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SCCM Pod-449 Family Nurse Practitioners in the ICU

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Family nurse practitioners (FNPs) who do not have acute care certification may be recruited to work in ICUs that lack enough acute care nurses, which is a challenge for both the ICU and the FNP. When the FNP moves on to another institution, that institution may not consider the FNP’s ICU experience to be an adequate qualification. Host Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, is joined by Christian Santos, MSN, FNP-BC, and Mariah Rose, ARNP, both nurse practitioners at Mayo Clinic in Jacksonville, Florida, to discuss the difficulties of FNPs who need acute care certification to work in ICUs. Christian Santos, MSN, FNP-BC, is a nurse practitioner at Mayo Clinic Hospital in Jacksonville, Florida, USA. Mariah Rose, ARNP, is a nurse practitioner at Mayo Clinic in Jacksonville, Florida, USA.

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Diane C. McLaughlin, DNP, AGACNP-BC, CCRN (Host): Hi, I’m Diane McLaughlin on behalf of the SCCM APP Resource Committee. We’re starting a podcast to talk about topics relevant to APP practice. I’m here with Christian Santos, who works in the ICU at Mayo, and Mariah Rose, who works in the ICU at Mayo, both in Florida. We’re going to have a conversation today about FNPs in the ICU.

Christian Santos, MSN, FNP-BC: Thanks for having us. I’m really excited to talk about this topic because this is something that we talk about on our days off and we talk about it at work and I think it’s pretty relevant across the board for a lot of nurse practitioners in different areas, whether FNPs should be in the ICU or whether acute care should be in primary care.

Mariah Rose, ARNP: I’m Mariah Rose and I echo Christian’s sentiment. Yes, this is something that’s near and dear to our hearts, particularly with us receiving our education as family nurse practitioners but being mainly employed and only employed in critical care, so it’s good to have this conversation.

Dr. McLaughlin: It’s interesting, I’m a little outnumbered, I’m the acute care representative here, but when I first started working with nurse practitioners, one of my early mentors was an FNP. To this day, I think she’s one of the most brilliant people I’ve ever met. When I joined the practice at Mayo, I think there were only two acute care nurse practitioners. Everybody else was family.

Christian: I think how you get started as an FNP and end up in acute care is a common track to take for some people who either were going to school in an area that didn’t have acute care options available locally or you have been grandfathered in now because you’ve been practicing for a decade plus and acute care either wasn’t an option to take anywhere or wasn’t readily available to you. For me, when I went to school, I knew that I wanted to be in the ICU, I was an ICU nurse and I loved it, and a lot of my mentors were ICU practitioners or, I should say, practitioners in the ICU, but I was very naive as to what scope of practice meant, and the resources available to me for acute care were a lot fewer than for family practice. And my little naive self thought that family practice would make me more marketable. So I decided to get it. I’ll definitely get a job in the ICU because now I can take care of anybody and that’s a common misconception or at least it had been historically.

Mariah: Christian, I don’t think that’s naive at all. It was the way it was marketed, that you see people across the lifespan from birth to death. I chose family in my case because it was really the only option. I graduated in 2011 and started school in 2009, and that was the only option at the university that I attended in Alabama. It is still currently the only option there, they have alternate tracks, but acute care is not an option. I definitely think that just working as a family nurse practitioner in critical care has its challenges and, yes, there was a learning curve, but I don’t know that the learning curve was any more steep than anyone else’s but that’s just because I started working in a very specialized unit. I don’t think necessarily any acute care nurse practitioner track probably prepares you to work in a transplant ICU or cardiothoracic or neuro ICU, it’s more of a broad, general education regarding acute care.

Dr. McLaughlin: Your background is interesting too, because you never worked in the ICU, right? You were an ED nurse.

Mariah: Yes, exactly. That was another reason I didn’t feel that I was at a disadvantage because there wasn’t an acute care option. Had I been at a university that presented me with two options, I probably would have chosen acute care because I knew I wanted to be in the hospital setting. I had always worked as an ED nurse. I liked the acuity of those patients. My thought process when I graduated was, I’ll go work in the ED. But we relocated from New York to Florida, and Mayo had positions available, so I sought employment in the ICU. I thought that I would be able to see patients when they’re in the ED but also see the evolution of the things that we do. We treat things in the ED, but then they go home. I wanted to see how the interventions that we did in the ED played out in the ICU.

Dr. McLaughlin: The vision initially was that they wanted you to go back and get your acute, right?

Christian: Yes, I think when a lot of us were hired, that was the original thought process. But then our model is not unique in the sense that a lot of rural institutions have FNPs in the ICU, because that’s the supply of nurse practitioners that they have. But for a large city in an academic institution, it is a little bit unique for us to have such a high FNP population in our group. So they originally thought, well, we’ll just send them all back to school later and it’ll be fine, but it’s become such a successful model that we haven’t been pushed to go back and get any kind of certification because we are fully integrated into our practice.

Mariah: Agreed. The focus for most of us, and which has probably been more personal than the institution’s idea, is to obtain our DNPs. That’s where the majority of us are headed at this point. I’m hopeful that in the future there may be such an option as family nurse practitioner eligibility to sit for the emergency nurse certification. Something similar will be for family nurse practitioners who work in critical care. Once you meet specified criteria of education in the ICU, continuing education, clinical hours, and skills competency, we will be eligible to sit for the acute care boards.

Christian: Yes, this is something that Mariah and I have had lots of very heated discussions about because it’s silly to me that we have practiced in the ICU for years and years. We take care of incredibly high-acuity patients and we teach for local acute care programs. We precept local acute care students. We post our own educational opportunities in the sense of CME courses. Yet we have to go back and take clinicals to get our acute care certification. That really burns me up.

Dr. McLaughlin: Yeah, that doesn’t seem like it makes a lot of sense or that it would add much to your practice at this point in your career.

Christian: Exactly.

Dr. McLaughlin: It’s interesting. From the acute care standpoint, I also was naive in regard to what scope of practice meant. I thought it was more setting based rather than population based, but over the last 10 years, in acute care now, you see patients in clinic, it goes the opposite way too. But there are a lot more FNP programs than there are acute care, and there are fewer acute care jobs right now. So I think there’s some animosity building that people who are graduating from acute care programs are the ones who think, no, FNP needs to stay in the FNP lane and acute care needs to stay in acute care just because there’s so much competition for every new job.

Christian: I think that makes sense, especially for cities and larger tertiary centers. But if you go into rural America, that’s not the case. Then you’re technically telling those nurse practitioners that they are practicing outside of their scope because they’re practicing in an ICU when there is no other option.

Mariah: I don’t know what to say about that. I don’t think there should be any animosity among any of us. We all have the same objective and that is to take care of patients, to provide high-quality, cost-effective care. But I think, in the future, as there are more acute care programs, that it is wise that nurse practitioners who are educated in acute care go into acute care. My problem with it is that for family nurse practitioners from 10 years ago, it’s almost punitive. If I am to go into work in primary care after having never done that at all, I feel ill-equipped to go and find a job. I’m faced with that now. I’m relocating from Florida to North Carolina and every job that I apply for says acute care certification required. I even contacted one of the human resources personnel and told them I have 10 years’ experience in an ICU and they said they’re only interviewing people for acute care who have acute care certification. That is insane to me.

Dr. McLaughlin: That’s insane to me because, not only is it 10 years, it’s good years of some of the most difficult patients. Instead, they’d rather take somebody who is brand-new with no experience because the certification is correct.

Mariah: But I also feel like their hands are tied. If they want to be in compliance then they’re doing what they feel they have to do. So, although I don’t feel like it makes sense, I can also understand it from their standpoint. That’s the reason I argue and advocate so much. There has to be something done for these people who are in between, the people who went to school years ago and have only been practicing in critical care. There has to be an option for those people or you’re going to start having a shortage. There were multiple jobs online for acute care nurse practitioners in the city where I moved. I could fill one of those jobs with ease, but I can’t because I don’t have the certification that is required.

Christian: Do you have something to add to that?

Dr. McLaughlin: That’s crazy because it’s the opposite in the urban center, that one job posting in a city that’s saturated with acute care. That job is not going to stay open and there’s going to be high levels of competition. That’s what Cleveland was like. It was nice to come in with experience and the right certification because I didn’t have that problem. But teaching up there, all of these new grads, it was taking a lot longer for them to get jobs than it has ever in the past, just because there are so many of them between the different schools in the area.

Christian: It brings up an interesting point as to the consensus model, that was 2008, right? Medicine is changing rapidly. The population is aging rapidly and becoming more medically complex. Sicker. We are holding ourselves back by trying to be in compliance with this certification problem where you have a 10-year-plus-experienced FNP who’s had 10 years of critical care experience, and you’re not going to hire them simply because of this certification rule. So are we holding ourselves back by that? Should there be changes to that as medicine changes and as nurse practitioners change? That’s opening a whole can of worms.

Dr. McLaughlin: Nurse practitioners are the only group that does that. As a registered nurse, I can work in a pediatric ICU and then next year, say that really made me sad, taking care of those sick babies, I’m going to go to a nursing home, and then I’ll think, oh, this is boring, I think I’m going back to the ICU, but let’s do adults this time. And it’s no problem. Same with PAs. Same with residents. They can jump programs. Physicians can take care of anybody, but nurse practitioners, we’ve said, no, you have this, this, this, and this. And that’s it. Even though everything we’re trained to do is essentially the same up until the point of clinicals, which is where it diverges a little bit but probably not enough to say that after a little bit of education, I can go and practice.

Christian: Yes, I’m sure it’s great for the programs, right? Because now they’re more competitive because they have this label on them to say, I’m an acute care program, come to mine because you get to work in the hospital, or I’m a family program, come to mine. But for those of us practicing, it’s really limiting. We may want to be rocking in the ICU for 15 years, but then you may get tired and you might want to go someplace like a PICS clinic, for example. And can you, if you are acute care, starting in the ICU and then merging into the clinic, you’re practicing outside your scope at that point, which is crazy to me.

Mariah: Yes, I echo your sentiments as well. We talk about this over and over but I think it’s a much-needed conversation and I’m glad to be here with you today. Santos, you mentioned the complexity of patients, I think that this is where all the dual certifications come into play. I think they’re putting forth effort to try to eliminate some of that. But at what point is enough enough? Trauma is a very specialized thing. Cardiothoracic procedures that have these mechanical circulatory devices are very specialized things. At what point is there going to be, I don’t want to say almost a one-size-fits-all, for lack of a better term, that I can do from birth to death and choose acute care. That’s one option. Then you can do birth to death and do family as an option. I don’t know. I think that there’s still some work to be done on this.

Dr. McLaughlin: Then it brings up on-the-job training and, dependent upon the strength of the orientation or now residencies and fellowships and postgraduate, which is another hot topic, is everybody created equal? It’s more individual than certification based when you graduate. It’s the quality of the training that you receive that really makes you ready to practice.

Christian: PAs do that, right? PAs come out as essentially generalists and then if they want to specialize or further their training individually, they can go to postgraduate fellowship programs. If you wanted something very specific, like cardiothoracic ICU, you may be able to find a fellowship and it works for them. It works for physicians. I’m not saying that NPs don’t do that as well, because they do, but their hands are tied by this rule. And I do think that it will take years and years to change something like that because you’re changing the minds of nurse practitioners who have practiced like this for decades across the country. But I do agree with Mariah as to: What can we do for FNPs now? What can we do for the acute care nurse practitioners now who maybe want to do primary care?

Dr. McLaughlin: Or a 12-year-old is admitted to the ICU and we can’t take care of them, or we do take care of them, but the attending has to write the notes. So nobody knows who is ever taking care of them. It’s like these ridiculous games.

Christian: And that number is so arbitrary.

Dr. McLaughlin: Right. Because a lot of these 12-year-olds have beards and drive cars.

Mariah: I don’t have that kind of 12-year-old yet, Diane. Hold back, hold back.

Christian: It’s true though, that you’re limited by these rules that people made, right? We’re human. We can make a rule that we think makes sense at the time, but we also have to be humble enough to reevaluate if this is the right thing to do, or was it the right thing to do at the time. And now we have to readdress it and catch up with the times. And I think that that’s what we’re going to look at as nurse practitioners in the next decade.

Dr. McLaughlin: There are so many more nurse practitioners than there were 10 years ago.

Christian: Absolutely.

Dr. McLaughlin: And there is not one FNP whom I’ve worked with that I have questioned their ability to provide excellent critical care.

Mariah: One thing I was thinking about is, as I’ve kind of belabored this point, that all of my experience is in critical care and having to go into a primary care setting and being expected as an experienced nurse practitioner to function at the same level as an experienced nurse practitioner in primary care, to see 20 or 25 patients a day and to be efficient at that, to be knowledgeable about disease prevention, health promotion, all of those things. Yes, we are all educated. All nurse practitioners should have knowledge of those things, but it’s not the same, the experience that I have gained over my years in the ICU has equipped me to take care of ICU patients, it has not equipped me to take care of family. And now I just simply feel kind of stuck in between. I don’t really know much what to do, outside of going to an acute care nurse practitioner program and obtaining that certificate. But when you think I have 80,000 hours in critical care attended, I don’t know how many conferences from SCCM to Harvard to Mass General to AANP, a lot of ongoing clinical education work at an academic institution have been checked off in multiple procedures. I don’t want to make it seem like I don’t feel that the programs have anything to offer because I am open to learning anything. I do think that there’s value in ongoing education, but I do not feel that the value that I’m going to get out of going through an acute care program is going to be beneficial in the sense of the thousands of dollars it would take for me to do that, the time away from my family and the limited hours, then I would probably need to work at my actual full-time job.

Christian: Yes, that makes me sad. It makes me sad that there NPs out there like you, Mariah, who have such excellent experience and, working alongside you for the last 10 years, I can fully attest to the fact that I would let Mariah take care of any of my family in the ICU, but I’m just baffled by the fact that we have providers out there who have such excellent experience and we’re not utilizing it. Making them go back for a certification and do clinicals just so that they can find a job is crazy.

Mariah: I understand that the consensus model says everything has to line up and I am an advocate of the consensus model.

Dr. McLaughlin: Really?

Mariah: Certain components of it, having the uniformity of education across state lines I think makes us stronger as nurse practitioners. A nurse practitioner who had received their education in Alabama is the same as a nurse practitioner in Florida is the same as a nurse practitioner in Washington State. If that improves the quality and the reputation of our education as nurse practitioners. I simply think that there were unintended consequences of the implementation of the consensus model.

Christian: I can absolutely agree with the education aspect, keeping consistency of quality because you’re right, you don’t want a nurse practitioner from one state.

Dr. McLaughlin: I’m sorry, this is a buildup. People attach all of these amendments, because times have changed. There are components that maybe were good, but not even all states endorse it. So what good is it?

Mariah: That true. I’m just pointing out that you can look at the positives in anything, right? There’s something positive.

Christian: Mariah is always bringing the light in the room. I agree with you in the sense that there are good aspects of it but, as Diane pointed out, you have all these things attached to it. Yes, you could argue that it does make sense, it is a good model, it does keep us in line of quality, and I know this is going to upset some people, I think it’s holding us back.

Dr. McLaughlin: Yes, I think it’s outdated. I think it’s time to have the conversation.

Mariah: Absolutely.

Dr. McLaughlin: I’m hoping that this does that and reopens it. Every five years or so, somebody gets really excited and starts bringing it up and then nothing happens.

Mariah: Absolute agreement that there need to be, quote, amendments to the model. I thought of one more thing. If you want to be in compliance, every five years we have to go and recertify, right? So, I just did my recertification for my family nurse practitioner license with my hours that I worked in critical care.

Dr. McLaughlin: And that’s cool. Not a problem.

Mariah: I’ve never had a problem. No one’s ever told me there was a problem.

Christian: I’ve never had a problem. Now, and this is something that annoys me, I have always gone to specific conferences to try to get more family practice hours for my recertification that have nothing to do with my practice clinically. I am an academic at heart. I am constantly in school. I work at an academic center, academically productive. I love learning and I have no problem going to these conferences and learning. I usually take a friend or two and we have fun but I can truly say that I’ve rarely taken something from those and implemented it into my practice just because it’s not the setting. I solely do it for recertification purposes.

Dr. McLaughlin: We have to start wrapping it up, but I think my closing point would be that a lot of my training came from FNPs and I value the ones I work with. So thank you for teaching me and being great team members and being inclusive in care. And I’m all for changing the way that things are.

Christian: I love my team and it’s full of both FNPs and acute care nurse practitioners. I never think of whose certification is whose and I really advocate for all of us to grow professionally, and this is just one step in that direction.

Mariah: Agree. I love being a nurse practitioner. And I think that, although this has been challenging for me and hindsight is 20/20, there’s nothing else I would rather do.

Dr. McLaughlin: We’re hoping to release at least one episode of this podcast a month and I think this was a great way to open this conversation. I think there are many more to come. So thanks for tuning in and thanks for being here.

Christian: Thank you so much.

Diane C. McLaughlin DNP, AGACNP-BC, CCRN, is a nurse practitioner in neurocritical care at University of Florida Health Jacksonville. She has worked in critical care for almost 20 years. She has taught at the ACNP program at Case Western Reserve University, acted as a clinical preceptor for University of Florida and Ohio State University master of science in nursing students, and is currently an assistant professor of neurology at the Mayo Clinic School of Medicine. She has published over 25 peer-reviewed articles between 2017 and 2021, authored multiple chapters in textbooks and nurse practitioner board review books, and was sole author of Fast Facts About Neurocritical Care, a Quick Reference for the Advanced Practice Provider. Dr. McLaughlin is active in national organizations and is currently chair of SCCM’s APP Resource Committee. She is a member of the SCCM Ultrasound Committee, as well as faculty for the ultrasound course. She is active in the Neurocritical Care Society, serving on both the Guidelines Committee and in APP leadership.

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