Acute care nurse practitioners (ACNPs) are a unique and highly trained subset of nurse practitioners. Pediatric and adult nurse practitioners have been in practice since the 1990s; however, it was not until 2004 that the National Organization of Nurse Practitioner Facilities (NONPF) published a description of an acute care nurse practitioner.1 Between 2012 and 2013, the organization collaborated with the American Association of Colleges of Nurses to delineate more specific adult and geriatric population acute care nurse practitioner competencies.1 Typically, patients in the cardiothoracic intensive care unit (CTICU) require a high level of care. Acute care nurse practitioners working in a CTICU must be knowledgeable of various procedures such as coronary artery bypass, cardiac valve replacement or repair, heart or lung transplants, and use and management of mechanical circulatory devices, as well as the management of surgical and nonsurgical complications in this patient population. Acute care nurse practitioners in the CTICU are also expected to collaborate with an interdisciplinary team to provide high-quality care to this complex patient population.
Cardiothoracic intensive care units are highly specialized, high-stress environments, and it is vital to hire appropriate APRN candidates and foster an environment of learning. Transitioning from a role as a registered nurse (RN) to an ACNP is a significant career change that involves a high level of vulnerability, stress, and doubt.2 During this period, as ACNPs navigate their transition from expert RNs to novice ACNPs, they can experience changes in role identity and loss of confidence.2 Formal role-transition programs exist, but they are scarce.3 Barriers to formal transition programs may include lack of preceptors or mentors, as well as the short-term cost of such programs.3 Mentorship is an effective strategy for a smooth role transition for novice ACNPs. Mentorship supports the novice ACNP as they evolve into an expert clinician in one of the most complex critical care environments. Mentorship in the CTICU both provides the ability to learn specialized skills and allows the novice ACNP to develop improved communication and leadership skills.
More than 36 000 new nurse practitioners completed their academic programs between 2019 and 2020,4 and there are more than 300 000 licensed nurse practitioners in the United States.5 The novice to expert model, derived from the Dreyfus Model of Skill Acquisition,6 was adapted into nursing practice by Dr Patricia Benner in 1982 to provide a more objective way of evaluating the progress of nursing skills.6 The model encompasses stages of clinical competence—from novice, advanced beginner, competent, and proficient to expert levels. These stages are intertwined and build upon each other. In the past 40 years, the nursing literature has been replete with various scholarly articles supporting the application of novice to expert models in nursing research, education, and practice informing policy across health care settings and continuum. The vast real-world application of the model has also changed the perception of what being an expert means; the expert is not the nurse with the highest-paying job but the nurse that provides the most advanced nursing care within the role.6
Despite the continued increase in the supply and demand for ACNPs in the United States,7 little is known about the context of the lived experiences of nurses transitioning from an RN to an ACNP role, specifically in the CTICU.7 Anecdotally, collective experiences suggest that imposter syndrome is highly prevalent among high-achieving novice ACNPs in CTICUs. It has been speculated that low confidence and feelings of imposter syndrome may be related to the lack of CTICU-specific clinical content, inadequate mentorship support, and lack of socialization of the graduate student into the ACNP role. Although one might argue that each RN has a different progression pathway, many new ACNP graduates experience some challenges in their ACNP role transition. This column delineates the transition of an experienced RN into an ACNP in a CTICU with a description of the role of an expert ACNP-leader serving as a mentor and advocate for the novice ACNP. Drawing from narratives of novice and expert ACNPs, we present implications for research, practice, and policy.
Career Progression in Clinical Nursing Practice
The RN-to-ACNP transition is a complex process and represents a challenging evolution.8 Despite being an important milestone for many novice ACNPs, it can also be a turbulent time filled with uncertainty.9 Some nurse practitioner students experience challenges with their preparedness for clinical experiences and the quality and availability of their preceptors and clinical sites. Many nurse practitioner programs facilitate adequate access for students to clinical sites and preceptors.10 Other programs lack a network of preceptors, leaving students with the responsibility of finding their own preceptors to fulfill their clinical hours.10 Preceptors have expressed concern regarding students’ preparation level and questioned their preparation for practice.11 Most ACNP programs require students to complete clinical hours, but this does not mean students will be proficient in essential competencies for skills acquisition. For example, some positions require ACNPs to get credentialed on various procedures such as intubation and placement of arterial catheters, central venous catheters, and chest tubes. However, most ACNP students are not expected to be proficient in these skills prior to graduation. Access to quality clinical education is imperative for ACNPs’ successful transition to practice.
Preceptorship and Mentorship
Preceptorship is necessary for new APRNs to acclimate to their role. Preceptorship supports professional growth by helping novice ACNPs strengthen their skill set and gain confidence, all while ensuring safe and effective patient care.12 A preceptorship typically occurs with new hires during their orientation, a time dedicated to learning about a new institution, a unit, policies, and procedures. Preceptors use specific strategies, such as role-modeling, to assist novice ACNPs in learning their role. The preceptor observes the novice ACNP in their performance and provides feedback, with the ultimate goal of gradually stepping back and providing less support until the novice ACNP can practice independently.
Although preceptorship is key during the ACNP orientation phase, mentorship can also be fundamental for an ACNP’s transition to practice.13 Mentorship can be formal or informal, but a key component of effective mentorship is the building of trust between the mentor and mentee.13 Effective mentors provide support, encouragement, guidance, and motivation, with the purpose of helping the novice ACNP acclimate to their new role. The mentor presents the novice ACNP with opportunities for professional growth, and in particular, the development of self-efficacy.14
Several studies explore the effects of mentoring on imposter syndrome.15 Students achieve skills based on their hard work; nonetheless, they are still affected by feelings of inadequacy.15 Clinical knowledge and emotional support are needed to prepare ACNP students for their role transition. Without a balance of clinical knowledge and emotional strength, novice ACNPs can be affected by feelings of inadequacy, causing poor assimilation to their new role. This can ultimately lead to persistent pessimistic behavior, which can affect their performance.15
Transitioning to the Cardiothoracic Intensive Care Unit: One Nurse’s Experience
For one of the current authors (LH), having RN experience in a CTICU before becoming an ACNP was fundamental to skills acquisition and aided the role transition.2 In addition, the transition from an expert RN to a novice ACNP at the peak of the COVID-19 pandemic was a turbulent yet defining moment for this novice ACNP. From onboarding to orientation, the process was more complex due a multifactorial set of circumstances. Eight years of RN experience in a CTICU can give a significant advantage in both graduate school and during role transitioning. This type of experience helps prepare a nurse not only for the didactic portion of graduate school but also for clinical work in a CTICU—for example, an understanding of hemodynamics and mechanical circulatory device physiology can facilitate an understanding of disease processes and management.
The ACNP role transition for this author began in a high-acuity CTICU in one of the largest medical centers in the United States. Going from the role of an experienced RN, regarded as a resource in a CTICU, to a novice ACNP in a different CTICU was challenging and at times confusing. This CTICU hires specialized adult or adult-geriatric ACNPs to augment their intensivist staff. Being a part of a highly qualified, diverse team of medical professionals caring for some of the sickest patients in the United States can be exhilarating as much as it can be intimidating.
The first 2 months of orientation consisted of figuring out a practice style and routine, as well as becoming acquainted with the structure of the institution, team, and unit. During the orientation process, various preceptors from different backgrounds and with different teaching styles worked together to assist in incorporating me into the new role. Preceptors consistently worked closely with other preceptors to adequately address needs. The expectations and standards of care were the same across the entire team. This consistency was vital to my adjustment to a new environment, primarily because newly exercised clinical decision-making skills can be clouded by insecurities and a sense of not belonging, that is, imposter syndrome.
Imposter syndrome can result from stressful situations, such as role transition in a high-paced, performance-driven, stressful environment like most critical care units.15 In my case, working with a team of high-achieving providers further exacerbated insecurities and fears of being perceived as a fraud. In turn, these thoughts and feelings can cloud an ACNP’s focus and impact work performance and self-efficacy.
Fortunately, I was supported by a group of advanced practice provider (APP) leaders composed of experienced APPs able to recognize imposter syndrome. This leadership provided emotional support and guidance to aid in my successful transition to the APRN role and to help combat anxiety driven by the feelings of clinical-skill inadequacy and a lack of self-confidence. After 3 months of orientation, an additional month was allocated with a mentor. The mentor was a member of APP leadership and a former orientation preceptor with whom I built a trusting relationship. The ACNP mentor was not only experienced but a true leader and expert in the field of cardiac surgery and heart failure. The ACNP mentor understood various challenges of new ACNPs and valued acquired skills. Notably, the mentor’s education and background in critical incident stress debriefing contributed to their effective mentoring style. The ACNP mentor developed a personal process for mentoring based on modified principles of the Critical Incident Stress Management Seven Core Components.16 The purpose of mentorship in this situation was to provide emotional support, motivation, and guidance and to encourage the new ACNP to trust in their clinical competence and ability to use available resources.
Phases of Mentorship
The ACNP mentor in this situation used a process loosely based on the Critical Incident Stress Management principles16 and comprising 4 phases: introduction, conceptual, response, and coaching (See Table 1). The introduction phase focused on areas needing improvement and allowed for the establishment of a daily routine and clinical-skill development strategies for the day. For example, the novice ACNP obtained patients’ background information from the electronic health record and then physically assessed the patients and presented their conclusions and plan to the mentor and sometimes a CTICU fellow. This approach allowed for feedback on the presentation and plan but also created space for a general dialogue about disease processes and management, helping to address the ACNP’s areas of weakness in a structured, less-intimidating manner.
In the conceptual phase, the mentee and mentor debriefed about clinical encounters at the end of the day, which created an opportunity to acknowledge strengths and weaknesses and build the mentee’s confidence while empowering their growth as a clinician. In this phase, the well-attuned mentor was able to acknowledge signs of imposter syndrome and counter them with positive affirmations and motivation.
The response phase was an opportunity for the mentor to provide and analyze the mentee’s receptiveness to feedback. This phase allowed for upholding of accountability for both the mentor and mentee, allowing for a more trusting relationship. For example, the mentor’s evaluation of how the mentee perceived constructive criticism helped to maintain the trusting bond between mentor and mentee. This was vital to building the mentee’s confidence and allowed promotion of ownership, minimized self-pity, and helped the mentee take initiative as a part of the team.
In the coaching phase, the mentor developed an individualized plan for the specific needs of the mentee. Discussions about resources provided for the mentee by APP leadership and the mentor—such as written materials, online learning modules, and podcasts—created an opportunity for the mentor and mentee to bond over specific interests within the specialty. The asynchronous nature of the learning resources allowed the mentor to tailor the learning environment to the needs of the mentee. The coaching phase allowed for a positive culture of communication for the mentee and other members of the ICU multidisciplinary team. For example, the mentor recruited a group of ACNPs within the CTICU team to collaborate with other ICU team members to implement a more standardized extracorporeal membrane oxygenation ambulation protocol. This helped create a more positive mindset for the novice ACNP and had a long-lasting impact during the challenging role transition.
The challenges encountered during this author’s role transition were a lack of preparedness, difficulty utilizing resources and taking accountability, and lack of organization. It was a mistake to assume that role transitioning would be smooth solely based on former RN experience and education. It involved more than graduating and passing an exam; it required hard work, perseverance, and a compatible mentor. Mentorship, like most relationships, requires compatibility and commitment from both the mentee and mentor. For the mentorship to be effective, expectations and goals must align between mentor and mentee.17 In this case, the mentor and mentee were able to build a relationship based on mutual respect and admiration. This process of mentoring with the identified phases assisted the mentee in finding solutions to the challenges that arose (See Table 2).
Mentorship is the gateway to adapting to a new role. Under the guidance of a mentor, novice ACPNs develop their ability to overcome obstacles, which allows them to transform uncertainty and self-doubt into opportunities to evolve as clinicians. Navigating a challenging role transition with a mentor who was supportive, nonjudgmental, enthusiastic, and an expert in the field was vital to overcoming a challenging transition period. A successful role transition depends on the mentor’s hard work and dedication to the team. Mentors should be able humanize mistakes and normalize failure. This allows for successful transition into a team of highly trained and skilled providers. With the right support, the novice ACNP’s apprehension and uncertainty can be transformed into appreciation for the team and excitement; the ACNP can also optimize acquisition and development of the required competencies for the new role as ACNP in the CTICU.
To ensure delivery of high-quality patient care, it is essential for hospitals to understand the role transition of novice ACNPs.17 Clinical knowledge alone is not sufficient to prepare a novice ACNP to enter an already complex health care system amid a pandemic.17 With the increased number of ACNPs in the United States, hospitals should provide a structured, high-quality onboarding process to promote a salubrious role transition. The aim of this column is to show how mentorship can positively impact role transitioning from experienced RN to novice ACNP in a CTICU. We also aim to help novice ACNPs recognize imposter syndrome and through our experience (as mentee and mentor) help conceptualize the root of feelings of inadequacy, seeing them as a psychological response to a dysfunctional context versus a limitation within themselves.
In conclusion, this article provided an initial narrative about challenges experienced and strategies used for one nurse’s clinical career transition from an expert bedside RN to a novice ACNP in the CTICU. Further research is needed to examine the role of novice ACNPs’ social context in reshaping imposter syndrome through mentorship and to identify barriers and facilitators to development of such a syndrome. This shift in thinking about imposter syndrome among novice ACNPs in a complex environment such as the CTICU can lead to a systemic change, thereby changing the dynamics of the novice ACNP role transitions.
The authors declare no conflicts of interest.