Responsibility

Contacts

Supervision

Mental Efl‘ort

Physical Eflon

Job Conditions

JOB REQUIREMENTS

A broad knowledge of a technical work field applicable to duties such
as economics and business theory, and an understanding of statistical
methods and the application and analysis thereof. Equivalent to
college degree in Economics or Business Administration.

Job requires practical experience in statistical methods and analysis and
a period to acquire a knowledge of various information sources. Time
- six months to a year.

Job requires judgment and initiative in determining sources of
information and judgment in selection of significant data and
application of statistical formulas to develop informative results.
Under general supervision.

Considerable care is required since most errors are diflicult to locate.
Reports and publications are distributed beyond the bank and relied
upon as being correct and indicative of trends. Work must be
prepared promptly, and deadlines met.

Routine staff contacts plus frequent public contacts by telephone and
occasionally in person requesting or furnishing information. Courtesy
and tact are required.

Does not supervise.

Requires considerable care and attention due to the concentration

required for the selection, development, and analysis of economic
information.

Medium ofiice position. Job requires fiequent use of calculator and
adding machine. Also requires fi'equent referral to department library

and occasional trips to public library and other outside oflices for
information.

Average office conditions.

APPENDIX B

38

APPENDIX B

JOB DESCRIPTION WORKSHEET
Job Title:
Reports to: Dept.:
Duties Performed:
Equipment Used:
Skills Used:
Leadership Responsibility:
Responsibility for Equipment:
Responsibility for Money:
Other Aspects of Job:
Special Working Conditions:
Performance Standards:

Analysis Made by: Date:

APPENDD( C

39

APPENDIX C

SAMPLE JOB DESCRIPTION, BEXAR COUNTY HOSPITAL DISTRICT

Job Description:

SUMMARY

Function

Scope

DUTIES

Typical

Periodic

SUPERVISION
Received

Given

Clinical Nurse Specialist

As expert in specialized area of nursing, serves as guide to other
personnel using skill in interpersonal relations to identify problems or
barriers to individualized care and their solutions. Responsible for
high-level patient care.

Areas of assigned responsibility may include broad areas of medical,
surgical, psychiatric, obstetrical, pediatric, and rehabilitation nursing in
BCHD and be directed to specific specialty areas of expertise;
compliance with BCHD policies and procedures.

Gives direct care to selected patients and serves as role model of
excellence in practice to others on unit. Evaluates nursing care
requirements of patients, develops written nursing care plans, and
evaluates care plan in operation and revises as indicated. Consults
and makes rounds with medical staff, nursing personnel and other
disciplines to achieve patient-directed goals. Teaches and
demonstrates specific nursing care techniques. Plans and participates
in orientation, peer review, and staff development programs.
Performs related duties as required.

Identifies nursing problems in specific clinical area and conducts
studies and research in systematic manner. Participates as active
member of nursing and/or hospital committees. Prepares and submits

regular and special reports as requested. Serves as nursing consultant
to other medical areas in planning patient care.

Responsible to Associate Administrator for patient care.

None - advises, counsels, guides, and supports personnel in clinical
management of care.

EDUCATION

Required

Preferred
EXPERIENCE

Required

Preferred
EQUIPMENT

Required

ACCURACY

40

Master’s degree in nursing. Licensed to practice in Texas. Maintains
professional competency through participation in continuing education
and other related training.

Master’s degree with directly applicable specialized training.

Master’ degree in nursing. Licensed to practice in Texas. Maintains
professional competency through participation in continuing education
and other related training.

Master’s degree with directly applicable specialized training.

Thorough knowledge of all instruments, equipment, and mechanical
devices used in patient care in nursing specialty.

Efliciency and accuracy in all phases of work.

LIST OF REFERENCES

41

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