After nearly 13 years of ICU and rapid response team experience, I wanted more out of my career. I wanted to make an impact on patient outcomes, and being at the bedside was not going to fulfill the void. [...] After much contemplating of my career path, I decided that becoming an adult-gerontology acute care nurse practitioner made more sense. I knew this would prepare me for a career as a critical care NP. The best career decision I have made.
About Michelle Edwards, MS, AGACNP-BC, CCRN: Michelle Edwards is a Critical Care Nurse Practitioner for the Palo Alto VA Hospital, where she provides physical assessments, diagnoses, and critical care services to ill veterans. Prior to this role, Ms. Edwards was a Neurocritical Care Nurse Practitioner at The Queen’s Medical Center in Honolulu, Hawaii, where she delivered intensive medical care to patients suffering from complex neurological disorders and patients who had recently undergone neurological surgery.
Ms. Edwards earned her BSN from St. Luke’s College of Nursing in 1998, and her Master of Science in Nursing from the University of California, San Francisco (UCSF) with a specialization in Adult-Gerontology Acute Care Nurse Practitioner in 2013. Before enrolling in graduate nursing school, she worked as an ICU Bedside Nurse at Alaska Regional Hospital, as a Travel Nurse in the Neuro ICU at UCSF Medical Center, as a Clinical Nurse IV in the MS-neurotrauma ICU for Stanford University Medical Center, a PACU Staff Nurse at San Francisco General Hospital Foundation, and as a Clinical Nurse II at Alameda County Medical Center, where she worked as part of the Trauma and Rapid Response Teams and ICU.
[OnlineFNPPrograms.com] Before we launch into the main questions, may we have a brief description of your educational and professional background?
[Michelle Edwards, MS, AGACNP-BC] I began my career as a critical care RN after obtaining my BSN at St. Luke’s College of Nursing in Kansas City, MO. For most of my career, I was a travel critical care RN taking assignments in Honolulu, Anchorage and prestigious medical centers such as John’s Hopkins, Duke, and Stanford Medical Centers. After nearly eight years of travel nursing, I took a staff critical care, trauma, and rapid response team RN position at Highland Hospital (Alameda County Medical Center) in Oakland and Stanford Medical Center. I obtained my CCRN and TNCC credentials and maintain Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), and Pediatric Advanced Life Support (PALS) certifications. My experience includes neurotrauma, neurocritical care, cardiothoracic surgery, coronary, and med-surgical critical care. I had been an ICU nurse for thirteen years when I decided to return to graduate school to obtain my MS degree from UCSF with a focus in Adult-Gerontology Acute Care Nurse Practitioner. Upon graduation, I accepted my first position as a Neuro Critical Care NP at The Queen’s Medical Center in Honolulu, HI. I provided and managed care to critically ill patients with complex neurological diseases and injuries. I then returned home to Oakland, accepting a position as a critical care NP at the VA Palo Alto Hospital for which I provide care to veterans suffering from complex critical illnesses.
[OnlineFNPPrograms.com] Could you please describe your role and responsibilities as an Adult Gerontology Acute Care Nurse Practitioner at Palo Alto VA Hospital? What kinds of medical conditions and challenges do your patients face, and how do you help manage their conditions?
[Michelle Edwards, MS, AGACNP-BC, CCRN] As a part of a multi-disciplinary team of interns, residents, fellows, NPs, and attending physicians, pharmacists, 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. We 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. We do not manage care of trauma or transplant.
Most of our veterans’ care is complicated by pre-existing PTSD and other psychological disorders, which makes it quite challenging to care for them. We often seek psychological consultation to assist with their care. 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. I am credentialed to place central lines, trialysis lines, pulmonary artery catheters, arterial lines, and oral intubations. When I work overnight, I oversee the service with the intern and make decisions appropriate to the patient’s needs. I seek help with my fellow in times of crisis. During the daytime, I may oversee the service with the fellow. I manage care of these patients throughout their stay in the MSICU.
As a triage NP, I serve as a resource to the hospitalist who is concerned that their patient requires ICU care. I also determine if appropriate admissions and transfers are occurring throughout the hospital. I follow up on veterans who have transferred out of the MSICU within the past 24 hours to determine if their transfer was safe and appropriate. I utilize a ward acuity tracker to guide appropriateness of veteran level of care outside of the MSICU.
I am a part of the ICU Liberation project and ABCDEF Bundle collaboration spearheaded by the Society of Critical Care Medicine. This is a process improvement project that has shown to decrease ICU ventilator days, hospital and ICU length of stay, hospitalization costs, and morbidity and mortality, while improving patient outcomes. The ABCDEF Bundle is defined as a collaborative effort among health care practitioners to improve the care of critically ill patients in ICU settings in the following areas: Assess, Prevent and Manage Pain; Both Spontaneous Awakening and Spontaneous Breathing Trials (SAT and SBT, respectively); Choice of Analgesia and Sedation; Delirium: Assess, Prevent and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment. I am a part of the “Delirium” task force for the bundle, teaching housestaff and bedside nurses the CAM-ICU and development of a delirium order set and nonpharmacological treatment of delirium. I have been collecting data about our veterans that will help guide the success of this project.
I am also developing an acute alcohol withdrawal protocol and order set. This will include the use of dexmedetomidine as adjunctive treatment, which is a continuous infusion medication that has shown to decrease alcohol withdrawal when used with medications such as Ativan. This project will be carried over to the intermediate ICU so that our veterans can continue to have care outside of the MSICU that will continue to provide safe care.
[OnlineFNPPrograms.com] You were also a Neurocritical Care Nurse Practitioner at The Queens Medical Center, where you provided intensive care to patients with complex neurological conditions. 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 current position at the Palo Alto VA Hospital?
[Michelle Edwards, MS, AGACNP-BC, CCRN] As a Neurocritical Care Nurse Practitioner, I worked collaboratively with a neurointensivist. This position was very involved and intense. We did not have interns, residents, or fellows. Not even another NP to assist with managing these complex, critically ill neurological patients. I worked collaboratively with my neurointensivist, keeping him/her informed of the patient’s condition and my decision for a treatment. I was never assigned to just one patient. We were a team of two.
My day would start out by receiving signout from the night NP. We performed advanced neurological exams on every patient on our service; whether they were in the NSICU or SICU/MSICU or neuro stepdown unit. Afterwards, the attending and I would do bedside rounds with the nurses; the attending wrote the progress notes while I wrote orders. We responded to stroke codes, performed the NIHSS and determined if the patient met criteria for tpa (a type of clot dissolver medication). We ordered and interpreted CT scans, MRIs, CXRs and many other imaging modalities. We even had a portable head CT scanner on the unit that allowed us point of care imaging for patients who demonstrated an acute neurological change. We were consults for the neurosurgical and trauma teams to manage TBI, spinal cord injuries, and craniotomies for epidural and subdural hematoma evacuations.
When I covered nights, I was the only provider (neurointensivist available by phone) for these patients. I continued to manage and optimize the patients and responded to emergencies, stroke codes, and consults. I performed comprehensive H&Ps on all new admission throughout the night. I was credentialed to place central lines, arterial lines, and lumbar punctures.
[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?
[Michelle Edwards, MS, AGACNP-BC, CCRN] After nearly 13 years of ICU and rapid response team experience, I wanted more out of my career. I wanted to make an impact on patient outcomes, and being at the bedside was not going to fulfill the void. I knew I wanted to return to school but wasn’t certain if I wanted to do nurse anesthesia or specialize in adult-gerontology acute care nurse practitioner. However, I was certain that I wanted to continue my career in critical care. After much contemplating of my career path, I decided that becoming an adult-gerontology acute care nurse practitioner made more sense. I knew this would prepare me for a career as a critical care NP. The best career decision I have made.
[OnlineFNPPrograms.com] What have been some of the most rewarding aspects of working as an adult-gerontology acute care 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?
[Michelle Edwards, MS, AGACNP-BC, CCRN ] 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. A major challenge that may be difficult to overcome would be if you are a RN with none to very little experience. This will make it very difficult to find a job in the hospital setting; particularly critical care or ED. There are few adult-gerontology acute care nurse practitioner jobs in the market. We are a small breed compared to FNPs or ANPs. (AGACNPs have only been around since early 2000 due to intern and resident hours being cut; which left unmanned hours to manage hospitalized patients).
I think potential employers are looking for strong candidates with many years of RN experience in a chosen specialty. When I was job hunting, many employers had very specific requirements and wanted experienced NPs or very experienced RNs. When I graduated, there were no jobs for critical care NPs in the Bay Area, so I had to look beyond my community to find a job. I received an email from The Queen’s Medical Center in Honolulu two months before graduation. I inquired but didn’t really think it was a possible job for me as a newly graduated AGACNP. I interviewed in May and was offered the job the day before my June graduation. I would say that I didn’t face many challenges because I planned and prepared for this career. The only challenge I had was to move to Hawaii to accept my first position as a neurocritical care NP, and that rewarded me the best experience thus far. I gained so much knowledge and expertise that has really been sought after in my current career at the VA Palo Alto. Many of my colleagues will seek me for neurological diseases and management. I also teach newly hired RNs on critically ill patients with neurological diseases.
[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?
[Michelle Edwards, MS, AGACNP-BC, CCRN] First and foremost, I would say, before pursuing a MSN for advanced practice nursing, I would recommend having at least two years of inpatient RN experience. This will take you far and open more job opportunities upon graduation. If you have not done so at this point, get connected on LinkedIn. 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. 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 terms of preparing for your return to graduate school, it may be helpful to refresh any course work that may be old. For me, I wished I had taken a refresher statistics course. My knowledge of this subject matter was far in the past and would have helped me to understand the terminology a bit more, but I had a basic statistic research guide to assist me through the courses. As for board certification review courses, I highly suggest going to a live course if you can do it, but on demand may be just as easy. You can find review courses on American Nurses Credentialing Center or npcourses.com. Bottom line, if you want to specialize as an adult-gerontology acute care nurse practitioner as I did, get your experience as a RN and specialty certification before you return to school because you will stand out stronger against other candidates and excel in your career.
[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?
[Michelle Edwards, MS, AGACNP-BC, CCRN] Well, to better grasp the difference between the two, acute care providers work in the hospital inpatient settings; whereas primary care providers usually work in the outpatient setting, albeit a clinic or physicians’ office. Both types of adult-gerontology nurse practitioners provide care to the adult and older adult population (ages 18-100+). They both can provide and manage chronic illnesses, but the acute care provider in the hospital setting will manage acute and chronic illnesses. There are FNPs and ANPs in the ER setting that have been the mainstay of advanced practice providers in the past because ERs are like urgent care centers and a place for uninsured to receive medical care. Oftentimes, they do not provide care to the acute and/or critically ill patients because they did not receive the education to provide appropriate care to these patients. However, it’s hard to argue this scenario if the provider was trained on the job after their education and board certification.
According to the APRN Consensus Model, advanced practice providers should only practice within the setting in which they were educated and board certified. This model is a set of guidelines that ensure APRNs are working in appropriate clinical settings for which they are educated and trained to provide safe and effective care to patients. In other words, acute care nurse practitioners should work within the hospital setting but may also work in primary care, but primary care providers should only work in clinics or outpatient settings, unless they have received specific training (such as a post-master’s certificate, formal on-the-job training, or other credential) that qualifies them to provide care in critical care settings.
Thank you Ms. Edwards for participating in our APRN career guide interview series!