American Journal of Critical Care. 2005;14: 211-219
CE Article
Acute Care Nurse Practitioner Practice: Results of a 5-Year Longitudinal Study
By
Ruth M. Kleinpell, RN-CS, PhD, ACNP.
From
Rush University College of Nursing and Our Lady of the Resurrection Medical Center, Chicago, Ill.
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Abstract
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The role of acute care nurse practitioners (ACNPs) has developed in capacity. More than 3500 advanced practice nurses have been certified as ACNPs, and the number of practice settings where these professionals work is continually expanding. Beginning in 1996, a series of surveys were conducted of nurse practitioners seeking national certification as ACNPs. What started as an attempt to gather information on the role of ACNPs evolved into a national 5-year longitudinal survey of ACNP practice. The cumulative results of the project are reported, and how the role of the ACNP was established in advanced practice nursing is discussed.
Notice to CE enrollees:
A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:- Describe the progression of participants involved in this acute care nurse practitioner (ACNP) study of practice
- Recognize the manner in which the ACNP role has evolved over the 5 years studied
- Understand outcomes measured and influenced by ACNP practice
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In the newest subspecialty area of nurse practitioner practice, acute care nurse practitioners (ACNPs) provide advanced nursing care to patients with complex acute, critical, and chronic health conditions.1 The role and the scope of practice of ACNPs continue to expand. Originally described as a role suited for nurses who managed complex issues of patients’ care in high-acuity settings, most often in intensive care units (ICUs), the role of the ACNP has broadened in capacity. ACNPs work in traditional settings, including acute and critical care inpatient settings, and in nontraditional care settings such as specialty-based clinics and private practice groups.2,3 However, although ACNPs are acknowledged members of acute care teams, uncertainty about the role of ACNPs persists.
| ACNPs are primarily involved in direct care of patients with acute and critical illness.
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Background and Overview
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In order to gather information about the developing role of ACNPs, a survey research study4 was begun in 1996 with the first group of nurse practitioners who took the national ACNP certification examination. Results from this first survey of 125 practitioners indicated that ACNPs practice in tertiary and secondary healthcare settings, including unit-based areas, urgent-care centers, and multipractice clinics. Predominant role components reflected nurse practitioners’ focus on obtaining histories and conducting physical examinations, prescribing treatments, and initiating transfers and consultations. Although a variety of invasive therapeutic procedures were being performed by the ACNPs, the 3 most frequent aspects of care were discussing care with patients’ family members, ordering laboratory tests and interpreting the results, and initiating discharge planning—all evidence of the integrative nature of the ACNP role.
The survey research was then extended to include the first 3 groups that obtained national ACNP certification. In this study5 of 384 ACNPs, aspects of practice were explored further, including specialty area work settings, major components of the ACNP role, hours worked, salary structures, and work satisfaction levels. The survey results revealed that ACNP practice was expanding to a variety of specialty-based settings, including step-down units, units without house staff coverage, and oncology, transplant, cardiology, and radiology units, among others. Roles were often specialty based, collaborative practice, or unit based. Although most ACNPs were involved in direct management of patients’ care, additional tasks such as teaching, research, program development, staff education, and administrative responsibilities such as committee-based involvement were evolving aspects of the role of these practitioners.
The survey research was then extended to the first 6 groups to obtain national ACNP certification (n = 740), with follow-up on a yearly basis. Longitudinal results from year 1 (n = 619) revealed continued growth of the role of ACNPs.6 Participants also began to identify implications for ACNP educational programs and suggestions for those contemplating pursuing an ACNP position. Study results from year 2 (n = 545) indicated further development of ACNP practice.7 Issues in practice, including the benefits of being an ACNP, resources for role development, and role changes were highlighted.
Yearly follow-up surveys were then conducted for year 3 (n = 530), year 4 (n = 465), and year 5 (n = 437) with the respondents remaining in the longitudinal study (64% cumulative response rate). In order to compare the roles and practice profiles of ACNPs who obtained certification in the first years it became available, an additional survey was conducted in 2001 with all ACNPs certified from 1998 through July 2000 (n = 1027). This comparison group (n = 743; 72% response rate) highlighted additional changes in the ACNP role. The cumulative results of the national longitudinal ACNP survey are described in the following material.
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Study Methods
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A survey with 44 questions on role aspects, practice components, and role changes after certification as an ACNP was mailed annually to participants who had responded to the preceding year’s survey. The survey addressed characteristics of practice settings, role responsibilities, and aspects of practice, including credentialing and privileging status, frequently performed procedures, work requirements, role changes, and plans for employment. Each year, an additional aspect of practice was assessed, including negotiation of benefits, recommendations for practitioners, recommendations for educators, and outcome evaluation. Second mailings were sent to ACNPs who had not responded within 4 weeks of the first mailing.
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Results
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During the 5-year study period, responses were consistently received from 437 participants. Annual response rates ranged from 78% to 97%, with an overall response rate of 86% (Table 1
). Most respondents were women (95%), 29 to 63 years old (mean 43.13 years) (Figure 1) and white (95%). Most worked full time in the ACNP position (Figure 2). National geographic distribution of the participants is depicted in Figure 3. Organizational affiliations included teaching hospitals, acute care and community hospitals, and clinic settings (Table 2).
Most ACNPs reported practicing in tertiary care practice settings including ICUs, with 20% to 26% in coronary ICUs, 14% to 18% in surgical ICUs, 17% to 19% in cardiothoracic ICUs, 13% to 16% in medical ICUs, 6% to 8% in neurological ICUs, 5% to 8% in trauma ICUs, and 3% to 4% in transplant ICUs. Other specialty areas of practice included emergency care (9%–12%), oncology (7%–8%), multipractice clinic (5%–8%), and pediatric (1%–2%) settings. Consistently throughout the 5 years of the longitudinal survey, nearly 50% of respondents did not identify a traditional ICU or an urgent/acute care practice setting, but acknowledged a growing number of practice sites. Table 3 outlines the various practice sites reported by practitioners during the 5-year study.
| Most ACNPs practice in tertiary care practice settings, although nearly 50% did not list intensive care or acute care practice sites, indicating the expansion of the ACNP role.
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Unit-based roles remain an option for practice, with 10% of practitioners continuing to report this type of role. Both specialty-based (increasing from 37% in year 1 to 49.5% in year 5) and collaborative practice roles (increasing from 17% in year 1 to 25% in year 5) have become more popular options for ACNP practice. The main focus of ACNPs is direct management of patients’ care, with 85% to 88% of time spent on that responsibility. Table 4 lists other aspects of the role reported by respondents, including teaching, research, program development, quality assurance, and administrative components.
Most practitioners reported that they were credentialed (81%–86%) and had privileges (79%–84%). Most received their credentials and privileges through the medical staff office (69%–83%) or from the department of nursing (8%–12%) or human resources (2%–4%). Credentials were received through the medical staff office (69%–83%), department of nursing (8%–12%), or human resources (2%–4%). Most respondents received practice privileges from the department of medicine or medical staff office (79%–84%) or an allied health department (11%–13%).
Components of the ACNP position that were identified included gathering medical histories and performing physical examinations, conducting rounds, writing orders, interpreting results of laboratory and diagnostic tests, performing procedures, providing education, consulting, and doing discharge planning. Table 5 lists the activities and procedures that ACNP respondents reported performing. Mean salaries for ACNPs ranged from $59 590 in year 1 to $72 408 in year 5, with the top of the range as high as $130000. The importance of negotiating salary and benefits for the ACNP position was a common anecdotal comment.
| Respondents emphasized the importance of negotiating for salary and benefits.
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Reports of respondents’ satisfaction with the ACNP role are summarized in Tables 6 and 7. Critiques of the role are provided in Table 8, and aspects of change in the ACNP role are listed in Table 9.
In years 3 through 5 of the study, participants were asked to rate the degree of impact they were making in their role as an ACNP on several outcome measures and were asked whether they were assessing outcomes of practice. The results are summarized in Table 10. The number of survey respondents who reported that they were not currently working in an ACNP position remained constant throughout the study at 20% to 22% each year. Reasons for not being employed as an ACNP are summarized in Table 11.
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Discussion
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Although ACNPs were originally envisioned to function primarily in ICUs and high-acuity settings, the role of these practitioners has expanded dramatically. As the results of this 5-year national study reflect, the practice settings of ACNPs are diverse. By virtue of educational preparation and national certification, ACNPs focus their care on patients with acute and critical illnesses. However, as the traditional boundaries of acute and critical care have extended beyond the hospital setting, so too have the opportunities for ACNP practice. Newly developed competencies of ACNPs highlight key aspects of the role, including assessment and diagnosis of health status, management of acute illness states, and performance of interventions and diagnostic strategies to promote stability. The competencies also address other aspects of the advanced practice nursing role such as teaching-coaching and ensuring quality care.8 As highlighted in this study, ACNPs are practicing in a wide variety of practice settings. Although ICU and specialty acute care tertiary settings are areas where a significant number of ACNPs practice, the list of unique practice settings continues to grow.
ACNP roles have also evolved with respect to type of practice, with increases in specialty-based (from 37% in year 1 up to 49.5% in year 5) and collaborative practice roles (from 17% in year 1 up to 25% in year 5), but unit-based roles remaining constant (10%).
The primary responsibilities of ACNPs remain those related to direct management of patient care. Although a number of other subroles have evolved, including education, quality initiatives, and research, the focus of the role is direct management of patient care, reported to account for 85% to 88% of time spent in the role. The most frequent aspects of the ACNP position are conducting physical examinations, gathering patients’ medical histories, writing orders, conducting rounds, initiating transfers and consultations, and preparing patients for discharge. Discussing patients’ care with the patients’ family members, ordering laboratory and radiological tests and interpreting the results, initiating consultations, and initiating discharge planning have remained the top 5 frequently performed activities of ACNPs. The focus of ACNP practice is not the performance of work involving invasive skills, a common misperception among those unfamiliar with the role. Performance of tasks involving invasive skills depends on job descriptions, patients’ acuity, and collaborative practice agreements. The role aspects identified by the practitioners who responded to the surveys highlight that coordination of care is a major role of ACNPs.
| A common misperception is that the focus of ACNP practice is work involving invasive skills.
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Salaries of ACNPs have increased, and although the information on the national salary base of ACNPs is of interest, salaries are negotiated on an individual basis and often also depend on job responsibilities (eg, whether on-call time is required) and the experience of the individual practitioner (eg, nursing experience, experience as an ACNP). Negotiation of benefits aside from base salary (eg, conference attendance to meet requirements for continuing education, journal subscriptions, malpractice insurance) and bonus structures (eg, profit sharing, productivity-based structure) are additional aspects to consider, as cited by survey respondents.
ACNPs continue to report satisfaction in the role and with their collaboration with physicians, citing autonomy, involvement with patients and patients’ care, and collaboration as advantages of the role. However, some practitioners also continue to cite that lack of recognition and not being considered a professional peer are disadvantages in the role. Often, such problems stem from inadequate knowledge of the role of ACNPs or the capabilities of ACNP practitioners. Publicizing the role of ACNPs is a continued requirement to secure identification of the role. On-line searches with the term "acute care nurse practitioner" yield only 53 citations in Ovid MEDLINE and Cumulative Index to Nursing and Allied Health (December 28, 2004). These citations are a mix of articles describing aspects of ACNP education, program development, and practice. A more general search on info.com, a Web engine that combines 14 search engines including Google, Ask Jeeves, Yahoo, AltaVista, Overture, Inktomi, LookSmart, Overture, and Open Directory, resulted in 61 "hits," most of which are descriptions of ACNP education programs. Much work remains to promote the role of ACNPs, and all practitioners can be influential in educating healthcare providers, legislators, and the public on aspects of ACNP practice.
| Advantages of being an ACNP include autonomy, involvement with patients and their care, and opportunities for collaboration.
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Affecting patients’ outcomes was identified as an advantage of being an ACNP. Participants report that they are making a fairly high impact on outcomes, including length of stay, costs, readmission rates, adherence to best practices, medical management, complications, resource utilization, continuity of care, patients’ access to care, patients’ satisfaction, and education of patients, patients’ family members, and staff. The monitoring of outcomes of ACNP practice is a priority and is essential for further advancing the role. By assessing the outcomes of ACNP practice, the benefits of the role can be demonstrated. Existing research data provide support for the contention that ACNPs provide high-quality, cost-effective care and promote beneficial outcomes for patients in a variety of settings. Recent research indicates that ACNP care results in beneficial care, including decreasing length of stay9–11 (M. J. Cowan, M. Shapiro, R. D. Hays, A. Afifi, S. Vazirani, S. L. Ettner, unpublished data, 2005); decreased costs of care9–11; decreased rates of urinary tract infection and skin breakdown10; compliance with clinical practice guidelines, including deep vein thrombosis/pulmonary embolus prophylaxis, stress bleeding prophylaxis, and anemia12; management of patients receiving mechanical ventilation13; enhanced communication and collaboration14; and continuity of care.15 Yet only selected aspects of ACNP practice have been examined. Respondents in this study reported a significant increase in the percentage of ACNPs who assess outcomes of practice. The results of those efforts should be published and disseminated because the existing research focused on the role of ACNPs is insufficient, especially when various types of practice settings and specialty roles that exist are considered.
| ACNPs provide high-quality, cost-effective care and promote beneficial outcomes for patients in a variety of settings.
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On average, 20% of those certified as ACNPs reported that they were not currently practicing as ACNPs. Although various reasons were listed, including working in another position, seeking employment, and family and child care responsibilities, this trend remains important to monitor. Of significance is that the number of ACNPs seeking positions during the 5 years of the study has decreased substantially. In year 1 of the study, 61 (37%) reported they were currently seeking employment; that number declined to 27 (18% ) in year 2, 13 (9%) in year 3, 9 (8%) in year 4, and 5 (4%) in year 5. When the ACNP role first evolved, finding a position was challenging in some demographic areas that were saturated with ACNP educational programs or in areas where the role was not recognized as a new area of advanced practice nursing. Nationally, advertised positions for ACNPs are now common, as recognition of the role has evolved.
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Summary
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This longitudinal study provides information on aspects of practice of ACNPs and the development of the role of ACNPs from a national perspective. The data provided by more than 400 ACNPs provides important information on the role of these practitioners and on the development of the role during the 5-year study period. Study limitations include attrition over the longitudinal study time and limited geographic representation from the West, Pacific, and South Central parts of the United States. Additional study of the ACNP role and outcomes of practice are needed.
This study is the largest study of ACNP practice to date and has provided beneficial information to ACNP practitioners, educators, and students. The information has also been useful to physician collaborators and administrators, who have astutely identified that the ACNP role holds much potential for meeting the healthcare needs of acutely and critically ill patients.
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ACKNOWLEDGMENTS
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Research funding from the American Association of Critical-Care Nurses, the American Nurses Foundation, Alpha and Gamma Phi chapters of Sigma Theta Tau, and Rush University College of Nursing is gratefully acknowledged.
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
Commentary by Mary Jo Grap (see shaded boxes).
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REFERENCES
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- American Nurses Association. Standards of Clinical Practice and Scope of Practice for the Acute Care Nurse Practitioner. Washington, DC: American Nurses Publishing; 1995.
- Hravnak M, Kleinpell R, Magdic K, Guttendorf J. The acute care nurse practitioner. In: Hamric AB, Spross JA, Hanson CM, eds. Advanced Practice Nursing: An Integrative Approach. New York, NY: Elsevier Science; 2005:475–514.
- Kleinpell RM, Hravnak M. The acute care nurse practitioner. In: Crabtree MK, Pruitt R, eds. Advanced Nursing Practice: Curriculum Guidelines and Program Standards for Nurse Practitioner Education. Washington, DC: National Organization of Nurse Practitioner Faculties. 2002:113–126.
- Kleinpell RM. Acute-care nurse practitioners: roles and practice profiles. AACN Clin Issues. 1997;8:156–162.[Medline]
- Kleinpell RM. Reports of role descriptions of acute care nurse practitioners. AACN Clin Issues. 1998;9:290–295.[Medline]
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- Kleinpell-Nowell R. Longitudinal survey of acute care nurse practitioner practice: year 2. AACN Clin Issues. 2001;12:447–452.[Medline]
- National Panel for Acute Care Nurse Practitioner Competencies. Acute Care Nurse Practitioner Competencies. Washington, DC: National Organization of Nurse Practitioner Faculties; 2004.
- Burns SM, Earven S, Fisher C, et al. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med. 2003;31:2752–2763.[Medline]
- Russell D, VorderBruegge M, Burns SM. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners. Am J Crit Care. 2002;11:353–364.[Abstract/Free Full Text]
- Miers S, Meyer L. Effect of cardiovascular surgeon and ACNP collaboration on postoperative outcomes. AACN Clin Issues. 2005;16:149–158.[Medline]
- Garcias VH, Sicoutris CP, Meredith DM, et al. Critical care nurse practitioners improve compliance with clinical practice guidelines in the surgical intensive care unit [abstract]. Crit Care Med. 2003;31:12. Abstract 93.[Medline]
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D. Becker, R. Kaplow, P. M. Muenzen, and C. Hartigan
Activities Performed by Acute and Critical Care Advanced Practice Nurses: American Association of Critical-Care Nurses Study of Practice
Am. J. Crit. Care.,
March 1, 2006;
15(2):
130 - 148.
[Abstract]
[Full Text]
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Abstract
Background and Overview
