On April 10–11, 2019, the American Academy of Emergency Nurse Practitioners (AAENP) was invited to attend the American College of Emergency Physicians (ACEP) Board of Directors quarterly meeting in Dallas, TX. A diverse group of emergency physicians from across the country involved in policy development, resident education, research, and practice were eager to hear updates on recent AAENP initiatives. Perhaps, more important than the brief update on committee accomplishments, membership, and certification numbers was addressing the “elephant in the room”—specifically, the issue of nurse practitioner (NP) “independent practice” and recent publicized concerns regarding advanced practice providers (APPs) voiced by individual physicians and the American Academy of Emergency Medicine. I began my report by reiterating AAENP's mission statement: “AAENP promotes high-quality, evidence-based practice for nurse practitioners providing emergency care for patients of all ages and acuities in collaboration with an interdisciplinary team.” I went on to emphasize that AAENP supports team-based care, with our emergency physician colleagues as team leaders. This led to an open dialogue with the Board members who posed thoughtful questions about our role and scope, educational preparation, and certification and praised the impressive work and recognition that AAENP has garnered in the past 4 years as the organization representing emergency nurse practitioners (ENPs) on a national level. Our dialogue allowed me to better understand ACEP's concerns and provided the opportunity for further collaboration.
Key concerns from ACEP included:
- Reports by physician graduates of emergency medicine (EM) residencies of declining availability of emergency department (ED) positions attributed to increased staffing with APPs. In response, ACEP established a workforce committee in 2018 that is launching a large-scale national survey to assess current and projected EM workforce needs. AAENP is represented on this committee. The findings from this survey and analysis will be completed in 2020 and will directly impact and inform APP workforce needs.
- There is growing concern and discussion about the wide disparity in readiness to practice among NPs entering the EM workforce. Physicians are now aware that many NP students attend online programs, are responsible for finding their own clinical sites, and may have no or limited oversight by faculty. EM physicians who precept NP students have found that some are lacking in physical assessment, case presentation, ED documentation, diagnostic reasoning, and differential diagnosis skills/competencies.
- There is also growing uneasiness that NPs are accepting jobs without the requisite competencies to provide safe emergency care, especially in rural and critical access EDs. Physicians are concerned that NPs are willing to accept positions in remote sites without EM physician support. ACEP recognizes that there are significant workforce gaps in rural EDs. Targeted efforts are being made by ACEP to increase rural EM residency rotations.
- ED physicians are often required to “supervise” and sign charts for patients who are seen by APPs and for whom they have no personal contact or collaboration in determining a plan of care. In addition, many physicians are now required to simultaneously “supervise” multiple APPs, many unfamiliar to them. There are currently no research-based policies to guide safe MD to APP staffing ratios based on ED volume and acuity.
- Confusion about the meaning of ENP certification, NP scope of practice, and licensure and regulation nomenclature, which is easily misinterpreted, is contributing to an adversarial climate regarding ENP practice.
Opportunities for ENPs to mitigate and address our EM physician colleagues’ concerns begin with clarifying definitions:
- “Independent practice” is a charged term. It is misinterpreted to imply an entrepreneurial endeavor devoid of collaboration and in direct competition. This has no place in emergency care practice. “Independent practice” is described by the National Organization of Nurse Practitioner Faculties (NONPF) in its Nurse Practitioner Core Competencies as consisting of several elements. First, the “NP is a licensed independent practitioner” (NONPF, 2017, p. 14). As a licensed independent provider, an NP assumes full responsibility for clinical decisions and medicolegal liability by demonstrating “the highest level of accountability for professional practice” (NONPF, 2017, p. 14) and by collaborating with “professional and other caregivers to achieve optimal care outcomes” (NONPF, 2017, p. 15). An ENP is fully accountable for the care that he or she provides and optimizes patient outcomes through consultation and shared medical decision-making with physician colleagues.
- “Full scope of practice” is not the same as the definition of independent practice but instead refers to being able to assess, evaluate, and treat conditions within one's educational preparation as an NP. It is an NP's ethical and legal responsibility to obtain additional training in emergency care and to obtain emergency-specific competencies to ensure the safety of the public. An NP practicing up to his or her full scope of training is better able to care for patients safely and efficiently within a team-based model of care.
- The term “collaboration” has several meanings. In states that restrict an NP's ability to practice up to his or her full scope, collaboration refers to a formalized regulated relationship for licensure to practice where physician colleagues are legally liable for patients they may not actively be managing. Collaboration within the emergency care context, however, refers to well-coordinated interprofessional, team-based care.
- Board certification for an ENP acknowledges that the NP has obtained additional knowledge in the care of patients of all ages and understands prioritization, resuscitation, and initial management of urgent and emergent medical conditions. Board certification does not empower an ENP to work independent of physician consultation and collaboration.
Priority efforts and opportunities moving forward:
- It is imperative that NPs working in emergency settings maintain clinical competency through continuing education in emergency care. AAENP, the Emergency Nurses Association, the American Association of Nurse Practitioners, ACEP, and the American College of Osteopathic Emergency Physicians all provide emergency-specific continuing education that NPs can use to prepare for ENP Board certification. Pediatric, adult-gero, and acute care NPs working in the ED who are interested in obtaining emergency-specific certification need to work with their population certifiers to request a process for acknowledgement of their experience and education as emergency care providers.
- There are many areas where future research will improve policies related to APP clinical practice. Interprofessional collaborative research can test educational models and outcomes to determine what best prepares NPs for emergency care practice. Research to study educational models to prepare NPs for rural practice and exploring innovative care model outcomes, such as telehealth in ED settings, is critical to improving emergency care throughout the country. Finally, research to assess the APP ED workforce and projected needs with consideration of APP/MD team staffing models is needed as ED trends continue to be tracked.
Our practice is more energized and our relationships with our EM colleagues stronger than ever before. New models of care reaching from the confines of the traditional hospital-based ED bring with them new opportunities for ENPs to work collectively with our MD colleagues to improve emergency care within our communities. What attracts us to emergency care practice may range from lifestyle benefits to the challenge of serving our communities and patients at their most vulnerable moments. But ultimately, it is having the opportunity to participate as members of well-coordinated, highly efficient teams that entices our continued work as ENPs. I left the ACEP Board meeting with a clear understanding that our ACEP physician colleagues respect our work, support our role, and value our contributions as team members in emergency care. I believe our future in emergency care depends on the interprofessionalism that we achieve as a team each and every day we serve the public as ENPs.
—Dian Dowling Evans, PhD, FNP-BC, ENP-C, FAANP, FAAN
Clinical Professor and Emergency Nurse Practitioner Speciality Coordinator
Nell Hodgson Woodruff School of Nursing
National Organization of Nurse Practitioner Faculties (NONPF). (2017). Nurse practitioners core competency content. Retrieved from https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/competencies/2017_NPCoreComps_with_Curric.pdf