The advanced registered nurse practitioner (ARNP) emerged in the 1960s as an alternative provider to meet the demands of an escalating healthcare resource deficit. Due to declining medical residency and fellowship programs, the impetus was undertaken for the development of a quality nonphysician provider that produced optimal outcomes while achieving overall cost reductions (Byers & Brunell, 1998). The first ARNPs were specifically trained to meet these demands in primary care, pediatrics, anesthesiology, and neonatology (Howie & Erickson, 2002). As a result of the success in those areas, the use of ARNPs in practice has broadened to include most settings in the healthcare environment. The impact of ARNPs has been measured by evaluating outcomes in both outpatient and inpatient settings and has been reviewed in the literature (Shultz, Liptak, & Fiorayanti, 1994). Examples of positive outcomes resulting from the use of the ARNP in various practice settings include decreased length of stay in hospitals, decreased overall cost of care, competent and comprehensive care, improved communication to families, and increased patient satisfaction (Kleinpell, 2003).
By the early 1990s, ARNPs began to appear more frequently in acute care settings (Howie & Erickson, 2002). Models with ARNPs providing care that successfully met the acute needs of hospital patients were described (Jastremski, 2001). These successful ARNP models in the acute care environment led to the creation of the acute care nurse practitioner (ACNP) as a recognized specialty (Kleinpell, 2003). Recent interest in alternative nonphysician staffing models in intensive care units (ICUs) is exploding nationally (Garland & Gershengorn, 2013). The newest frontier for the ARNP is providing care in neurocritical care units (Caserta, Depew, & Moran, 2007). As the neurocritical care specialty programs develops, the need for well-trained and competent ARNPs in these highly specialized critical care environments is increasing (Caserta et al., 2007). Out of all the neuroscience ICUs throughout the country, it is believed that over half employ ARNPs in some capacity (Caserta et al., 2007). The use of ARNPs appears to be a safe and effective alternative to traditional resident teams (Gershengorn et al., 2011). Some studies have reported that ARNP models have led to a significant reduction in ICU length of stay with no increased incidence of any complications (Gillard et al., 2011).
In 2008, the University of Florida & Shands Jacksonville (UF) administration decided to embark on the development and implementation of a neurocritical care unit with a neurointensivist physician and an ARNP provider model. The impetus resulted from a rising regional demand for a comprehensive and specialized unit for neurological critical care illness in the face of dwindling financial resources and declining medical resident numbers. The facility had recently become a regional stroke center and the strategic goals focused on alignment with the national trend toward developing specialized units for patients with acute strokes, neurological emergencies, complex neurosurgical recovery, and complex neurointerventional recovery.
A nurse practitioner in the neurology research department at UF on the planning committee for the new unit was instrumental in presenting a cost-effective and successful neurocritical care model cited in the literature (Caserta et al., 2007). This model utilized a mix of physician and ARNP providers for a neurocritical care unit. The concept was accepted, and a similar provider model was selected for the future neurocritical care unit at UF. The model kept purely ARNPs throughout the UF project, with the goal in mind to effectively measure future outcomes. The measurement of outcomes has been identified as one of the most important activities in assessing the effectiveness of any intervention (Kleinpell, 2013). Once this model was chosen, the next step required the hiring of two attending neurointensivist physicians and the hiring and training of five ARNPs with the goal of providing 24-hour neurocritical care coverage once the unit was developed and opened.
The medical director of neurology hired a neurointensivist in 2008 to operationalize the unit and appointed a senior ACNP at that time to coordinate the hiring and training of the ARNPs. The unit successfully opened 6 beds the following year and expanded to 12 beds by 2011. In 2013, the unit currently has five well-trained ARNPs and will be expanding to seven ARNPs to facilitate a higher census, as well as a consult and referral service. Finding, developing, and training competent ARNPs for the multicomplex ICU environment, especially neurocritical care, can be daunting. The purpose of this article was to present the orientation and competency model successfully designed, implemented, and utilized for the ARNPs in our newly developed neurocritical care unit at UF.
Through the UF experience, the first step in a comprehensive ARNP orientation and competency model for neurocritical care begins with the interview process. Candidates who should take precedence and be sought include those ARNPs who are already exposed to acute care with previous experience in neurology or ICU as ARNPs. The reality is that an ARNP with neurology or critical care experience represents less than 1% of all ARNPs currently in practice (Kleinpell, 2003). Rarely is an ARNP candidate already prepared with the required skills. In addition, the specialty milieu is recently changing for acute care academics and certification for ARNPs. According to the American Nurses Credentialing Center (2013) for nurse practitioner regulation and certification, the acute care certification will be retired and be replaced with adult gerontology. Therefore, the interviewer should also focus on an ARNP candidate with practical experience and background in critical care as a registered nurse (RN). In addition, the candidate should preferably have completed the equivalent of an acute care track in advanced practice academia and be board-eligible for certification as an ACNP or a future equivalency. Keeping abreast of the national changes in acute care advanced practice and regulation should be at the forefront of the selection process.
Once an appropriate ARNP candidate is selected and completes the hospital credentialing process, an individualized orientation program needs to be formulated based on actual and perceived learning needs. Each hospital and each state may differ in the credentialing process. At UF and in the state of Florida, ARNPs are hired with collaborative physician protocols and awarded basic privileges. These privileges include performing history and physicals, discharge processes, order implementation, progress notes, diagnostic and laboratory interpretation, differential diagnosis, and plan of care. Each state and facility may vary for credentialing requirements and protocols.
For the ARNP in neurocritical care, advanced privileges and skills above and beyond the basic competency were required. Because this project was the first time ARNPs were given privileges for intubation, central lines, bronchoscopy, and other advanced skills, the ARNPs were held to the same standard as the critical care medical residents. Any specialized skill had to be successfully performed five times under the supervision of a physician credentialed in that skill before the ARNP was privileged to perform that skill independently.
During the inception of our neurocritical care program, UF first required that newly hired ARNPs complete both a critical care needs assessment written examination (100 questions) and an acute neurology needs assessment written examination (100 questions). These examinations were internally developed utilizing standards from the American Association of Critical Care Nurses core curriculum (Alpach, 2008) and the American Association of Neuroscience Nursing (AANN) core curriculum (Bader & Littlejohns, 2004) to identify the candidates’ knowledge base deficits. The tests were developed with the assistance of the attending physicians in those specialties and the nursing education advanced practice division. The tools were tested on expert staff nurses and ARNPs in the ICU and neurology units already certified in critical care or neurology from national certifying boards for reliability.
Next, a series of meetings from all specialties, which included ARNPs, nurses, physicians, educators, clinical nurse specialists (CNS), and administrators, were conducted. This group discussed and devised a list of needs and skills that each believed necessary to appropriately train a new ARNP to meet the diverse needs of a nonphysician provider in neurocritical care. The compilation of the meetings resulted in the development of a neuroscience nurse practitioner orientation and competency skills list (Figure 1). Once the written examinations were completed and needs were identified, the neurocritical care orientation and competency skills list (Figure 1) was tailored to each new ARNP.
Specifics of the Skills List
Each area of the skills list is an important component to a successful orientation process. Specified areas on the list require completion that is evidenced by a signature from a responsible trainer or supervisor in one of the following ways:
1. The ARNP attends an internal class or
2. The ARNP passes internal examinations by 80% or greater, or
3. The ARNP provides evidence and proof of current certifications and/or skills in an area listed on the skills list.
The neurocritical care skills list can be divided into the following areas:
1. General orientation
2. Testing and certifications
3. Advanced classes
4. Specialty rotations
5. Procedure and skills-based competencies
Each healthcare facility that employs ARNPs will have unique standard processes in place for general orientation requirements. At UF, the requirement involves general hospital orientation set up for all employees by the Human Resource Department in the first 2 days of employment. This includes the overall UF system of orientation to policies, computers, mandatory education, and entry procedures that all providers complete. Provider orientation is also required at UF that includes compliance training and orientation to the clinical systems such as laboratory, electronic medical record, compliance standards, billing standards, and radiology systems. Once the ARNP completes these requirements, the section on the neurocritical care skills list is signed and dated by the department director. Signature requirement is necessary for each area and always necessitates the authoritative specialist identified by the UF facility. This may be the direct supervising ARNP, attending physician, CNS, educator, or administrator.
Testing and Certification
Testing and certification are processes employed to assist in establishing a standard of basic knowledge in the specialty and evaluating whether a knowledge deficit exists for the new ARNP. The following tools assist in efforts to design educational opportunities to provide an adequate knowledge acquisition for the ARNP. As previously mentioned, the acute neurology examination was developed with the assistance of our neurointensivist and based on the AANN Core Curriculum for neuroscience nursing (Bader & Littlejohns, 2004). A passing score of 80% or higher is required. If unable to achieve that goal, the ARNP must complete a neurology rotation for 1 week and participate in the internal online learning module, which is the AANN Foundations of Neuroscience Nursing electronic training product. This educational product includes 21 self-learning neurology-based, 16 adult, and five pediatric modules (AANN, 2004). Only the adult portion of the self-learning module is required by UF. For any ARNP holding a national certification as a neuroscience RN, the examination requirement is waived.
The ARNP orientee, as previously mentioned, is required to take the critical care examination unless he/she is a certified critical care RN (CCRN). If the ARNP has no official critical care certifications, the facility requires an achievement score of 80% on the examination. If the ARNP scores lower than 80%, he/she required to attend the critical care classes listed under the advanced classes section and delineated on the skills list form.
Other certifications required include Advanced Cardiac Life Support certification and Advanced Stroke Life Support certification. Both of these certification classes are offered by UF. New ARNPs have the option of providing proof of current certification from another facility. Basic knowledge of dysrhythmias and 12-lead electrocardiogram was also identified as necessary skills for the ARNP in neurocritical care. The requirement may be satisfied with dysrhythmia certification, which can be achieved by the ARNP passing our internal examination established for all RNs in our facility. In addition, a 12-lead electrocardiogram certification must be accomplished by passing an internal written examination or attending the internal class. An example of our internal certification form is seen in Figure 2.
Because UF is a stroke center, a further requirement is that the ARNP obtain National Institute of Health Stroke Scale (NIHSS) certification because the neurocritical care unit admits and cares for patients who experienced stroke. This certification is available via the NIHSS (2012) website. Because our facility is also a level 1 trauma center and admits a large volume of traumatic brain injuries and spinal cord injuries, Advanced Trauma Life Support certification is preferred but is not presently required.
The facility has available critical care classes that are routinely held at monthly intervals for the medical residents and fellows in the ICU units. The ARNP who is not CCRN certified and who has not achieved 80% on our internal examinations is able to attend the following classes or participate in learning modules available on the following: Hemodynamics, Critical Care Pharmacology, Mechanical Ventilation, Diabetic Ketoacidosis/Hyperosmolar/Nondiabetic/Ketoacidosis, External Ventricular Devices/Increased Intracranial Pressure, and Continuous Veno–Veno Hemofiltration.
Neurocritical care encompasses many aspects of critical care specialties. Because our specific neurocritical care unit did not exist during the training phase, program leadership recognized the need for rotations for the ARNPs in the surgical intensive care service, medical intensive care service, neurology service, neurosurgery service, and anesthesia service. With each rotation, a set of learning goals were established. An example of these goals for the medical ICU (MICU) rotation is seen in Figure 3. Attending physicians in each area evaluated the ARNP based on the established goals and objectives (Figure 4). The evaluation form directly mirrors the objectives established for each rotation and follows specific goals identified for that specialty. Rotations through the critical care areas, both MICU and SICU, were 4 weeks in duration. Rotations in neurology, neurosurgery, and anesthesia were 1 week.
Skills identified as necessary, such as intubation and airway management, central line insertions, chest tube insertions, bronchoscopy, and other needed competencies, were obtained during these rotations. Competency in skills, overall critical care management, and focused assessments and management of neurocritical care patients were the overriding goals for all rotations. The facility benefitted from a group of intensivists, neurologists, neurosurgeons, and anesthesiologists who were educational champions for the ARNPs.
The following competency training process was developed for ARNPs in neurocritical care at UF. As mentioned, central line insertion and other needed competency skills were identified and not yet established. Standards of safe and effective performance objectives were researched and a tool was developed based on the New England Journal of Medicine (2012) standards for procedures. In compliance with these standards, competency skill lists were developed. For those procedures not available in the literature as standards, internal experts were enlisted to develop appropriate performance objectives. An example of one of the many skills lists, internal jugular central line insertion, is illustrated in Figure 5. The mentoring provider would follow the “see one, do one” approach for training. The senior provider would perform the behaviors while the ARNP observed (see one). The next time, the roles would reverse and the ARNP would perform the behaviors while the senior provider observed (do one).
The ARNP was responsible for obtaining the mentoring providers’ sign off on the competency skills form each time a procedure was successfully performed. The UF medical staff office has determined designated numbers of special skills that delineate privileges to perform that skill independently. The standard number of successful procedures is five for each skill. The competency training process remained compliant with the internal number of procedures required before the ARNP was considered independent and competent in a particular acquired skill. In addition, the ARNP logged in the hours spent in orientation to each area on our internally developed clinical time form (Figure 6). All these records were placed in the ARNP employment and credentials file.
Once the original group was effectively trained and the unit opened, it became evident after a year of operation that the ARNP in neurocritical care required a process for evidence of maintaining competency in the specialized skills obtained. The teaching simulation laboratory on campus provided an effective option for ongoing training needs. Annually, a skills laboratory experience with specific skill stations tailored to the needs of the ARNP was conducted. Attending physicians coordinated the learning stations. An internal form was designed to document continued competency of training and placed in the ARNP’s file (Figure 7). The facility continues to provide this opportunity each year for the ARNP in neurocritical care and it serves to verify continued compliance and competency for the necessary skills attained.
Costs and Success Rate
The estimated costs of the project varied with the pay awarded when each ARNP was hired that was based on previous experience. The initial costs ranged from $20,000 to 25,000 per orientee. Most ARNPs trained were practicing with independence after 3 months and able to produce revenue for the facility. As the ARNP program in neurocritical care advanced and the unit opened, training was completed in the actual unit, resulting in costs dropping to half. The original start-up project successfully trained three ARNPs and, quickly, within 3 months extended to five. Over the years, UF lost two original ARNPs from attrition and one trainee could not successfully complete the process and changed job settings for a less complex patient mix. Therefore, seven out of a total of eight new ARNPs were successfully and effectively trained.
The well-trained neurocritical care ARNP is an asset to any unit caring for neurological critical illness (Caserta et al., 2007). Although the ARNP role in neurocritical care is relatively new when compared with other provider roles, UF supports through the aforementioned efforts that the ARNP in neurocritical care is capable of functioning at a highly skilled level and able to provide safe and competent care to a group of complex critical patients. Other neurocritical care ARNP models have been adopted throughout the nation with equal success (Caserta et al., 2007). As ARNP models become more and more successful in the neurocritical care environment, roles will most likely expand. The neurocritical care unit at UF has recently expanded the ARNP role to include, with the assistance of attending physicians, the placement of percutaneous tracheostomies, percutaneous endoscopic gastrostomies, external ventricular devices, and intracranial bolt insertions.
As expansion of the UF neurocritical care unit continues, it has been recognized that the newly hired ARNPs are now effectively trained by the experienced ones already in the unit. New ARNPs no longer require rotations to other areas because the existing neurocritical care unit provides all the necessary opportunities and patient types required for a comprehensive orientation experience. Many components of the original orientation process and model continue to be utilized and are tailored to each new ARNP. It is the hope that the experiences at UF and the tools developed in the ARNP orientation and competency model may benefit other developing units creating ARNP models for neurocritical care.
The comprehensive orientation and competency model at UF for neurocritical care ARNPs may be utilized as guideline for facilities embarking on ARNP training models in critical care. The tools presented may provide the impetus to successfully navigate through the maze of knowledge and skill required to effectively provide care to these complex critical care patients. Roles of the ARNP will continue to evolve as specialties grow in critical care. There are approximately 6,000 ICUs in the nation managing large numbers of patients with critical care needs (Caserta et al., 2007). The well-trained ARNP is prepared to help meet those needs.
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