Adult-gerontology acute care nurse practitioners (AGACNPs) care for adult patients in intensive care settings such as urgent care departments, emergency departments, trauma centers, and intensive care units. AGACNPs’ clinical responsibilities typically include conducting intake assessments, diagnosing critical diseases and conditions, developing short-term and long-term patient care plans, completing procedures and administering treatments to address critical conditions, and advising patients on the management of their illnesses. Adult-gerontology acute care nurse practitioners can also serve as coordinators of care and leaders in the medical setting, managing patients’ care from admission to discharge and guiding nurses and other medical staff.
Unlike primary care nurse practitioners, who typically follow their patients’ health over the course of several years, AGACNPs generally work with patients for a shorter span of time, but interact with patients frequently and work closely with them and their families. AGACNPs work in collaboration with and/or under the supervision of physicians, with the aim of stabilizing their patients’ condition before they are transferred to outpatient care or home.
Advanced adult-gerontology acute care is a demanding field of work due to the complex and critical conditions that AGACNPs are required to address on a daily basis, the fast-paced nature of the inpatient medical settings in which they work, and the emotional strain of working with patients who could succumb to life-threatening illnesses. However, registered nurses who elect to become adult-gerontology acute care nurse practitioners may find the rewarding relationships they form with their patients and colleagues, the intellectual challenge of the daily work, and the ability to work in a more administrative and leadership capacity to improve healthcare systems as very rewarding and motivating aspects of their job.
AGACNPs must undergo rigorous graduate school and clinical training in order to obtain national certification in their specialty. Prospective adult-gerontology acute care nurse practitioners receive certification through either the American Nurses Credentialing Center (ANCC) or the American Association of Critical Care Nurses (AACN). In order to qualify for the certification exam administered by either the ANCC or the AACN, candidates must have completed a graduate nursing program that has been accredited by either the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission for Education in Nursing (ACEN), and complete a minimum 500 hours of clinical practicum in medical settings that are relevant to adult acute care nursing.
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They must also have graduate training in advanced health assessment, advanced physiology and pathophysiology, and advanced pharmacology. In addition to fulfilling national requirements for APRN certification, AGACNPs must meet and maintain state-specific requirements for licensure/certification. After earning their requisite credentials, adult-gerontology acute care nurse practitioners should maintain their certifications and licenses through continuing education and fulfillment of additional requirements.
Where Adult Gerontology Acute Care Nurse Practitioners Work
The most common setting for adult gerontology acute care nurse practitioners is in the hospital, where they can work within specific critical care units or across multiple departments. Critical care services are structured differently at different hospitals according to the hospital’s size and available resources, as well as state and regional regulations. Typically, however, critical care services in hospitals are comprised of an Emergency Department, Intensive Care Units (ICUs), and Intermediate Care Units (also known as Step Down Units). AGACNPs who work in hospitals can specialize in treating patients who suffer from a specific type of condition, such as cardiovascular, pulmonary, or neurological disease. Other AGACNPs may work across multiple critical care departments, in a general medical or surgical ICU, or in the Emergency Department, where they encounter a wider range of acute injuries and ailments. Below are some examples of medical settings that can employ adult-gerontology acute care nurse practitioners.
Emergency departments within hospitals employ AGACNPs to evaluate and triage incoming patients to determine their medical needs, to provide and coordinate direct medical services to ill and injured patients, and to manage patients’ transition to other medical units within the hospital setting. Emergency departments are very fast-paced environments, and health care providers in these settings must prioritize patients facing immediately life threatening injuries and illnesses. The care provided in these settings is short-term and meant to stabilize patients until they can be transitioned to longer-term care.
Intensive Care Units (ICUs)
Intensive Care Units, or ICUs, are medical units within hospitals that have specialized staff to care for seriously ill or injured patients. AGACNPs can work in one or more ICUs in a given hospital, or rotate their time between several hospitals. Depending on the hospital, ICUs can be categorized based on patient population, conditions treated, or a more general criterion, such as medical treatment versus surgical care. Some large tertiary medical centers may have a Pediatric ICU, a Cardiovascular ICU, a Pulmonary ICU, a Neurological ICU, and/or a Psychiatric ICU, to name a few. Small and medium-sized hospitals might have just two ICU divisions–a Medical ICU and a Surgical ICU, or a single Medical/Surgical ICU that serves patients in need of either intensive medical or surgical/post-surgical care.
AGACNPs who work in ICUs typically work as part of a highly trained team of specialists and advanced practitioners. Dr. Elizabeth Tomaszewski, MSN, DNP, AGACNP-BC is an Adult-Gerontology Nurse Practitioner at Geisinger Health Systems, where she provides critical care services to a wide range of patients suffering from various critical diseases and disorders. “As a nurse practitioner on the critical care medicine service, I see critically ill patients in the intensive care unit with a variety of different medical conditions,” she said, “All of these patients require detailed assessments, complex medical decision-making and life-saving procedures. At times, these patients also require compassionate care at the end of life. […] Our multidisciplinary team includes nurse practitioners, physician assistants, physicians, nurses, respiratory therapists, pharmacists, case management and pastoral care. We all work together to provide comprehensive care to our vulnerable patients.”
ICU staff also work closely with personnel from other departments, such as the Emergency Department and Step Down Units, to ensure patients receive appropriate continuity of care. Below is a more detailed description of the types of ICU environments in which AGACNPs work.
The Medical/Surgical ICU, also known as the MSICU, is a common work setting for AGACNPs. MSICUs treat patients suffering from a wide array of critical conditions, as well as patients recovering from major surgical procedures. Michelle Edwards, MS, CCRN, AGACNP-BC, is a Critical Care Nurse Practitioner at the Palo Alto VA Hospital, where she cares for veterans struggling with complex and severe illnesses and conditions. In an interview with OnlineFNPPrograms.com, she described the role that she and other AGACNPs have on the critical care team at Palo Alto VA Hospital. “As a part of a multi-disciplinary team of interns, residents, fellows, NPs, and attending physicians, pharmacist, RNs, and RTs, we perform daily rounds on all of the patients in the MSICU (Medical/Surgical ICU). We are primary providers of all medical patients and consultants for general surgery, vascular, neurosurgical, and CT surgery patients,” she said.
AGACNPs who work in the Medical/Surgical ICU must be prepared to encounter a wide assortment of critical ailments and post-surgical needs. Kimberly Zilske, MSN, ACNP-BC is an Acute Care Nurse Practitioner specializing in Pulmonary Critical Care at Memorial Hermann Health System, where she cares for patients in the ICU. “I take care of any patient that is admitted into the Medical/Surgical ICU. Some of the patients that are admitted have been diagnosed with Pneumonia, Acute Respiratory Distress Syndrome, Acute Myocardial Infarction, Atrial Fibrillation with Rapid Ventricular Rate, Septic Shock, and Post Cardiac Arrest to name a few,” she explained in an interview with OnlineFNPPrograms.com. Ms. Edwards similarly outlined the many different critical conditions she encounters on a daily basis in her work at the Palo Alto VA Hospital. “[My team and I] manage complex medical patients with neurological disorders (stroke or seizures), pulmonary disorders (COPD exacerbation, ARDS/ALI), cardiovascular disorders (acute decompensated HF and cardiogenic shock requiring vasopressors and/or IABP), renal disorders requiring CRRT/iHD, GI disorders (pancreatitis, U/LGIB), endocrine (DKA, HHNK, thyroid) and sepsis,” she said.
As mentioned previously, some adult-gerontology acute care nurse practitioners focus on a particular area of critical care, and accordingly work in specialized ICUs. John Kenna, MSN, ACNP-BC is an Acute Care Nurse Practitioner in the Neurological ICU at the Medical University of South Carolina (MUSC), which is also a designated Level I Trauma Center. In an interview with OnlineFNPPrograms.com, he explained the types of critical conditions he addresses on a daily basis in collaboration with other specialists on the Neurological ICU team. “We work closely with the Neurosurgeons and Neurologists to manage a variety of neurologic injuries including a variety of Stroke (Ischemic, Hemorrhagic, Subarachnoid Hemorrhage), Traumatic Brain Injury (TBI), Spinal Cord Injury (SCI) and Neuromuscular disorders such as Guillain-Barre Syndrome or Myasthenia Gravis,” he said.
In addition to her position at Memorial Hermann, Ms. Zilske also works shifts at the University of Texas Health and Science Center at Houston, as a Pulmonary Critical Care Nurse Practitioner in the Transplant ICU and Step Down Unit, and as a consultant in the Critical Care Unit and the Cardiovascular Intensive Care Unit. The multiple medical settings in which she works means that her workweek is often quite varied depending on what services the hospital needs, and what shifts she takes on. “I cover the Transplant ICU and the step down unit for transplant or the Heart and Vascular Institute as a Consultant,” she told OnlineFNPPrograms.com, “If I am assigned to the Transplant ICU, I am responsible for the 10 bed ICU as well as a 20 bed floor that has nephrology, hepatology, and gastroenterology patients. It is also where we send the post op transplant patients. We are responsible for all admits to the floor as well as the ICU. […] If I am assigned to the Heart and Vascular Unit, we are considered consultants for the Critical Care Unit (CCU) and the Cardiovascular Intensive Care Unit (CVICU). We see all patients that we are consulted on with the Pulmonary Fellows, write the notes, and trouble shoot issues overnight.”
Intermediate Care/Step Down Units and Hospital Wards
AGACNPs can also work in Intermediate Care Units, where patients in the ICU are transferred when their condition has stabilized. Like ICUs, Step Down Units can be specialized, and provide care for patients suffering from a specific type of disease or condition, or they can be general and treat a wide variety of patients. According to the American Association of Critical Care Nurses, Step Down Units must provide basic and advanced life support services, continuous medical treatment administration, standard procedures for advanced patient monitoring, long term mechanical ventilation, and other services aimed at ensuring patients progress in their recovery and do not experience health complications.
AGACNPs who work in Step Down Units manage patients’ transition from the ICU to the SDU, continually assess the health of medically vulnerable patients, administer treatments as necessary, guide other staff in the care of patients, and coordinate patients’ admission and discharge from the SDU when they have recovered sufficiently.
Hospital Wards are another tier of care below the Step Down Unit, and are where convalescing patients stay before they transition to outpatient care or home. AGACNPs can work in these settings to monitor patients and provide lower-level treatments and primary care services.
Urgent Care Clinics
Urgent care clinics are not based in hospital settings, but are stand-alone clinics staffed with medical personnel who are trained to address acute illnesses and injuries that require immediate treatment, but which are not life threatening or critical, and thus do not require a trip to the ER. The medical team at an urgent care clinic is often comprised of physicians, nurse practitioners, physician assistants, and registered nurses. Conditions treated range from the common cold to the flu, bodily aches and pains, fractures and other sports injuries, strep throat, gynecological and urinary conditions, and laceration repairs. Urgent care staff are also trained to evaluate the severity of a patient’s condition, and to ascertain whether he or she should go to the ER or an ICU.
Primary Care, Palliative Care, and Long-term Care Settings
While adult-gerontology acute care nurse practitioners work mainly in critical care settings such as the ones described previously, they can also work in primary care, long-term care, and/or palliative care settings, depending on their interests and previous work experience. The nature of the patient-provider relationship is quite different between acute and primary medical care; according to the National Organization of Nurse Practitioner Faculties, the role of the Acute Care Nurse Practitioner is a restorative one, aimed at helping patients heal after a severe injury, illness, or exacerbation of an existing condition, whereas the role of the Primary Care Nurse Practitioner is more focused on the lifelong maintenance of health through a long-term relationship and the continuous management of chronic conditions.
Despite these differences, however, the core concepts and many of the fundamental methods of effective nursing care, such as the advanced health assessment, patient consultations, labwork, and treatment of ailments, are the same between both acute and primary care nursing. Oftentimes, acute care nurse practitioners and primary care nurse practitioners treat the same conditions, but at different stages in these conditions’ progression (for example, while an acute care nurse practitioner may treat a patient during a severe asthma attack, a primary care nurse practitioner would help this patient manage his or her condition on a daily basis). These overlaps between acute care and primary care nursing can help acute care nurse practitioners transition to primary care settings if they wish. AGACNPs in primary, long term, and palliative care environments can use their knowledge of critical and terminal illnesses to develop and implement a sound health care plan for their patients, and to understand and meet their needs.
Mary Thiel, MSN, ACNP-BC is an Adult Nurse Practitioner at Premier Health, where she provides primary health care services to patients ages 14 and older. Though she is board certified in adult acute care, she has worked in palliative care, long-term care, and primary care settings for over 10 years since receiving her nurse practitioner certification. In an interview with OnlineFNPPrograms.com, she explained the nature of her work as an Adult Nurse Practitioner for Premier Health Partners. “I function as a primary care provider [at Premier Health Partners],” she said, “The practice only does outpatient, and the physicians have long-term care (LTC) practices. I cover the LTC practice patients when the physicians are on vacation, but do not have any of my own. […] I see essentially anything that walks through the door, such as the usual hypertension, diabetes, heart failure, and arthritis. I also see hepatitis C, breast cancer, substance abuse, and skin diseases of every sort.” Ms. Thiel also noted how her current work in primary care is quite similar to her past work with patients in geriatric and long-term care settings when she worked as a Geriatric Nurse Practitioner for Geriatric Providers, Inc. and as a Nurse Practitioner for UnitedHealth Group, specifically in their EverCare and Optum programs.
“The nearly 9 years that I worked for Geriatric Providers and Evercare/Optum were all spent in long-term care. […] In practice, the medicine is not different, other than sometimes in its application. Medicine in LTC is more nuanced. Does a 90 year old need to take a statin for hyperlipidemia? Does she need Aricept any longer? There was more risk/benefit analysis to what meds were prescribed, and which should be stopped. There was a lot of end of life planning, especially with Evercare/Optum,” she explained, “The medicine is the same between the settings. The circumstances are different, and the special situations are more variable in LTC. I still treat basic depression and anxiety in adult medicine, but refer out people who need more extensive help or those whom I feel would benefit from counseling.”
What Adult-Gerontology Acute Care Nurse Practitioners Do
Adult-gerontology acute care nurse practitioners’ primary mission is to stabilize patients who are suffering from critical conditions, and to ensure they have the medical support to make as full a recovery as possible. Their core responsibilities can generally be divided into the following categories:
- Direct medical services, such as health assessments, treatments, and procedures to address patients’ critical conditions in collaboration with a larger medical staff of physicians, nurses, and medical assistants.
- Care coordination services, which include organizing the services of other health care providers and medical departments to ensure patients receive appropriate care during their tenure in an intensive care setting.
- Administrative leadership in the hospital setting, which entails working to improve systems of care through program development, trainings, and evaluation of workflows within their hospital.
Below is a more detailed description of the typical responsibilities that adult gerontology acute care nurse practitioners fulfill.
Direct Medical Care
Adult gerontology acute care nurse practitioners complete a wide range of advanced medical tasks, including conducting intake assessments, ordering labs and screenings, performing complex medical procedures, administering (and in certain states, prescribing) medications, and monitoring patients during their stay in the hospital. Their workday is typically quite varied and dynamic, as patients’ complex conditions and health needs often mean AGACNPs must constantly monitor and provide treatments as part of a multidisciplinary team.
In her interview with OnlineFNPPrograms.com, Ms. Edwards described the myriad responsibilities she completes on a daily basis at the Palo Alto VA Hospital. “I manage the day to day needs of all of the patients, including daily progress notes. I perform a comprehensive H&P (medical history and physical assessment) on all new consults and/or admissions, develop differential diagnoses, order labs, diagnostics, therapy and imaging, and consult other services. I respond to codes and e-teams (rapid response teams, or RRTs), determine the diagnosis, and make decisions on the appropriate level of care after resuscitation,” she said.
Mr. Kenna described the importance of the initial and continual assessment of patients upon their admission into a critical care setting. “As a member of the neurosurgical team, we would be responsible for the initial evaluation of the patient’s primary neurologic problem and determine if they needed immediate neurosurgical intervention; if they did, we would provide that,” he said of his time working as an Acute Care Nurse Practitioner at Beth Israel Deaconess Medical Center Division of Neurosurgery. Thorough health assessments are important because they help to ensure that patients are efficiently directed to the care they need. “If [patients did not need immediate intervention], then we would determine the most appropriate setting for them depending on their needs, whether that would be the Intensive Care Unit (ICU), the Step Down Unit, general neurosurgical floor or even home based upon how closely they needed to be monitored,” Mr. Kenna added.
AGACNPs also play an important role in the administration of intensive treatments and/or the completion of complex medical procedures, often in collaboration with a physician. “We would also assist in the Operating Room and follow-up with patients in clinic. For many of these patients, they require very close neurologic monitoring and that’s where the Neuro ICU team comes into play. This team is dedicated to the ICU and although very focused on the patient’s neurological needs they also take into account all other body systems (ie, respiratory, cardiac, GI, renal etc.),” Mr. Kenna said of his position at Beth Israel Deaconess. His present work as an Acute Care Nurse Practitioner in the Neurological Intensive Care Unit at Rhode Island Hospital is no less varied. “My [current] responsibilities involve rounding on the patients in the ICU and evaluating their condition in order to develop a plan of care for that day,” he said, “We order a variety of tests including blood tests, XRAYs, CT scans, and ultrasounds to name a few,” he said, “We also perform a number of procedures including endotracheal intubations, central line placement, chest tube placement, bedside ultrasound and lumbar punctures.”
Dr. Tomaszewski also described in her interview the many procedures she completes, treatments she administers, and palliative care and support she provides patients in collaboration with her colleagues. “As a nurse practitioner on the critical care medicine service, I see critically ill patients in the intensive care unit with a variety of different medical conditions. All of these patients require detailed assessments, complex medical decision-making and life-saving procedures,” she said. “At times, these patients also require compassionate care at the end of life. Some of the conditions I treat include diabetes, respiratory failure, accelerated hypertension, stroke, cardiac arrest, and septic shock. […] Some of the procedures that I may do on a daily basis include endotracheal intubation, central venous catheter placement, arterial catheter placement, temporary hemodialysis access placement, and therapeutic bronchoscopy. I may also be assisting residents and students in learning these same procedures.”
While direct patient care is an integral part of the work that AGACNPs do, equally important is their role as a coordinator of patient care and a leader of staff. Care coordination in acute medicine is defined as the creation and ongoing management of an effective plan of care for patients, from their admission into the hospital to their discharge to outpatient care or their home. Care coordination involves conducting thorough health assessments, meeting with a larger medical team in order to discuss and develop a plan of care, and directing nursing staff, medical assistants, and residents in the completion of tasks around the hospital and the provision of care to patients. Care coordination also involves evaluating patients’ mental, emotional, social, familial, and financial situations and working to connect them with resources such as social services, health insurance, and hospital-based religious support as needed.
Ms. Zilske also described how her work involves balancing patient admissions and discharges with addressing patients’ health issues as they come up during her shifts at Memorial Hermann Hospital. “I am able to manage every patient from admission through discharge; however, since I work the majority of my shifts on nights, I usually initiate their plan of care and trouble shoot other patients’ issues overnight,” she said, “Other roles that I fill are the liaison between the nursing staff and the physicians, an educator, and a patient advocate.”
John Kenna, MSN, ACNP-BC also described his role as a co-coordinator of care as part of a larger team in the Neurological Intensive Care Unit at Rhode Island Hospital. “Members of the team typically include a Neurointensivist, Nurse Practitioner or Physician Assistant, Registered Nurse, Pharmacist, and Nutritionist. Other members may include a Neuro ICU Fellow, Neurology, Neurosurgical, Anesthesia Residents, Pharmacy Resident and students of all backgrounds,” he explained, “We develop a plan as a team of experts, to best meet the needs of our patients and provide them with the best chance to recover from neurologic injury.”
Administrative Leadership, Education, and Program Development
In addition to their responsibilities as coordinators and direct deliverers of care, adult gerontology nurse practitioners can also improve the delivery of advanced practice nursing care through updating or streamlining hospital systems of care, developing programs serving both patients and staff, and educating nursing students, medical students, and residents in clinical and academic settings.
Administrative leadership in the hospital setting can be thought of as a more macro-level version of care coordination, in that its primary goal is to ensure that patients receive effective care when they need it. However, while care coordination is still very much close to the patient in that it involves creating individualized care plans, administrative leadership roles that nurse practitioners can take on in the hospital setting seek to make direct medical services and care coordination services easier and more effective on a larger scale, and over the long-term.
Projects and tasks that fall under the term administrative leadership include conducting surveys and other data collection methods in order to determine how well the hospital is serving its patients, making data-informed decisions about the restructuring of certain departments or teams, the purchasing of updated equipment, and the hiring of additional staff; and creating outreach or training programs that meet the needs of patients and staff, respectively. AGACNPs who are interested in administrative leadership can ask their supervisor for opportunities within their work setting. Designated roles in administrative leadership for nurse practitioners can take many forms; examples include Clinical Practice Manager and Education Outreach roles, which some NPs take on to supplement their clinical responsibilities.
In addition to educating staff and facilitating the improvement of systems of care within their clinical work setting, AGACNPs can also improve the quality of future nursing care by educating nursing students as faculty members of nursing school programs. Mr. Kenna worked as an Assistant Clinical Professor for the University of Rhode Island’s College of Nursing, where he also helped to develop the Acute Care Nurse Practitioner Track in September of 2010 and continues to work closely with the school on the content for their ACNP track. Prior to this role, he worked as the Acute Care Nurse Practitioner Program Coordinator for the Northeastern University Bouvé College of Health Sciences for almost three years.
In his interview with OnlineFNPPrograms.com, he explained how he views part-time faculty instruction of future ACNPs as a way to give back to the nursing community and to help train effective health care providers for the next generation. “I have always enjoyed teaching,” he said, “As nurses we are very trusted and I think still one of the most trusted professions in the US, if not the world. In order to be trusted, you have to know what you’re talking about. I always had fantastic professors and mentors and wanted to share what I learned with others. When offered the opportunity to coordinate the Northeastern ACNP program after graduation I thought it was a chance to do that.”
The Rewards and Challenges of Advanced Adult-Gerontology Acute Care Nursing
Advanced adult-gerontology acute care nursing can be a very rewarding field of work for individuals who enjoy challenging, fast-paced medical environments and forming strong relationships with patients and family members in great need of medical care and support.
“I think the most rewarding part of working as an ACNP in neurocritical care is the relationships with patients and their families,” Mr. Kenna told OnlineFNPPrograms.com, “Often times neurologic injury is abrupt and sudden and life altering for the patient and their families. We spend a lot of time meeting with patients and families communicating and explaining their diagnosis, plan of care and prognosis. Recovery from neurologic injury is often a very long road and presents a major challenge for patients and families. As providers in the ICU we are a pivotal, but also a very small part of patients’ long road, which may include weeks to months in the ICU or in the hospital and then weeks to months in rehabilitation.” Ms. Thiel similarly cited the bonds she makes with patients and their families, and her ability to guide them through the process of making important medical decisions, to be the most rewarding aspect of her work. “ I think my most rewarding work has been with the families of the terminally ill. Talking with them, listening to them, helping them make the difficult decisions is so powerful,” she said.
The role that AGACNPs play in connecting, supervising, and collaborating with the different groups that comprise a care team–including physicians, registered nurses, and medical assistants–can also be a challenging and rewarding part of the job. “I feel that the most rewarding aspect of working as a nurse practitioner is making a seamless union between nursing and medicine,” Dr. Tomaszewski said in her interview with OnlineFNPPrograms.com, “Nurses can bring different perspectives to medicine, and vice versa. I have learned a lot from my physicians, and hope that they have also learned from me.” As coordinators of care and oftentimes the liaison between physicians and nurses, nurse practitioners often must combine their medical knowledge and clinical skills with emotional intelligence and a sound knowledge of how the different departments and teams within a medical setting work together to optimize patient outcomes; such complex and multidisciplinary responsibilities can offer an intellectual challenge that some people may find engaging and gratifying.
Passing on their knowledge to other medical staff can also be a rewarding aspect of nurse practitioners’ role as an educator and leader in the medical environment. “Another [reward of my job] is teaching someone a topic and seeing the lightbulb go on; and to that fact, having the time to actually teach! As an RN, you do not have time to sit and teach your patients as much as you want to. But as an NP, you have more time to go over conditions, medications, and questions with nurses, patients, students, etc.,” Ms. Zilske said in her interview.
Seeing their patients make concrete improvements in their health through the efforts of a committed care team is also a reward that AGACNPs enjoy on a daily basis. Kimberly Zilske, MSN, ACNP-BC told OnlineFNPPrograms.com, “One of the most rewarding aspects of being an Acute Care Nurse Practitioner is seeing your plan of care work to improve the patient’s condition.” Mr. Kenna also noted that helping patients heal from life-threatening conditions is incredibly gratifying, and has sustained him throughout his years as an acute care nurse practitioner. “[One] of the most rewarding parts of the job is seeing a patient who had a small chance of a meaningful recovery come back and visit the staff. It reinforces that although we see a lot of devastating injuries in a very mentally and emotionally challenging work environment, that there is hope and we need to do our best to provide the best care possible to give them the best chance to recover,” he said.
With the rewards of the profession also come challenges in the form of emotional pain when a patient does not recover as hoped, feelings of overwork or burnout, and the challenges around making the transition from following orders to creating them in a fast-paced and high-acuity environment. “Albeit years ago, I think that one of the biggest challenges I faced was the transition between nurse and nurse practitioner,” Dr. Tomaszewski said to OnlineFNPPrograms.com, “One goes from being the expert nurse and the resource on the unit, to the sudden realization that you are responsible for medical decisions that could alter someone’s life. As nurses we carry out orders, but as nurse practitioners we are creating the plan of care. I think that many students underestimate the impact that this transition makes.”
With the additional responsibility of being a provider who creates plans of care and gives orders rather than follows them comes additional stress when a patient does not recover or experiences a worsening of his or her condition. “Most patients’ lengths of stay vary in the ICU. Depending on their diagnosis, they may stay anywhere from two to five days. There are others, however, who are very sick that we have had for weeks on end. Working twelve hour shifts, thirteen shifts a month with a patient that has been with us for 4-6 weeks, allows one to get attached at times, which can be difficult, especially when the patient takes a turn for the worse,” Ms. Zilske told OnlineFNPPrograms.com.
Mr. Kenna described the unpredictable nature of acute nursing care, and how the lack of certainty can pose stressors to patients, families, and medical personnel alike. “Some patients are able to make remarkable recoveries and others are not. Prognosticating who will do well and who will not is very challenging and something we are not very good at as a whole in Neurocritical Care,” he noted. Mr. Kenna advised that AGACNPs manage this stress by staying attuned to the needs, desires, and concerns of patients and their families, and to maintain a degree of separation between work and their personal life. “My recommendation for preparing and managing [this challenge] is to always listen, never be too sure of what the future holds and take care of yourself,” he said, “Always listen to your patients and their families. Never be over confident and sure of the outcome, patients will amaze you all the time. Take care of yourself, your family and live life, because you never know what may happen.”
Advice for Registered Nurses Interested in Becoming AGACNPs
Registered nurses who are interested in becoming adult-gerontology acute care nurse practitioners must complete a graduate nursing program that has been accredited by the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission on Education in Nursing (ACEN). They must also complete at least 500 hours of clinical practicum in a medical setting that gives them the chance to work with critically ill or injured adults.
In addition to meeting these minimum requirements, prospective AGACNPs should proactively seek opportunities to gain additional experience and insight into adult acute care nursing through volunteer work, shadowing, and talking with AGACNPs in their current workplace. “I think the first thing one should consider is what type of environment and population do they hope to work in when they graduate. That will help guide their decision as to which track of NP focus they would like to pursue. Also I highly recommend shadowing providers in different settings and taking advantage of your clinical rotations in grad school. This is your chance to explore different areas in health care and get a feel for what you think you may like to explore further,” Mr. Kenna advised.
Dr. Tomaszewski recommended that registered nurses spend at least several years preparing for the acute care work setting prior to their graduate nursing program, in order to fully understand the kind of work they will be expected to do as nurse practitioners. “I always recommend that students interested in becoming adult gerontology acute-care nurse practitioners have several years of critical care experience. Although not every acute-care nurse practitioner goes into critical care medicine, the complexity of the care and exposure to various conditions that nurses providing care in the ICU have experienced creates the best basis for their advanced practice,” she said, “I also recommend that nurses have at least 3 to 5 years of nursing experience before venturing into advanced practice. Nurses require at least two years to become fully confident after graduation from their initial program, and mastery is required in the advance practice role.”
Ms. Edwards advised prospective AGACNPs to network, have a concrete plan for after they graduate from their program, and to seek additional certifications and experiences that will distinguish them from other candidates after they earn their graduate degree. “I would say that anyone contemplating a career as an adult-gerontology acute care nurse practitioner must go into the program with a plan upon completion,” she said, “Networking is key to landing the best job opportunities that you know nothing about. Also, become a member of the American Association of Nurse Practitioners. They have a job database that is updated weekly. I also suggest NPjobs.com,” she said, “I would also recommend to become certified (i.e. CCRN for critical care) if your career goals are going to keep you within the same specialty as an adult-gerontology acute care nurse practitioner.”
In her interview with OnlineFNPPrograms.com, Mary Thiel advised prospective AGACNPs to try to complete their clinical practicums in several different settings in order to build a strong and broad set of skills and experience that optimizes job flexibility. “[Y]ou should try for as much variety as possible in your clinical experiences. I tailored my clinical experiences to match my expected job, and when it failed to materialize, I found myself with limited skills,” she said, “Do clinicals that are as varied as you can find. If they really like you, you may find a job through this rotation. But it helps round out your skills and level of comfort.”
A strong level of commitment and excellent time management skills are also important when preparing to become an AGACNP. “As far as advice for those wanting to obtain their AGANCP, and how to prepare, the most important words of advice are organization and drive. To get through any program these days, you have to be organized,” Ms. Zilske advised in her interview with OnlineFNPPrograms.com, “My program was 17 months long, online with multiple classes having assignments due throughout the week. I color coordinated my classes so I knew when assignments were due on which days. You also need to be driven. You have to want this degree; and nothing can stop you. I was ready for a change from my RN position in the ER. Nothing, I mean nothing was going to stop me; I was driven. I worked 16 hour ED shifts, slept for four hours, got up and went back to work. On my off days, went to my clinical rotation. But seventeen months later, it was all worth it.”
Once they have earned their certification and begin working as health care providers, AGACNPs should take care to avoid burnout by developing a strong support network of friends, family members, and colleagues. Nurse practitioners in adult-gerontology acute care nursing can craft impactful careers that allow them to improve, not only the health of their patients, but also the overall health care system for adults across the lifespan. AGACNPs also have the opportunity to train and serve as mentors for the next generation of nurses and nurse practitioners in this field. “Becoming an Acute Care Nurse Practitioner was the best decision I have ever made,” Ms. Zilske said, “I never feel as though I am going to work, because you are not working if you love what you do.”
- “Adult-Gerontology Acute Care Nurse Practitioner Competencies,” aacn.nche.edu, The American Association of Colleges of Nursing, February 2012, http://www.aacn.nche.edu/geriatric-nursing/Adult-Gero-ACNP-Competencies.pdf
- “Statement on Acute Care and Primary Care Nurse Practitioner Practice,” c.ymcdn.com, The National Organization of Nurse Practitioner Faculties, September 2011, http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/imported/NPPrimaryCareAcuteCarePracticeFINAL.pdf
- “Progressive Care FACT SHEET,” aacn.org, American Association of Critical Care Nurses, http://www.aacn.org/wd/practice/content/progressivecarefactsheet.pcms?menu=practice