The Acute Care Nurse Practitioner in Hospital-Based Practice

By Bruce, Kira; Steinke, Elaine

Description of the Acute Care Nurse Practitioner Role

The Acute Care Nurse Practitioner (ACNP) is an advanced practice nurse that provides care for acute and chronically ill patients in a variety of settings. The ACNP role arose from adult Nurse Practitioners (NP) whose role evolved to include hospital-based practice and was developed to fulfill a need for inpatient care of acute and chronically ill patients. The adult ACNP role evolved in the late 1980’s and was developed to provide comprehensive care using a holistic model in collaboration with all members of the health care team, patients and their families. As changes in health care reflect the trend of cost containment and shortages of health care providers, the ACNP role continues to emerge. In order to meet the ongoing needs of critically ill patients, ACNPs are being educated to identify health risks, encourage health promotion, and manage acute and critically ill patients in the hospital-based setting (Rust & Magdic, 2000). The important role that the ACNP could play in Kansas was recognized in the mid-1990’s, and Wichita State University implemented an ACNP program in 1996. Since that time, graduates of the program have contributed to quality acute care of Kansans and across the nation. Wichita State University offers the only ACNP program in Kansas.

According to the American Association of Critical Care Nurses (AACN) Critical Care Nursing Fact Sheet, critical care nursing is specialized nursing that “deals specifically with human responses to life-threatening problems (AACN, n.d, p. 1).” Critically ill patients are those patients who have developed or are at risk for developing life threatening complications, and therefore require intense monitoring by critical care nurse. According to AACN, critical care nurses “rely upon a specialized body of knowledge, skills, and experience to provide care to patients and families and create environments that are healing, humane, and caring” (AACN, n.d., p. 5).

Managed health care has promoted the growth of advanced practice nurses in hospital-based settings. An advanced practice nurse is a nurse who has received additional training at the master’s or doctoral level and demonstrates a high level of independence. The ACNP is an advanced practice nurse with specialized training in the clinical management of critically ill patients. In the critical care setting ACNP’s make clinical decisions in the management of critically ill patients and with the problems often discovered in the critically ill. The activities of the ACNP include history and physical exam, assessment of risk factors, ordering and interpretation of diagnostic studies, and providing treatment, including medication, to treat the diagnosed illness (AACN, n.d.).

The ACNP Role in Hospital-Based Practice According to Klein (2005), in a review of the scope of practice of NP’s, the ACNP is described as being prepared to manage patients in a hospital-based setting. She describes the ACNP training as a “specialty focus in acute, episodic, and critical conditions” and the role is targeted toward inpatient focus versus outpatient practice, which is focused on the management of chronic disease. Educational preparation as an ACNP is nationally recognized as the standard for acute care scope of practice. In 2004, the role of the ACNP was further clarified with the development of a document outlining ACNP competencies (National Panel for Acute Care Nurse Practitioner Competencies, 2004). A national certifying exam for ACNP practice is administered by the American Nurses Credentialing Center, and is necessary to be able to practice in many states.

The effectiveness of the ACNP role has been demonstrated in several studies. In a descriptive article by Howie and Erickson (2002) on the initiation of ACNPs as general medical staff for an inpatient general medical service (hospitalist role), multiple studies were cited that reviewed the role and effectiveness of the care ACNPs provide. In those studies, the ACNP was noted to provide care comparable to that provided by medical residents. They also frequently provided more cost effective, individualized care, and provided for increased staff and patient satisfaction. Due to these findings, a large medical center in California established a medical service staffed primarily with ACNPs, who were assisted by a resident and an attending I physician. The ACNP team admitted and managed patients with general medical conditions in the general hospital area. This team did not follow patients in the intensive care units (ICU). The primary goal of the ACNPs was to provide excellent care with a patient-base focus without being distracted by the educational requirements that a medical resident encounters.

The initiation of the ACNP in the medical management setting required the development of the role in this specific institution. Part of establishing the role was that standardized protocols had to be developed in order to reflect the practice of the ACNP. In addition, the institution also worked with the ACNPs to develop protocols for all procedures performed by the ACNP. Continuing education requirements were also mandated for each of the ACNPs because the NPs were originally family nurse practitioners or adult nurse practitioners and required further education for their acute care role. Educational material was distributed to the staff of the institution to educate them on the role of the ACNP. At the end of the initiation period, the allied health team found the ACNP medical management team highly effective, sensitive to their patients needs, and approachable as colleagues (Howie & Erickson, 2002). This article is a good description of the development of the role of the ACNP in a hospital-based setting.

Kleinpell (2005) conducted survey research that tracked the working conditions, job satisfaction, role, and job expectations of ACNPs over a period of several years. Many aspects of these conditions were explored in order to obtain accurate information about the ACNP role. The study was conducted over a 5 year period of time, and the survey was conducted among those practitioners who took the national certification exam for the ACNP role.

The ACNP role was originally intended to function primarily in the ICU and high-acuity setting; however, results from this survey reveal that the ACNP now functions in a variety of settings (Kleinpell, 2005). In addition, the role of the ACNP has expanded greatly since the initiation of this specialty. The competencies that ACNPs learn enable them to provide services that no other advanced practice nurse can offer. The primary responsibility of the ACNP continues to be that of direct management of patient care. A common misperception of the role is that the majority of the ACNP’s time is spent in performing invasive skills. However, often misperceptions of the role stem from inadequate knowledge of the health care team on the role and abilities of the ACNP (Kleinpell, 2005). The advantages of being an ACNP were primarily identified as affecting patient outcomes. The other advantages to the ACNP role for the practitioner include the autonomy of the role, the involvement with patients and their care, and the opportunities to collaborate with other members of the health care team (Kleinpell, 2005).

The ACNP in the Intensivist Role

The ACNP in the intensivist role primarily focuses on the management of critically ill patients in the Intensive Care Unit (ICU). The intensivist role requires the ACNP to have a strong knowledge of the medical conditions and evidence-based treatments for those conditions to result in optimal outcomes. In order to achieve optimal patient outcomes, the ACNP needs to practice in collaboration with other members of the health care team. According to Rust and Magdic (2000), collaboration includes the following: cooperation, assertiveness, shared decision making, communication, planning together, and care coordination. The emphasis for the collaboration should always be the best patient outcomes.

In the intensivist role, the ACNP provides direct patient care in the ICU setting to patients who are acutely and critically ill with complex and multiple health problems. Key competencies for the ACNP include the following:

1. Demonstrates a knowledge of advance pathophysiology

2. Completes a health history

3. Conducts physical exams

4. Demonstrates the ability to order and interpret diagnostic tests

5. Demonstrates technical competence with procedures

6. Collaborates with other care providers to facilitate positive outcomes. (Rust & Magdic, 2000)

These competencies allow the ACNP to practice safely in the intensivist role of managing critically ill patients.

In a multi-disciplinary study by Hoffman, Happ, Scharfenberg, DiVirgilio-Thomas, and Tasota (2004), the perceptions of the contributions ACNPs make to medical management teams in critical care units were explored. Opinions regarding the care provided to critically ill patients by two ACNPs were obtained from physicians, respiratory therapists, and staff nurses in two ICUs in each of two adult teaching hospitals. The responses were grouped into four main areas: accessibility, competence/knowledge, care coordination/ communication, and system issues. The study findings revealed that ACNPs were accessible, experts in the management of patients, and met patient and f\amily needs in the ICU. In addition, the health care team respected the commitment the ACNPs made to provide quality care to critically ill patients, the communication skills they possessed, and the educational role that they provided to not only patients and their families, but also the nursing staff (Huffman et al. 2004). While this study demonstrated several limitations, including the overall response rate of 35% and the review of only two ACNPs from two different units within the same academic system, it does provide a good sense of how the ACNP role is perceived to function in the intensivist role by other members of the health care team.

Huffman, Tasota, Scharfenberg, Zullo, and Donahoe (2003) compared the work activities of physicians in training and ACNPs based on the time spent in management of critically ill patients in the ICU. The authors noted that several research studies have shown that patients managed by ACNPs vs. resident physicians in the ICU tend to have the same outcomes, if not somewhat better. Therefore, the purpose of this study was to explore the rationale behind those findings. This study was conducted over a 19-month period of time in which data was collected in a 6-bed step-down MICU in a university medical center. One ACNP and 6 resident physicians were evaluated during the course of this study. The findings of this study demonstrated that the ACNP and resident physicians spent about the same amount of time in routine management of the patients. However, the ACNP spent much more time (45% vs. 18%, p

This study also found that while there was no real difference in the amount of time the ACNP and the resident physicians spent in direct patient care, there was a significant difference in the amount of time each group spent interacting with other members of the health care team, patients and their families, and in other patient-related activities in the ICU. Due to small sample size of this study, further study is needed to determine if these findings are significant to patient outcomes (Hoffman et al., 2003). However, this study allows us to see the difference in how the ACNP functions in the intensivist role vs. resident physicians.

Conclusion

The ACNP is an advanced practice nurse specializing in the care of acutely and critically ill patients in multiple settings. They are a valued member of the health care team with demonstrated contributions toward improved patient outcomes. Following national trends, ACNP’s in Kansas are finding an increased demand for their role in a variety of hospital-based settings. Kansas ACNP’s collaborate daily with their physician colleagues in specialty practices, Emergency Rooms (ER) and trauma care, hospitalist practices, and intensivist roles. As the ACNP role continues to expand, these practitioners will play a vital role in the recovery of acutely ill hospitalized patients.

“Following national trends, ACNP’s in Kansas are finding an increased demand for their role in a variety of hospital-based settings.”

References

American Association of Critical Care Nurses (n.d). Critical care nursing fact sheet. Retrieved November 20, 2005, from http:/ / www.aacn.org/AACN/practice.nsf

Hoffman, L. A., Happ, M. B., Scharfenberg, C., DiVirgilio- Thomas, D., & Tasota, F. J. (2004). Perceptions of physicians, nurses, and respiratory therapists about the role of acute care nurse practitioners. American Journal of Critical Care, 13, 480- 488.

Hoffman, L. A., Tasota, F. J., Scharfenberg, C., Zullo, T. G, & Donahoe, M. P. (2003). Management of patients in the intensive care unit: Comparison via work sampling analysis of an acute care nurse practitioner and physicians in training. American Journal of Critical Care, 12, 436-443.

Howie, J. N., & Erickson, M. (2002). Acute care nurse practitioners: Creating and implementing a model of care for an inpatient general medical service. American Journal of Critical Care, 11, 448-458.

Klein, T. A. (2005). Scope of practice and the nurse practitioner: regulation, competency, expansion, and evolution. Topics in Advanced Practice Nursing eJournal, 5(2). Retrieved November 20, 2005, from medscape.com Web Site: http:/ / www.medscape.com/viewprogram/4188_pnt

Kleinpell, R. M. (2005). Acute care nurse practitioner practice: Results of a 5-year longitudinal study. American Journal of Critical Care, 14, 211-221.

National Panel for Acute Care Nurse Practitioner Competencies (2004). Acute care nurse practitioner competencies. Washington, DC: National Organization of Nurse Practitioner Faculties.

Rust, D. M., & Magdic, K. S. (2000). The Acute Care Nurse Practitioner. In A. Hamric, J. Spross, & C. Hanson (Eds.), Advanced nursing practice: An integrative approach. (2nd ed., pp. 425-457). Philadelphia: Saunders.

By Kira Bruce, RN, BSN and Elaine Steinke, PhD, ARNP

About the Authors

Kira Bruce, RN, BSN is a graduate nursing student in the Acute Care Nurse Practitioner option at Wichita State University. Mrs. Bruce received her undergraduate degree from Northwestern Oklahoma State University in Alva, Oklahoma in 2000. She is currently employed by Via Christi Regional Medical Center in Wichita, Kansas as a staff nurse in the Surgical Intensive Care Unit on the St. Joseph Campus and is a member of the American Association of Critical Care Nurses.

Elaine E. Steinke, PhD, ARNP is a professor of nursing at Wichita State University. She is the coordinator of the Adult Health & Illness Clinical Nurse Specialist and Acute Care Nurse Practitioner graduate options, and teaches courses related to the acutely, chronically, and critically ill adults. Dr. Steinke presents and publishes nationally and internationally on her research area of sexual counseling and cardiac disease. She is a member of KSNA District 6

Copyright Kansas State Nurses Association May 2006

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