I think that one of the biggest challenges I faced was the transition between nurse and nurse practitioner. 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.
About Dr. Elizabeth Wirth-Tomaszewski: Dr. Elizabeth Wirth-Tomaszewski is currently the track Director for the Adult Gerontology Acute Care nurse practitioner program at Drexel University, where she is also an assistant clinical professor. She also continues to practice clinically with the Critical Care Medicine service at Geisinger Wyoming Valley Medical Center in Wilkes Barre, Pennsylvania, seeing patients in the Intensive Care Unit. She previously worked with the Pulmonary-Critical Care Medicine service at Lehigh Valley Hospital in Allentown, Pennsylvania, as a nocturnist. She is licensed with prescriptive authority in multiple states due to her teaching responsibilities.
Dr. Tomaszewski began her nursing career with an associate’s degree in nursing from a community college immediately after graduating high school. She worked in critical care, emergency room and trauma unit settings. She returned for her bachelor’s degree, and with every intention of continuing on for a masters in nursing for nurse practitioner. She chose the acute-care track because it matched her goals of continuing work in the ICU as an advanced practice nurse. After a few years with her master’s degree, she continued on for a doctorate of nursing practice degree, enabling her to teach, as well as to continue working with the critically ill in her clinical position. Dr. Tomaszewski’s doctoral focus centered on end-of-life education for critical care nurses and palliative care in the ICU.
Dr. Tomaszewski is currently a member of the American Association of Critical Care Nurses, Society of Critical Care Medicine, and the National Organization for Nurse Practitioner Faculty. She has presented nationally on topics such as end-of-life care and methods on breaking difficult news to patients and families. Dr. Tomaszewski is board certified in acute care as ACNP-BC through the American Nurses’ Credentialing Center, and ACNPC through the American Association of Critical Care Nurses.
[OnlineFNPPrograms.com] Could you please describe your role and responsibilities as a Nurse Practitioner for Geisinger Health System? What kinds of medical conditions and challenges do your patients face, and how do you help them manage their conditions?
[Dr. Elizabeth Tomaszewski] 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. 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. I also see patients on surgical services who have medical conditions that require complex management with a collaborative team of services. 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.
In our critical care medicine practice, nurse practitioners and physician assistants are collectively referred to as advanced practitioners. We work together seamlessly to provide life-saving care. We care for the patients for the period of time that they are in the intensive care unit, and at times continue to follow while they are on the medical-surgical floor or step down unit. We also take care to ensure proper follow up as outpatients once patients are discharged. The advanced practitioners are provided the opportunity to practice with a high level of responsibility in terms of patient management and procedures, while collaborating with experienced physicians daily. We enjoy a high-level of collegiality in the group, inclusive of the advanced practitioners and the physicians.
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.
[OnlineFNPPrograms.com] You were also a Certified Registered Nurse Practitioner in Pulmonary Critical Care for Lehigh Valley Health Network. Could you please elaborate on this role, your daily and long-term responsibilities, and how your team, tasks, and work setting differed from those of your other position at Geisinger Health System?
[Dr. Elizabeth Tomaszewski] In this particular role, I was a nocturnist on the pulmonary critical care medicine service. I exclusively worked 12 hour night shifts to cover for admissions, consults, and crisis mitigation, such as “code blues.” This position differed from my current position, in that the responsibilities mainly focused on continuing the established plan of care, as opposed to creating the plan of care. I had a desire to learn more about the conditions I was treating and the rationales behind the plans of care. Rounding in the ICU with the multidisciplinary team provides more education and current evidence-based practice, which help guides the plan of care for each patient.
[OnlineFNPPrograms.com] You are also the Track Director for the Adult-Gerontology Acute Care Nurse Practitioner Program and an Assistant Clinical Professor at Drexel University’s College of Nursing and Health Professions. Could you explain the types of courses that comprise the Adult Gerontology Acute Care Nurse Practitioner Program, and what courses you teach as a Professor? What key knowledge and skills do AGACNPs need to have in order to take care of their patients?
[Dr. Elizabeth Tomaszewski] The Adult Gerontology Acute Care Nurse Practitioner Program at Drexel University provides practicing nurses who hold a bachelor’s degree with the education needed to sit for the board certification for adult gerontology acute-care nurse practitioners. The courses include advanced pathophysiology, advanced pharmacology, advanced assessment and diagnostic reasoning, and clinical medicine. The program lasts approximately three years for most students. I teach the clinical medicine courses which include medicine, surgery, and critical care; as well as the advanced pharmacology course for acute-care nurse practitioners. Adult gerontology acute-care nurse practitioners must have a working knowledge of pathophysiology, pharmacology, and clinical medicine in order to care for their patients. Acute care nurse practitioners are different from other nurse practitioners in that we care only for patients who are acutely ill or injured, or have an acute exacerbation of their chronic illness. Acute-care nurse practitioners are not formally educated in the chronic management of diseases, as the family nurse practitioners or primary care nurse practitioners are. The acute care nurse practitioners are generally found in the hospitals and on specialty services that commonly take care of patients with acute illnesses.
[OnlineFNPPrograms.com] Why did you decide to become an adult-gerontology acute care nurse practitioner, and what professional experiences helped you determine that this area of advanced practice nursing was the right one for you?
[Dr. Elizabeth Tomaszewski] I spent nearly a decade as a nurse in the level one trauma unit at Cooper University Hospital in Camden New Jersey. I learned a great deal from the experienced nurses who were there long before I was, and I soon found myself as being one of those experienced nurses training others. Trauma is a unique specialty in that the nurses who care for these patients see and treat unspeakable injuries and devastation every day, that most common individuals would never see in a lifetime. There seems to be a certain personality type of a nurse that is drawn to this specialty. As an advanced practice nurse, I wanted to continue taking care of critically ill and injured adults. That being said, after 10 years of treating injured children, I wanted to treat exclusively adults. I refer to this as self-preservation. I give an enormous amount of credit to those who continue to care for critically ill children.
[OnlineFNPPrograms.com] What have been some of the most rewarding aspects of working as an adult-gerontology nurse practitioner thus far? On the other hand, what specific challenges have you encountered in this field of work, and how have you managed these challenges?
[Dr. Elizabeth Tomaszewski] I feel that the most rewarding aspect of working as a nurse practitioner is making a seamless union between nursing and medicine. 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.
Albeit years ago, I think that one of the biggest challenges I faced was the transition between nurse and nurse practitioner. 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. My goal is that my students will begin this transition in their final year of graduate school so that there is support available from the professors to acclimate to their new position. Mentorship with an experienced NP, as well as with previous students, is an important aspect of easing this transition. I ask my former students to return to assist those just starting their clinical year to provide advice and suggestions. All students seem to move through feelings of being confident, then overwhelmed, by their educational undertaking.
[OnlineFNPPrograms.com] For current and prospective MSN students who are interested in becoming adult-gerontology acute care nurse practitioners, what advice can you give them about optimally preparing for this field while pursuing their degree?
[Dr. Elizabeth Tomaszewski] 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. 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. I also ensure that my students are aware that the demands of graduate school are very pervasive, regardless of the track that he or she chooses. A student should expect to spend a great deal of time reading and researching, as well as in clinical rotations.
The education of AGACNP students focuses on didactic content, skills acquisition, and clinicals. The classroom teaching involves several disease states and conditions. Hands-on practice with skills such as central line placement and endotracheal intubation prepares students for the experiences they will have on patients. Clinical placements include medical, surgical and critical care as these are settings where AGACNPs are commonly found. I typically suggest students find clinical rotations in settings outside their comfort zone as nurses, so they can become familiar with different settings prior to graduating.
[OnlineFNPPrograms.com] What is the difference between adult-gerontology acute care and adult-gerontology primary care, in terms of the work settings, the types of patient conditions treated, and the certifications necessary to work in either field? How much does a nurse practitioner’s specialization dictate his or her work setting?
[Dr. Elizabeth Tomaszewski] The difference between acute care and primary care nurse practitioners in adult gerontology focuses on the patient population that we treat. Acute care nurse practitioners treat patients who are suffering an acute illness or injury, or an exacerbation of a chronic illness. Primary care nurse practitioners focus on prevention and chronic management of disease states. According to the consensus model, nurse practitioners should only practice in the setting for which they were formally educated. Currently many nurse practitioners are practicing out of scope, such as family nurse practitioners in critical care. One reason for this situation stems from the lack of acute-care nurse practitioner programs several years ago. For instance, an ICU nurse may have attended a family nurse practitioner program, to return to work in critical care medicine based on nursing experience. As another example, my current group also cares for pulmonology patients. While I can see the patients with acute pulmonary conditions in the hospital, I am not able to see the patients being chronically managed in the clinic because my formal education is in acute care.
Today we know that there are many gaps in education between the specialties that need to be filled in order for one type of nurse practitioner to practice in a setting outside of his or her scope. The nurse practitioners board certification should dictate the setting that he or she works in. There are programs that help to fill the gaps in the formal education, such as postmaster certificates. Some universities will give credit for faculty supervised hours as long as they meet the criteria for their respective program.
Thank you Dr. Tomaszewski for participating in our APRN career guide interview series!