Acute care nurse practitioners, prepared as providers for a variety of populations of patients, continue to make substantial contributions to health care. Evidence indicates shorter stays, higher satisfaction among patients, increased work efficiency, and higher quality outcomes when acute care nurse practitioners are part of unit- or service-based provider teams. The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education outlines detailed guidelines for matching nurse practitioners’ education with certification and practice by using a population-focused algorithm. Despite national support for the model, nurse practitioners and employers continue to struggle with finding the right fit. Nurse practitioners often use their interest and previous nursing experience to apply for an available position, and hospitals may not understand preparation or regulations related to matching the appropriate provider to the work environment. Evidence and regulatory guidelines indicate appropriate providers for population-focused positions. This article presents history and recommendations for hiring acute care nurse practitioners as providers for different populations of patients.
Controversy persists about preparation for advanced nursing practice based on prior nursing experiences as compared with specific educational training and certification. In addition, state boards of nursing do not all ascribe to national recommendations. Inconsistencies are also apparent in the details of interpretation of advanced practice nursing roles between states. Despite evidence that supports the success of the acute care nurse practitioner (ACNP), evidence that documents outcomes on the basis of preparation, certification, and nursing experience is lacking. The evolution of the ACNP role, national recommendations, published population-based competencies, and scope of practice strengthen the differentiation of advanced practice registered nurse (APRN) roles, but do not specify hiring guidelines. The following discussion, gleaned from the available publications, attempts to provide assistance for making appropriate hiring decisions and offers insight and guidance for selecting a suitable candidate.
Two nurse practitioners apply for the same position at a large urban medical center. The job description indicates the need for critical care expertise with preferred experience in cardiology or cardiac surgery to care for a population of patients with heart disease, including postoperative cardiac surgery patients. This team member will provide evaluation and management as well as coordination of operative and discharge planning. The first applicant is a nurse practitioner who attended a primary care educational program and has worked for 3 years in an outpatient cardiology practice and in a cardiac intensive care unit before attending graduate school. The second applicant is a new graduate who attended an acute care nurse practitioner program after working as a nurse in the intensive care unit for 2 years. She has completed clinical rotations in the emergency department, an inpatient medical-surgical unit, and a cardiac intensive care unit. Which of these applicants is the best match for this position and the most appropriate provider based on identified scope of practice?
History of the Acute Care Nurse Practitioner
Neonatal nurse practitioners were truly the first acute care providers, having practiced in neonatal intensive care units since the 1970s.1 Pediatric and adult ACNPs have existed since the early 1990s, with the role originally developed for adult critical care nurse experts. In 2000, 3 programs had been designed to educate pediatric critical care nurse practitioners.2 In 2004, the National Organization of Nurse Practitioner Faculties (NONPF) published a description of the ACNP as one who provides nursing care across the continuum of acute care services to patients who are acutely and critically ill with a focus on stabilization of acute medical problems, prevention and management of complications, comprehensive management of injury and/or illness, and restoration to maximum health.3 In 2008, the Consensus Model established standards for population-focused practice based on licensure, accreditation, certification, and education, which would match the proposed role function.4 In 2012, NONPF and the American Association of Colleges of Nurses collaborated on a document that outlines acute care adult and gerontology competencies, and in 2013, NONPF published a document delineating the population-focused nurse practitioner competencies.5,6 Currently, the publication of these national guidelines and supportive terminology for population-focused nurse practitioners distinguishes and validates the role of the neonatal, pediatric acute care, and adult-gerontology acute care nurse practitioners (AGACNPs) as those who are recognized as trained and educated to care for acutely, chronically, and critically ill patients, typically in the inpatient hospital setting.
The first acute care nurse practitioners worked in the neonatal intensive care unit, beginning in the 1970s.
Before the advent of acute care educational programs and currently in states where ACNP programs or graduates are lacking, exceptions exist, and primary care prepared providers are hired to work within hospital settings, often on the basis of the patient population and acuity.7 Obviously, research to fully support recommendations for ACNP practice is needed, but with very little information available for employers at present, it is important to address the current evidence. Table 1 provides examples of education, certification, and patient population, along with recommendations for ideal previous nursing experience that can provide guidance with respect to hiring preferences for ACNPs.
Scope of Practice
Scope of practice is defined as the “procedures, actions, and processes permitted for a licensed individual in a specific profession. Scope of practice is limited to areas of practice for which the individual has received education and gained experience, and in which he or she has demonstrated competency.”8 The American Nurses Association describes scope of practice as the “who, what, where, when, why and how,” of nursing practice.9 Scope of practice for nurse practitioners is defined also by national organizations. The National Association of Neonatal Nurse Practitioners provides a position statement for neonatal nurse practitioner care and a collaborative publication with the American Nurses Association that proposes neonatal nurses’ scope of practice and standards of care.10,11 The National Association of Pediatric Nurse Practitioners has developed and maintained a position statement for pediatric acute care nurse practitioners (ACPNPs).12 Acute care is considered in Pediatric Nursing: Scope and Standards of Practice, published by the American Nurses Association, National Association of Pediatric Nurse Practitioners, and Society of Pediatric Nurses.13 The American Academy of Nurse Practitioners, the National Panel for Acute Care Nurse Practitioner Competencies,14 and the American Association of Critical-Care Nurses15 specifically address scope of practice for AGACNP practice. All of these national organization statements, which are validated by individual and group experts, reflect evidence and are incorporated in regulation and licensure.8,10
Delineating and incorporating scope of practice ensures public safety and expands patients’ access to health care as well as offering guidelines for payers, employers, regulators, and other stakeholders.16 Scope of practice for hospital-based nurse practitioners may also include expanded role responsibilities such as education, research, quality review, program development, and administrative activities.17 In many institutions, scope of practice is positively influenced by the ACNP’s ability to generate revenue by billing for services, allowing financial benefits of the role to be defined. Other outcome measures of the ACNP include improved quality of care, no difference in patients’ outcomes with care provided by ACNP versus by fellows, and decreased length of stay.17–19 In a recent survey of pediatric intensive care units, medical directors described ACPNPs as partners who provided supervision of resident physicians, continuity of care, and skill with procedures.20
As scope of practice has evolved, so has the ACNP role. The neonatal focus now encompasses the care of critically ill neonates in inpatient and transport services and continued care of infants up to the age of 2 years.10 Initially, the work of ACNPs and ACPNPs was focused on critically ill patients, but it has expanded to include the breadth of all critical and acute care services such as care of patients in cardiothoracic surgery, cardiology, and medical, neurosurgical, and surgical intensive care units.17,19 Other areas of practice for ACNPs and ACPNPs include working on a hospitalist service, in the emergency department, in specialties such as hematology/oncology, or as part of a trauma team.17,21 Within these practices are underlying regulations and competencies that outline boundaries or basic premises relative to the population of patients served. Despite the work environment, a scope of practice defines specific functions of ACNPs relative to the various populations of patients.17 Job descriptions are typically based on scope of practice for ACNPs, created from models of core competencies and specialty-specific competencies. The core competencies for all nurse practitioners published by NONPF in 2013 reflect expectations for both master’s and doctoral level educational preparation, which also provide a basis for role and job expectations.8 Nurse practitioners should not practice on the basis of previous nursing experiences.
The acute care nurse practitioner role focuses on stabilization of acute problems and prevention and management of complications.
Education and Certificatio
Guided by national criteria, educational programs for neonatal nurse practitioners, ACPNPs, and AGACNPs have been developed to train nurses in providing care for neonates, children, or adults with complex acute, critical, and chronic health care needs in a variety of inpatient and outpatient settings. In order to validate competency, certification is available for all populations in acute care, taking into consideration some overlap of patients’ ages and acuity. Evidence suggests that specialty nursing certification enhances patient care.22 Credentialing of individuals, which invariably includes certification, establishes a standard of quality for practice.22,23 Role delineation studies, completed at regular intervals by the certification organizations, validate current practice to justify the content and criteria of certification examinations.13,23,24 Definitions of nurse practitioners’ roles are created by the certification organizations, using data from these studies. The Pediatric Nursing Certification Board’s definition of the ACPNP includes the following: “designed to meet the specialized physiologic and psychological needs of children with complex acute and chronic health conditions.”24 The most recent role study was completed for acute care pediatrics in 2010 with changes to the current certification examination. ACPNPs “respond to rapidly changing clinical conditions, including the recognition and management of emerging health crises, organ dysfunction, and failure.”24 The definition of an AGACNP by the American Association of Critical-Care Nurses Certification Corporation states that an AGACNP is a registered nurse who has completed an accredited graduate program that prepares him or her as a nurse practitioner with supervised clinical practice to acquire advanced knowledge, skills, and abilities.15,23 AGACNP’s
focus on the stabilization of acute medical problems, prevention and management of complications, comprehensive management of injury and/or illness, and restoration to maximal levels of health within an interdisciplinary and collaborative environment.23
Even though qualifications are added in specialty certification such as emergency medicine or oncology, population-based certification as it accompanies completion of an advanced practice educational program is designed to document competency and can assist in measuring and ensuring safety.22 Certification, although not required in all states, should reflect the population of patients for which the nurse practitioner has been trained and is an expected portion of the candidate’s portfolio.
Key Points for Hiring Practices
It is essential that specific job descriptions clearly define the role of the nurse practitioner sought by an organization. The employer must identify the population of patients that will be cared for by the nurse practitioner. The job description should reflect the practice environment and should spell out the professional and organizational goals for the proposed role, including direct patient care, research, staff education, interprofessional collaboration, and administrative responsibilities.25 Challenges in finding the right nurse practitioner for the position persist. Bahouth et al26 discuss the need for strong nurse practitioner leadership to support the nurse practitioner as well as the institution. Despite the Institute of Medicine’s initiative for increasing the number of nurse practitioners, data on pediatric nurse practitioners indicate that the graduation rate is flat and that there are not enough pediatric nurse practitioners to fill both primary and acute care positions.27 Table 2 lists challenges in hiring, orienting, and retaining ACNPs. Kleinpell et al14 describe regulation and scope of practice for ACNPs with discussion of the continuing conflicts that arise when different agencies, including hospital credentialing and privileging processes, support a practice setting or patient population that is not parallel with the education and certification of the nurse practitioner. Table 3 highlights examples of roles, brief job descriptions, and patient populations that are appropriate for ACNP positions. Prior nursing experience with a specific population does not qualify a nurse practitioner to practice without the population-focused education and certification. Education, past nursing experience, and advanced practice nursing experience required of the applicant should be outlined for the candidate, while salary and benefits should be commensurate with the current market.
CASE STUDY CONCLUSION
The appropriate candidate for the cardiovascular intensive care nurse practitioner role is now clearly identified as the new graduate who has been educationally prepared to fulfill the role, has had pertinent clinical experience as part of the educational program, an experiential component that has provided exposure to the population and work responsibilities, and certification in acute care mandated by the state board of nursing. Finally, in creating a “perfect” hiring match, the new graduate will be offered an orientation or internship that allows a slow immersion in the new role, opportunities to make decisions with team support, and a mentor who can facilitate individual learning and assist in determining the right time frame for independence.
The provision of additional compensation or benefits for the role such as dollars for continuing education, both for licensure and certification maintenance as well as formal tuition reimbursement are important details to share as they may be factors that influence the appropriate candidate to accept a position.25 Additional professional benefits of interest to a candidate include paid time for professional development activities; fee reimbursement for licenses and certification; additional compensation with value-added certifications or formal education; or reimbursement for books, journals, or professional publications. The demonstration of a commitment on the part of the employer for the continued maintenance of competency and professional development of the nurse practitioner may be a very strong incentive to recruit and retain appropriate candidates.26
As ACNPs continue to be used in many different specialized programs, it is also enticing to a candidate to offer an orientation process with a preceptor and mentoring opportunities to optimize the candidate’s role development and enhance satisfaction of the employee and employer. Orientation programs offered as paid internships in which newly graduated nurse practitioners can obtain training and comfort in a specific or specialized service also offer benefit to the candidate and the hiring institution.28 In fact, programs have been initiated that perhaps offer an initial lower rate of pay in exchange for a longer internship or orientation period until the graduate is a competent practitioner, at which point the salary is adjusted.28
Key messages from the Institute of Medicine’s 2010 report on the future of nursing indicate that nurses should practice to the full extent of their education and training, achieve higher levels of education, and be full partners with physicians and other health care professionals in redesigning health care.29 This initiative encourages ACNPs to create additional opportunities to benefit patient care and improve health care systems. As nurse practitioner education evolves to include more graduates from practice doctoral programs, additional very competent leaders will emerge who can construct and build professional practice settings that enhance current evidence-based, high-quality patient care.
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To learn more about the role of acute care nurse practitioners, read “Addition of Acute Care Nurse Practitioners to Medical and Surgical Rapid Response Teams: A Pilot Project” by Kapu et al in Critical Care Nurse, February 2014;34:51–59. Available at www.ccnonline.org.