Finding Our Optimal Scope of Practice

Jane decided to go into nursing when she was in her second year of college. She had sustained an injury while playing softball and had a positive experience with the nurse who cared for her. Although she briefly contemplated going the premedical route, she decided that direct patient contact appealed to her most, so she pursued a nursing degree.

Jane always considered critical care nursing while in nursing school. What she found most appealing was what she called “managing the instability” and “the challenge and adrenaline” of such work. She completed nursing school and worked for 2 years on a general surgical patient floor, where she gained familiarity and experience in the care of non–critically ill surgical patients. She found that caring for these patients was rewarding but said she wanted something more challenging out of her nursing career.

She then took a position working as a bedside critical care nurse in a surgical ICU with occasional progressive care shifts. She gained the experience she longed for, working with critically ill patients. She managed people with acute respiratory distress syndrome, septic shock, aneurysmal subarachnoid hemorrhage, anastomotic leaks, acute renal failure, complex arrhythmias, anaphylactic shock, and abdominal compartment syndrome (just to name a few!), not to mention all the complex psychosocial and end-of-life issues that come with caring for patients with these problems. She loved it. It was difficult, but she knew that going in. She was particularly proud of the close professional relationships she’d developed with nursing colleagues and intensivists. She felt that her input was valued and valuable. She felt important and felt that her presence mattered, plus she loved the complexity and relished the challenges.

Jane enjoyed the combination of medical science and emotional connection. It was highly rewarding to be able to use her understanding of fundamental physiology and pathophysiology to save lives, especially when the situation was high stakes and high stress—often the norm in the ICU. Equally important, though, was the need for her to talk with families about what was going on with their loved ones and to allow human touch to make all the difference, whether it was holding the hand of a family member who just realized his or her loved one was dying or reassuring a patient recovering from surgery that all was well.

Jane first heard about becoming an NP from a colleague who was in the middle of her first year of an NP program. It sounded appealing to Jane, who thought such a career path might potentially integrate nursing and medicine. She began her NP program while working in critical care nursing.

Jane wanted to expand her scope of practice while remaining true to her nursing roots. In the first year she took 2 classes per semester, 2 days a week. She liked the challenge of going back to graduate school, including her pharmacology, pathophysiology, and research classes. She found the breadth of her clinical rotations challenging as well. She was pleased with her decision.

Her first clinical position as an NP was working in the outpatient office of a group of orthopedic surgeons. Jane had been an athlete her entire life, and thought it would be interesting to work with that population of patients. She felt she could connect with them and wanted to obtain a better understanding of what those patients were going through both emotionally and physically.

Her clinical role was to care for patients after orthopedic surgery, make follow-up telephone calls, and evaluate patients with outpatient orthopedic surgery emergencies in the office. Eventually she realized that outpatient medicine might not be the best fit for her temperament and personality. That became dramatically clear to her when, while caring for a patient who had come in having a seizure, she realized how much she missed the challenges of inpatient medicine. Although she enjoyed the professional working relationships she developed with the surgeons in the outpatient setting, she longed more for the connection she developed as part of the inpatient, critical care, multidisciplinary team.

Jane recently took a position working as a critical care nurse practitioner in the same ICU where she had worked previously as a critical care bedside nurse. She joined a team of house officers, critical care fellows, and attending intensivists. It was awkward at first, because the bedside nurses were asking her questions rather than her asking questions of the team.

Initially, she was concerned about being more independent and wondered if she was “doing the right thing.” But she had ample support, both from the bedside nurses and the attending intensivists. Everyone wanted her to succeed. She now looked at things differently. She quickly got up to speed with doing procedures such as central lines and arterial lines and learning other new techniques, but always with a continued focus on patient safety.

Most importantly, she started to see critical care research and literature differently. She was now looking more closely at articles she might have skimmed in the past. She was gaining a clearer understanding of the importance of the critical care research literature and how to figure out the “right” way to do things. She began to see that the literature was dynamic, and that the “right way” last week might not be the best way this week. She found that managing uncommon clinical disease processes can be common in an ICU, and she gained the necessary skills to quickly find clinically relevant and accurate answers to sometimes esoteric questions. Finally, her role on the team was changing in terms of caring not only for 1 or 2 patients, but helping to care for all the patients in the ICU. This took some adjustment time, but she found her new role to be rewarding.

After we spent some time interviewing Jane and hearing her story, we realized there were some important conclusions we could draw. First, each of our journeys is unique; we each must find our own best path to personal and professional fulfillment. Secondly, we each should decide with pride that we will “practice to the full extent of our education and training.”^1,2,6–9  For some of us that could mean pursuing a graduate degree; for others it might mean speaking up at a staff meeting or starting a quality improvement or research project. For still others—presumably for most of us—it might be feeling pride at a job well done, such as notifying a rapid response team early so a patient can be saved or having a patient smile at us when we relieve his or her pain.

Practicing to the full extent of our education and training is important, but it is also essential that we remind each member of the multidisciplinary team that his or her job is important and valuable. We want bedside critical care nurses to remember that their jobs are of the utmost importance. It is well known how physically and emotionally demanding critical care can be. We want to take a moment to thank critical care nurses for their hard work and for everything they do.

Our journeys vary. For some, becoming an advanced practice practitioner may be part of our journey. But we want everyone to remember that being a bedside nurse is a profoundly important professional role, and that practicing to the full extent of one’s education and training does not necessarily mean leaving the bedside.

We would like to thank “Jane” for being so generous with her time, for sharing her story with us, and for allowing us in turn to share it with the readers of AJCC.