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. Another 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.
About Kimberly Zilske, MSN, ACNP-BC: Kimberly Zilske is an Acute Care Nurse Practitioner who has over 20 years of experience in critical care nursing. She currently works as an Acute Care Nurse Practitioner in Pulmonary Critical Care at Memorial Hermann Health System, where she cares for patients in the ICU. Prior to her role at Memorial Hermann Health System, Ms. Zilske was a Pulmonary Critical Care Nurse Practitioner at The University of Texas Health Science Center at Houston, where she managed critically ill patients in the Transplant ICU and in the Heart and Vascular Institute Hospital. Before this position, Ms. Zilske was an Acute Care Nurse Practitioner at Lakeland Hospital and an Acute Care Nurse Practitioner in Cardiology at Memorial Advanced Cardiovascular Institute.
Ms. Zilske earned her Bachelor of Science in Nursing, her Bachelor of Arts in Liberal Studies, and a Minor in Biology from Bethel College in 1995. After receiving her BSN, she worked as an Emergency Room Staff Nurse for Elkhart General Hospital and as the Deputy Coroner for Elkhart County. She earned her Master of Science in Nursing with a concentration in Critical Care Nursing and Acute Care from The University of Tennessee Health Science Center in 2007. While completing her MSN, Ms. Zilske also received training as a Sexual Assault Nurse Practitioner for the Fort Wayne Sexual Assault Program in Indiana.
[OnlineFNPPrograms.com] Could we please have an overview of your professional and academic path in acute care nursing?
[Kimberly Zilske, MSN, ACNP-BC] I graduated in 1995 from Bethel College in Mishawaka, Indiana, with my Bachelor of Science in Nursing, Bachelor of Arts in Liberal Studies, and a Minor in Biology. I went on to practice initially in the Pediatric ICU which allowed me to gain experience in other areas such as NICU, Mother/Baby, as well as Adult ICU because back then, if you had ICU behind your name, you surely could work in any ICU! I later transitioned to the Recovery Room and worked my way up into management; learning both pre and post-op.
In 2002, after having my daughter, I knew that management was not where I needed to be and transferred to Elkhart General Hospital into the Emergency Room. Going back to the bedside, doing something different was exactly what I needed. I was able to see a whole new population of people that I had never seen before as a nurse working inside the hospital. Now I was on the frontlines! During this time, my eyes were truly opened. I was able to see how incredibly broken our healthcare system is. How the ER is misutilized, and yet how there are patients that have no choice but to come there for their healthcare. It was also during this time that I was able to obtain a position as a Deputy Coroner in Elkhart County. I was the only woman as well as the only Registered Nurse. All of the other Deputies were EMS personnel. This was an extremely enlightening position. I was able to take a great deal from this position as one would be surprised how much you can learn from someone who has died. A story is told at every scene, in every home, and at every autopsy. By that time, I had been practicing for twelve years, I had reached a time in my life that I realized that I needed to challenge myself by going back to school.
I attended the University of Tennessee Health Science Center in Memphis, Tennessee. I graduated in 2007 with my Master’s of Science in Nursing in Acute Care. I have my ACNP certification, not an Adult Gerontology Acute Care Nurse Practitioner (AGACNP) certification. The AGACNP credential began after 2007. I have been “grandfathered” in with my MSN. My Master’s program did not have as much focus on the Gerontologic Phase, thus no “G” in my title. It was with great pride that I completed this degree. I started immediately as the first Nurse Practitioner (NP), Hospitalist for Lakeland Hospital. I worked with just over twenty physicians, some more happy than others to work with an NP. As a Hospitalist, I was able to build my skills in Internal Medicine. By 2012, we had hired six NPs. Also, in 2012, I relocated after being hired by the University of Texas Health Science Center in Houston. I have worked in Pulmonary Critical Care in the Transplant ICU, in the Heart and Vascular Institute and now in Medical/Surgical ICU.
[OnlineFNPPrograms.com] Could you please describe your role and responsibilities as an Acute Care Nurse Practitioner at Memorial Hermann Health System? What kinds of medical conditions and challenges do your patients face, and how do you help them manage their conditions?
[Kimberly Zilske, MSN, ACNP-BC] My role and responsibilities at Memorial Hermann is that of a Pulmonary Critical Care Nurse Practitioner. 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. Some of the challenges that I face are the personal or religious beliefs that the patient may hold that limit my ability to treat the patient. For example, the patient has a gastro-intestinal bleed and is losing blood and needs a blood transfusion; however, they have a religious belief and do not believe in receiving blood products. This challenges my ability to treat the patient’s health issue; however, we are here to respect and support our patients throughout their stay. Another example is when a patient is critically ill and requires a breathing tube and can no longer tell us their wishes. We have had difficulty with various family members disagreeing on what the patient may want as their plan of care and advance directive. This makes it difficult to advocate for the patient without getting caught in the middle of family dynamics. It is important to remember to give good, quality information to the family so they can make informed decisions.
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. 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.
The multi-disciplinary team that I work with at Memorial Hermann consists of the Intensivist, RN for the patient, Charge RN for the ICU, Social Worker, Infectious Disease Physician, Palliative Care Physician, Pharmacy Department, Physical Therapist, Dietician, and Respiratory Therapist.
My relationship with my patients is truly episodic. I only get to see and know them during their time in the ICU. Once they are well enough to be transferred from the ICU to the floor, we no longer cover them or write orders for them. Their care is turned over to their primary care physician or the Hospitalist. Other roles that I fill are the liaison between the nursing staff and the physicians, an educator, and a patient advocate.
Lastly, I’d like to add that I am the first Nurse Practitioner that Memorial Hermann has hired as an employee. Having an NP is a new concept for the physicians, the nurses, and the hospital to experience. I am very excited to be the first in pioneering this role and look forward to promoting the relationships between nurse practitioners and the healthcare team.
[OnlineFNPPrograms.com] You are also a Pulmonary Critical Care Nurse Practitioner at The University of Texas Health Science Center at Houston (UTHealth). Could you please elaborate on this role, your daily and long-term responsibilities, and how your team, tasks, and work setting differ from those at your other position at Memorial Hermann Health System?
[Kimberly Zilske, MSN, ACNP-BC] My role at UT is the same as we provide care for Memorial Hermann Hospital at The Medical Center, whereas in my other role I am employed by Memorial Hermann at a smaller campus. I am providing care for two different Memorial Hermann Campuses, one is a level 1 Trauma Center, while the other is a smaller campus in an outlying suburb of Houston. For UT, I cover the Transplant ICU and the step down unit for transplant or the Heart and Vascular Institute as a Consultant.
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.
[OnlineFNPPrograms.com] Could you elaborate on your roles as an Acute Care Nurse Practitioner and Hospitalist at Lakeland Hospital and an Acute Care Nurse Practitioner in Cardiology at Memorial Advanced Cardiovascular Institute? How does advanced practice cardiovascular nursing care and general inpatient intensive care differs from pulmonary critical care?
[Kimberly Zilske, MSN, ACNP-BC] When working for Lakeland Hospital, I was a Hospitalist. I practiced Internal Medicine and was not able to use my full scope of practice. I would see multiple patients a day, complete admissions, write their notes, speak with my collaborating physician if I had questions, and do the discharges when ready. But because of the number of patients, the type of patients being cared for, and the time factor, I was never able to do any procedures. Even though I wasn’t working in the ICU during those first five years, I received the best training that I could ask for with regards to learning the basics of Internal Medicine. I had excellent physicians train me and I was able to see a variety of different conditions on a wide population. With this practice, I would treat COPD, Congestive Heart Failure, Pneumonia, Pancreatitis, Stroke, Myocardial Infarction, Electrolyte Imbalances, and many others.
During my short time with the Cardiology practice, I stayed as needed with Lakeland Hospital. I was hired to round on the inpatient population for the cardiology practice. I worked for two interventional cardiologists, two non-interventional cardiologists, and two electrophysiologists. There was also one other NP in the practice that worked in the office. I would round on patients that had congestive heart failure, a myocardial infarction, and/or heart arrhythmias; some of these patients also had issues with their blood pressure. After six months working for this group, rounding on this patient population, I realized that doing only cardiology was not what I enjoyed doing. I went back to Lakeland and walked back into my full time position.
[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? How did your work as a Deputy Coroner and your training as a Sexual Assault Nurse Practitioner impact your career path?
[Kimberly Zilske, MSN, ACNP-BC] I made my decision to further my education and obtain my MSN after practicing for twelve years, with three of those years in the emergency room. It appeared to me that it was time for a change. I was hitting a wall; the dreaded burnout. I was going into work and doing the tasks, going through the motions, but not enjoying what I was doing. I could feel that the old me, the one that lived to be a nurse and provide great care was slipping away. This was a time to shake things up. I was also seeing that the patients were not being listened to. The same order set was being put into the computer but the patient’s complaints were not being heard. I knew that if I had the opportunity to be a provider, I would listen more, order symptom specific tests, and maybe make a difference in my patients’ lives. So, this was my opportunity to make a change, to challenge myself, and rekindle my passion to provide care once again.
As far as my experiences as both a Deputy Coroner and my training as a Sexual Assault Nurse Examiner, they both gave me different perspectives from different patient populations. How patients and their families see and deal with a traumatic incident. I learned how to give bad news, how to speak to a patient that has just experienced a horrific event and obtain information and evidence from them during this time. These experiences helped me to grow personally and professionally as I entered graduate school.
[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?
[Kimberly Zilske, MSN, ACNP-BC] 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. Another 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.
On the other hand, some challenges that I have encountered as an ACNP have been a resistance from some physicians who feel I can not or “should not” be providing the care that I give in the ICU. It does not happen as often, especially at the larger teaching hospital, but at the smaller hospitals, it still occurs occasionally. When this happens, I realize that the issue is not with me; it is with that physician and their own discomfort. I never argue but smile politely and move on. Another issue that we all experience is losing a patient. There are times when no matter what is done, the patient is going to die. Regardless, this is difficult. No one wants to lose a patient. We are here to try and make them better, but sometimes, it just does not work so well.
In these times, I turn to my faith and pray for strength. I also pray for my patients and their families, that they may have the strength to make it through the difficult time.
[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? In your opinion, how helpful is it to specialize in a certain area of advanced practice nursing (such as women’s health, geriatrics, pulmonary care, or cardiology), versus practicing advanced nursing care more generally?
[Kimberly Zilske, MSN, ACNP-BC] 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. 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, I was an Acute Care Nurse Practitioner with a 3.5 GPA!
There are no particular classes you can take ahead of time to prepare. If you know you want to do acute care, then you need to ensure that you have at least one year minimum of ICU experience. I worked in various areas of ICU and had multiple years of experience and still felt unsure of myself throughout school. You have to think about your assessment skills, how confident are you in what you have heard, seen, and palpated. Are you now ready to use that to diagnose and treat? If you are not sure, then do not rush back to school.
When you are preparing for your board exam, everyone learns differently. Some will take a board review course and that is all they need. There are great classes with CDs that you can buy to listen to on top of the class. Some others will do that with book reviews too. I did both. I am a horrible test taker and needed to take practice tests to ensure that I knew what I knew! There are plenty of great books with practice tests. However, how the student best learns, is how he or she should prepare.
How helpful is it to specialize? Well, having never done anything but specialize, it’s difficult for me to say. I have never done Med/Surg in my life, I think that those nurses are extremely special. What they do is amazing, because I could not care for that population and do that kind of nursing. When it comes to being an Advanced Practice Nurse who can care for General Patients, I definitely think there is a need, but cannot speak to their board certification or what the difference is between them and a Family NP or a Woman’s NP. I am most familiar with NNP Neonatal NP, PNP, Pediatric NP, FNP Family NP, GNP Gerontolic NP, and of course the AGACNP.
The biggest question a nurse wanting to advance her degree needs to ask is what population do I want to serve? As an AGACNP, I can only see patients from 16 years old and up. All NPs have to work within their scope of practice. So working in an ED or urgent care center is not an option for me. A family nurse practitioner wanting to go into the ICU would be disappointed as, they too, would be out of their scope of practice. So, should one specialize or not, is a personal question. A specialty NP does seem to make more money according to the salary surveys.
[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?
[Kimberly Zilske, MSN, ACNP-BC] As I stated above, we all must work within our scope of practice. So, for AGACNPs, we can work in various settings as long as we are working within our scope of practice. We have been known to work in GI Clinics and perform endoscopies, we can work in Adult ERs, and because of our multiple skills, we can work in areas that allow us to perform procedures. We treat a variety of conditions from Influenza to Acute Respiratory Distress Syndrome. We also treat post-op surgical cases, we manage ventilated patients, septic patients requiring bedside dialysis, and those that are on multiple vasopressor drips. An Adult-Gerontology Primary Care NP would most likely be utilized in long term care facilities and offices. They are more familiar with the needs of the geriatric patient population and can use their expertise to assist that population in ensuring they are receiving the best acute and chronic care possible.
Becoming an Acute Care Nurse Practitioner was the best decision I have ever made. I never feel as though I am going to work, because you are not working if you love what you do. It has rekindled my passion as a nurse so now everyday I practice my passion.
Thank you Ms. Zilske for participating in our APRN career guide interview series!