Duquesne University Adult-Gerontology Acute Care Nurse Practitioner

I’m Dr. Dillon, and I’m just going to talk with you a little bit about an overview of the Adult-Gero Acute Care NP Program, which is a new NP track being offered here at Duquesne. What I want to cover today are the goals of the NP clinical specialty for Adult-Gero Acute Care to be a brief overview of the curriculum and the core courses, as well as the specialty courses and then I’ll provide you with some course specific information as well.

I’ll talk a little bit about clinical experience, including preceptors and what will be some of the proposed clinical sites for the students, talk about their national certification, professional organizations and some of the graduation requirements. First, what is an AGACNP? And that’s what I’ll call it from here on out, rather than the long Adult-Gero Acute Care NP. There are multiple types of nurse practitioners. There’s the family nurse practitioner, which we have a program here, of course. I just heard you talking about it. Adult Gero is divided into both the Primary Care NP, as well as an Acute Care NP.

The pediatric population is similarly divided. There’s an Acute Care Pediatric NP Program and a Primary Care NP. Then there is psych- mental health, which is the other new program that’s being launched. So the AGACNP is the NP that provides, and I’ll just read you the official definition. Comprehensive advanced nursing care across the continuum. So we go from age 15 to old, old adult. Healthcare services to meet individualized needs of patients with acute critical and or complex chronic health conditions. These are the patients who are unstable they’re in usually hospital settings. They rely on a lot of advanced technology and a lot of times there are aged population. So the material is built into the management courses to enable the students to be able to care for this patient population.

So why do nurses choose this role? And usually it’s registered nurses who are really into the technology part of healthcare. A lot of them have an intensive care unit background. They like the monitors. They like the invasive lines. They like to be titrating medications that adjust blood pressures and heart rates. They’re really into that aspect of care. They really like complex patients. They like somebody who has multiple medical problems that they’re trying to balance all in one setting. Why the AGACNP role has become so popular, the last several years is for a couple of reasons. There’s actually a shortage of physicians in acute care settings. Fewer physicians are actually enrolling in medical school today. That’s just adding to this burden of physician shortage because not only do we not have primary care, but then we don’t have physicians going into subspecialties like cardiology, pulmonary, et cetera.

Several years ago, there were changes in what was called the resident duty hour restrictions. So there was a lot of publicity on the evening news on this, where residents used to work like slaves. 80 hours in a week, and they were very fatigued and there’s a higher incidents of errors in medications and care delivery associated with this. There was a restriction that was put in place probably about, I hate to say close to 10 years ago now, where their duty hours were restricted. And so when they’d limited the residents to only working 40 hours a week or 50 hours a week, that left a huge gap in patient care that the residents were providing for that now the Acute Care NPs helped fill that gap.

So most Acute Care NPs, the important thing for everyone to understand about it, is they’re not specially or setting specific. You can be an Acute Care Nurse Practitioner and work in a cardiology practice in the community. The role is not defined by its setting, but by the population that you take care of. Most are employed though in acute care setting. So the vast majority will seek and be employed in a hospital setting. Intensive care units are a high demand for them because of the special skills that these NPs will provide. They can insert the central lines and the hemodynamic monitoring lines that are required for this technology that I was talking about. They also work a lot in the emergency rooms, not so much the urgent care area, but the actual emergency room part where a trauma patient may come in or an acute MI.

Somebody who’s very ill, very unstable, requiring very quick judgements to be made in their care. As I mentioned, they can be employed in a specialty practice. Those are some of the other areas that they’re employed in frequently. One very popular role within the Acute Care setting that Acute Care NPs are filling, that is the role of the hospitalist. If you’ve been in the hospital in the last five years, you know that your primary care physician no longer follows you to the hospital and manages your care while you’re there. It’s usually turned over to the hospitalist team and that’s a position or provider. Now it’s the Acute Care NPs who will manage your care from admission to discharge and employ consultants in the interim. Those are many of the places that Adult Gero Acute Care NPs are employed.

Salary? It’s getting better I can say that. Starting salary and this was from September of this year, starting salary is around 91,000, but it can be up to 104,000. That depends on, whether they take, say Allegheny Health Network has what they call a nocturnal hospitalist. That person really runs the hospital at night. So if there’s a patient that has a cardiac arrest, they are managing that, they’re inserting lines. There’s a lot of responsibility with that role. They’re compensated for that in their salary. The average salary, somewhere around 102 to 117,000. They get paid well and get reimbursed well. Career opportunities, as I mentioned, they’re continuing to increase for this role. And the AGACNP role has only been around since up 2000… No, I’m sorry, 1998.

Right after former president Bill Clinton passed the balanced budget act and that got reimbursement for nurse practitioners in settings other than in the rural community. So that’s really when the Acute Care NP programs started to take off. Then the physician shortage, the resonant duty hour restrictions, all this enhanced the career opportunities for them. The other thing that’s helped us is there’s an increase in aging population we’re fortunate. We’re treating a lot of diseases. We’re managing that diabetes and coronary disease a lot better. So our patients are living longer, but when they come in to the hospital, they’re really sick today. And so they have very high complexity of health care needs.

What are some of the challenges that Acute Care NPs face? And you probably have seen this on the evening news related to COVID. A lot of those providers are showing you, physicians are shown to you the infectious disease physicians, that some of the people behind those mask and that PPE are Acute Care Nurse Practitioners. It’s a very stressful job due to the acuity of the patients.

Hospital credentialing, getting employed is a process in itself. Sometimes it can take three months depending on how often the board meets to get an ACMP actually employed in the hospital setting. They go through the same credentialing that all other medical physician providers go through. There are still practice barriers, just like the FNP faces, the Acute Care NP faces that as well. Sometimes we are allowed by our scope of practice to say, do certain things like place central lines, intubate a patient who’s having breathing problems. And you may go to a hospital that says, you’re not doing that here. So there’s practice barriers at all of the space. Those are things that as NPs, we are working both at the local state and federal level to try to improve practice.

Opportunities in the role and advancement. As I mentioned, I think they’re just going to continue to be increased employment opportunities. I mean, unfortunately, right now with COVID, those patients are in the environment that the Acute Care NP works in. You can see from just watching the news, what the complexity is and how sick these patients are. Hospital systems are continuing to see the benefits of employing an Acute Care NP to help with these patient populations. They’re realizing from the data that’s out there, that we provide safe, reliable, quality care within the ICU setting with the same patient outcomes that physicians provide. Unfortunately we still do it at a lower cost than what they do. What’s the background and experience required to be an Acute Care Nurse Practitioner? This varies from program to program, but here at Duquesne, the requirement is one year acute care experience. That means the RN has to have worked in the hospital setting for one year.

Some schools require one year of ICU or emergency department experience for enrollment. And my doctoral work actually looked at, was there a difference in how these students transition to practice? If they have a background in ICU versus say, somebody who’s worked in a med surge area and much to my surprise and disappointment was there is no difference. My study has now been supported by two or three other studies saying the same thing. So from the faculty perspective, I just have to make sure that I supplement in the curriculum, what those needs might be. Maybe those students did not know how to read an EKG. So I have to make sure that they get that content in their curriculum, but there’s no difference. So there’s no reason to exclude people because they don’t have the experience. If I believe in research, which I do, then I have to believe my own.

Even if it isn’t what I thought I was going to be finding, that’s why you do the research. So preceptor information. Again, they’re going to be in the Acute Care setting. So ideally it would be nice if they were within the Acute Care NP as a preceptor. They could also be with a physician and that could be an MD or a DO. And because FNPs have been around a lot longer than Acute Care NPs, there are a lot of very skilled FNPs that had been working in an acute care setting for many years. And I am not opposed to them partnering with an FNP that has been in that role. They just cannot have a physician assistant as a preceptor and that’s for the board of nursing. So the sites that we use are some fairly large medical centers. Allegheny Health Network, University of Pittsburgh, and there’s other local healthcare systems or emergency departments. If the students are from other regions other than Pennsylvania, I have connections in Ohio that I’m helping some students with right now get preceptors connected to for spring.

Some of the associations and organizations that we definitely make sure the students are involved with are the American Association of Nurse Practitioners. They’re a great organization to belonged to as a student, as well as a practicing NPA, because they help guide our practice. You will know the latest things that are going on legislatively. They also help mentor new NPs, which is very important. We have the Pennsylvania Coalition of Nurse Practitioners, and there’s a Southwestern Pennsylvania chapter. We encourage students if they are from this area to join that because that’s a great way to meet other NPs and find preceptors or clinical sites to go to. It’s also a great way to find a future employer. These organizations provide as part of their membership. You get a free journals to journal for nurse practitioners, the nurse practitioner journal and journal of the American association of nurse practitioners, which are all great clinical and research journals for NPs.

So the APRN role; MSN with a specialty focus and Duquesne University school of nursing, the program is regulated by the PA board of nursing CCNE and NLNAC. So the course objectives, the clinical courses, who we allow as preceptors clinical sites, qualifications, including mine, are all regulated by these organizations. We remind the students of that periodically because once they wonder well, why can’t I be with a PA? And why can’t I do whatever that seems like a crazy rule. Sometimes they do seem that way, but we have to follow those rules to be accredited. So we also utilize not for the national organization of nurse practitioner, faculty for guidance, for curriculum. And again, it helps explain to everyone why we make the decisions we do for this program as really, as well as any of the NP tracks.

So requirements following graduation, they have to maintain their RN, state licensure, that the program prepares them for their national board certification. The state license. Again, that requirement may vary from state to state, but pretty consistent. Pennsylvania you renew every two years and you renew by continuing it in practice and malpractice requirements. It’s not always transferable between States, although some States are coming up with compact licensure. So, and don’t quote me on the state, but I’m just going to give you an example. Maryland’s really close to Virginia. So they may have a transfer of the state license, but we don’t have that in PA. Then the national board certification is exactly that. It is national and that certification is recognized from state, to state, to state. Again, they take an exam at the completion of the program for the Adult Gero NPs. That is the American nurses credentialing center and or the American association of critical care nurses are their two certifying bodies? They’re both certifications are accepted by every state, but with the renewable, every five years, both require a practice hour requirement and continuing to renew

The curriculum, there are core courses like there are for any NP program. We have the three Ps that we call it and that’s pathophysiology, pharmacology and physical assessment that all NPs have to take. During this part of the program, they are with the other NP tracks. The management specific courses for the Acute Care NP, there’s a total of 18 credits or four classes. It’s a total 11 don’t quote me on this one because I think it’s a moving target, but it’s about 33 credits. So the three Ps plus the six core MSN make-up 15 credits and the remaining 18 are specialty specific credits. So if you’re a post-master’s student, you don’t have to do the three Ps again, in most instances, as long as they have been cheerfully within a five-year timeframe. So they just have the AGACNP management courses and the clinical that’s associated with that.

So the course rotation, this is how it is set up at present. Their first clinical courses, the one of the three Ps physical assessment, it’s three credits. At Duquesne, they have 50 hours with a preceptor plus 25 hours of a campus week, which is hands-on skills such as suturing, et cetera. During that rotation, I really don’t want the AGACNP students to necessarily be in a hospital setting because I want them to be able to be with the patient that they can actually take a history from and examine. I don’t want them being in the ICU where somebody can’t talk to them or maybe the information is not reliable. So I want them to get a really good foundation and physical assessment. So for this clinical, they may be in a primary care setting, which is, I think perfect. Then the first management course is GNAG 550, it’s three credits, 75 clinical hours in 15 weeks.

They will also have a campus week. I’m in the process of developing that now, but I’m contemplating that because this course is airway management, management of a ventilator that their campus week will be insertion of arterial lines, inserting airways and intubating patients and managing patients that have difficult airways. Then their second management course, GNAG 551 is five credits, and they will be in an ICU setting for this clinical. There’s 200 clinical hours and 25 hours of a campus week. And part of the skillset for an Acute Care NP is inserting chest tubes, inserting central lines, human dynamic monitoring. That will be part of that campus week.

Then the third management course is GNAG 552 or AGACNP two. It’s also five credits and I have here central lines, but I am moving that up sooner because I want to get them to have the didactic and the hands-on. So then in the clinical setting, they have that more time to be performing those skills if the opportunities arise. If I put them too late in the program, they’re not going to get the opportunities that they need to really hone those skills. So that semester is 200 clinical hours and 25 hours of campus week as well. Then the final management course is GNAG 553, or the third course, five credits, 225 clinical hours in 15 weeks. I don’t have a campus week with that because I’m hoping they will have all of their skill content covered and they can be out practicing this in the clinical setting.

That’s a quick overview of the courses. As far as time management, this is probably one of the hardest things for any of the students in the NP track. And it’s probably why a lot of RNs do not choose the NP tracks because the clinical component is really., It’s hard. It’s hard to put in the 200 hours in a semester, 225, plus the course content. So we provide them with a little guide on what the minimum amount of time they should spend per week studying for these courses. You can see the breakdown there. And this minimum time per week is exclusive of their clinical hours that they have. The message we’re sending here is, it’S pretty hard to work full time during the program. Although a lot of students need to maintain a minimum amount of hours so they can continue to get tuition reimbursement from their healthcare systems.