The role of adult gerontology acute care nurse practitioners

Author(s): Heidi Elgart, MSN, RN, ACNP-BC

This growing field offers opportunities in a variety of settings.

Your perspective of the nurse practitioner (NP) role may be shaped by the NPs you encounter at work. Perhaps you think that adult-gerontology acute care NPs (AG-ACNPs) are limited to the hospital. But the truth is, AG-ACNPs manage patients based on their acuity and needs, not the setting. They care for adolescent, adult, and geriatric patients in a variety of inpatient and outpatient settings.

Knowing about the educational preparation required for AG-ACNPs, as well as the settings, roles, scope of practice, and job outlook, will help you decide if this is the right career step for you.

Education

Many AG-ACNP graduate programs (masters, post-masters, or doctor of nursing practice) require 1 to 3 years of experience working as an RN in an acute care setting. An understanding or familiarity with acute care diagnoses and interventions provides a baseline for learning advanced assessment and diagnosis skills and how to manage acute diseases or acute exacerbations of chronic conditions. NP students often draw from previous clinical situations or patient encounters while learning in the classroom and participating in NP clinical rotations.

Core curricula vary across AG-ACNP programs but they all must include advanced physiology/pathophysiology, pharmacology, and physical assessment (the “Three Ps”). AG-ACNP programs also focus on epidemiology, assessment, diagnosis, and treatment for a range of acute and chronic illnesses and injuries. Technology courses teach advanced diagnostics, including electrocardiogram (ECG) and x-ray interpretation, central venous catheter insertion, lumbar puncture, chest tube insertion, and lab result interpretation.

Simulation frequently is used to teach and evaluate clinical decision-making and criticalthinking skills. AG-ACNP students complete a minimum of 500 hours in faculty-supervised clinical rotations, which usually include different acute care settings and patient populations, giving students the opportunity to apply concepts learned in didactic classes and simulation to gain real life experience. A variety of clinical rotations allows students to explore specialty areas, network with other providers, and observe practicing AG-ACNPs.

Transition to practice

Learning doesn’t stop after graduation and certification. (See Certification and consensus.) Orientation and onboarding for new AG-ACNPs vary by institution, individual provider, and role. Differences in AG-ACNP programs and previous nurse experience mean that orientation should be individualized. For example, an RN who has spent several years working in an epilepsy unit and is then hired into the neurology practice as an AG-ACNP to manage the same population with the same providers might need less orientation time than an AG-ACNP who worked on a surgical unit as an RN but is hired onto a hospitalist team to manage patients with acute medical issues.

Many hospitals and outpatient practices have established onboarding processes and competency-based orientations to help provide a smooth transition. Some organizations offer fellowships or additional training. Postgraduate fellowship programs can help ease transitions and increase knowledge and clinical experiences, especially in high acuity settings like critical care. The duration and design of post-graduate fellowships vary.

Certification and consensus

After development of the Consensus Model in 2008, the American Nurses Credentialing Center (ANCC) certification exam was changed from adult acute care to adult gerontology acute care to reflect the population focus outlined in the Consensus Model (see bit.ly/2JKWklb). Adult gerontology acute care nurse practitioner (AG-ACNP) students now choose to take one of the two national certification exams:

AG-ACNP certification exam offered by ANCC
ACNPC-AG certification exam offered by the American Association of Critical-Care Nurses.

Implementation of the Consensus Model and its adoption by the state boards of nursing requires that NPs work with the patient population for which they received a formal education, were nationally certified, and received licensure. For example, if you’re a nurse with several years of experience working in an ICU and you complete and graduate from a family nurse practitioner or other primary care NP program, you don’t have the formal education and training to manage acute diseases and conditions. You would have to complete an AG-ACNP program and pass the certification exam before being permitted to care for acutely ill patients.

Settings and roles

The National Organization of Nurse Practitioner Faculties describes AG-ACNPs as providers who care for “patients with unstable chronic, complex acute and critical conditions.” This broad definition means that the AG-ACNP role isn’t limited to the hospital; instead, it’s defined by patient need. For example, a patient might present to the emergency department (ED) with chest pain where an AG-ACNP performs an examination, orders an ECG and serum troponin level, interprets the ECG, and diagnoses the patient with an ST-elevation myocardial infarction (STEMI). This prompts a STEMI alert and an AG-ACNP on the cardiology service works with the cardiologist to transition the patient to the cardiac catheterization lab for an interventional procedure. After the procedure, a cardiology AG-ACNP manages the patient and then after discharge, he or she receives follow-up care with another AG-ACNP in the outpatient cardiology office.

The results of a 2016 American Association of Nurse Practitioners (AANP) survey looking at the practice settings of AG-ACNPs show that more are working in outpatient areas, urgent care centers, and group practices compared to results of the 2012 survey. These results demonstrate an expansion of the AG-ACNP role beyond inpatient settings where most AG-ACNPs initially practiced.

In addition to role expansion outside of the hospital, roles within the hospital have expanded as well. For example, a hospitalist AG-ACNP might admit a medical patient from the ED, manage the acute and chronic healthcare issues while the patient is hospitalized, and help with communication back to the patient’s primary care provider on discharge. Palliative care is another relatively new role for AG-ACNPs, either as part of an inpatient team or in the outpatient setting. AG-ACNPs on palliative care services manage patients with life-threatening illnesses; treat symptoms like pain, dyspnea, or nausea; lead goals of care discussions; and coordinate complex care by collaborating with other members of the patient’s healthcare team. (See Where do AGACNPs work?)

Scope of practice

AG-ACNP scope of practice are defined and described in AACN Scope and Standards for the Acute Care Nurse Practitioner 2017. Additionally, scope of practice can be narrowed or limited by the state where the NP is licensed or the hiring institution, service, or practice.

AG-ACNPs are prepared to diagnose and treat patients with acute or critical issues, or acute exacerbations of chronic health conditions. Specifically, they’re qualified to obtain health histories, perform physical assessments, develop differential diagnoses, order and interpret diagnostic studies, determine management plans, order pharmacology therapies and other therapeutic interventions, collaborate and communicate with other members of the healthcare team, and facilitate transitions across different levels of care.

AG-ACNPs are hired into a variety of roles with different staffing models. Some are hired onto “NP services” and provide 24/7 coverage for a unit or service. Some AG-ACNPs manage a caseload of patients for a particular specialty practice, while others function as members of existing multidisciplinary teams (see My experience as a trauma AG-ACNP.)

Job outlook and satisfaction

Currently, a high demand for AG-ACNPs exists, and that trend is likely to continue. The U.S. Department of Labor estimates that from 2016 to 2026, the demand for NPs will grow by 36%. This statistic encompasses the projected demand for all NPs; the National Center for Health Work Force Analysis estimates that the need for AG-ACNPs in critical care settings will grow by 16% from 2013 to 2025. Initially, the high demand for AG-ACNPs in hospitals was triggered by the Accreditation Council for Graduate Medical Education 2011 limitation on residency work hours. The continued and projected demand for AG-ACNPs is due to many factors: An aging population and longer life expectancies, improved disease detection and treatments, physician shortages, and changing insurer payments have driven organizations to respond to the challenge of delivering high-quality, cost-effective care by employing AG-ACNPs.

US News and World Report, citing salary and projected growth, ranked NP as number 7 out of the 100 best jobs in 2019. Kleinpell and colleagues report findings from the 2016 AANP survey that 88% of acute care NP respondents said that they feel satisfied or very satisfied with their main NP practice site and that many (31%) intend to continue practicing at their current location for the next 10 years or more.

Exciting times

The AG-ACNP role can be professionally challenging and diverse. Projected demand for and continued growth make it an exciting time to take this next step in your career.

Heidi Elgart is a trauma nurse practitioner at Penn Presbyterian Medical Center in Philadelphia, Pennsylvania, and a course director in the adult-gerontology acute care nurse practitioner program at the University of Pennsylvania School of Nursing in Philadelphia.

Selected references

American Association of Critical Care Nurses. AACN Scope and Standards for Acute Care Nurse Practitioner Practice 2017. aacn.org/nursing-excellence/standards/aacn-scope-and-standards-for-acute-care-nurse-practitioner-practice

APRN Consensus Work Group, National Council of State Boards of Nursing APRN Advisory Committee. Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education. July 7, 2008. ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf

Bureau of Labor Statistics. Occupational outlook handbook: Nurse anesthetists, nurse midwives, and nurse practitioners. April 12, 2019. www.bls.gov/ooh/healthcare/nurse-anesthetists-nurse-midwives-and-nurse-practitioners.htm#tab-6

Doherty CL, Pawlow P, Becker D. The Consensus Model: What current and future NPs need to know. Am Nurse Today. 2018;13(12):65-7.

Hoffman LA, Guttendorf J. Preparation and evolving role of the acute care nurse practitioner. Chest. 2017;152(6): 1339-45.

Kleinpell R, Cook ML, Padden DL. American Association of Nurse Practitioners National Nurse Practitioner sample survey: Update on acute care nurse practitioner practice. J Am Assoc Nurse Pract. 2018;30(3):140-49.

National Center for Health Workforce Analysis. Health workforce projections: Critical care physicians and nurse practitioners. bhw.hrsa.gov/sites/default/files/bhw/healthworkforce-analysis/research/projections/critical-care-factsheet.pdf.

National Organization of Nurse Practitioner Faculties. Nurse Practitioner Core Competencies Content. May 2017. cdn.ymaws.com/nonpf.siteym.com/resource/resmgr/competencies/20170516_NPCoreCompsContentF.pdf

National Organization of Nurse Practitioner Faculties. Statement on Acute Care and Primary Care Certified Nurse Practitioner Practice. 2012. pncb.org/sites/default/files/2017-02/NONPF_AC_PC_Statement.pdf.

US News and World Report. 100 best jobs. 2019. money.usnews.com/careers/best-jobs/rankings/the-100-best-jobs.

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