National Level (Professional Organizations)

At the national level, the scope of ACNP practice is influenced by the following: the National Adult Gerontology Acute Care Nurse Practitioner Competencies (AACN, 2012); the Scope and Standards of Practice of the Adult Gerontology Acute Care Nurse Practitioner (American Association of Critical-Care Nurses, 2012), which describes expert ACNP role performance; Nurse Practitioner Core Competencies (National Organization of Nurse Practitioner Faculties [NONPF], 2011); and the ACNP national certification examinations.

The Scope and Standards of Practice for the Acute Care Nurse Practitioner was initially developed jointly by the American Nurses Association and American Association of Critical-Care Nurses in 1995 and later revised by the American Association of Critical-Care Nurses in 2012 to reflect the focus on adult gerontology acute care practice (American Association of Critical-Care Nurses, 2012). It further describes the scope of practice and standards of clinical and professional performance of the expert ACNP. The population for which the ACNP provides care includes acutely and critically ill patients experiencing episodic illness, stable and/or progressive chronic illness, acute exacerbation of chronic illness, or terminal illness. The ACNP’s focus is the provision of curative, rehabilitative, palliative, and maintenance care. Short-term goals include stabilizing the patient for acute and life-threatening conditions, minimizing or preventing complications, attending to comorbidities, and promoting physical and psychological well-being. Long-term goals include restoring the patient’s maximum health potential, providing palliative and end-of-life care, and evaluating risk factors in achieving these outcomes. The practice environment for the ACNP is identified as any inpatient or outpatient setting in which the patient requires complex monitoring and therapies, high-intensity nursing interventions within the range of high-acuity care (American Association of Critical-Care Nurses, 2012). The standards of clinical practice and standards of professional performance, along with measurement criteria examples for the ACNP as specified in this document, are summarized in Box 16-2. These standards, which are closely aligned with the APN core competencies in Chapter 3, describe a competent level of care and professional performance common to all ACNPs regardless of setting, whereby the quality of expert ACNP practice can be judged. Some common themes in the standards of ACNP clinical practice and professional performance that distinguish the practice of ACNPs from other NP specialties are the dynamic nature of the patient’s health and illness status, vulnerability of the patient population, need for continuous assessment and adjustment of the management plan in the face of rapidly changing patient conditions, and complexity of the required monitoring and therapeutics. Additional themes include the collaborative nature of the practice and interactive relationship between the ACNP and the health care system.

Finally, a resource that does not define scope of practice but does specify the knowledge necessary to perform within the specialty scope is the ACNP national certification examination. APN specialty certification serves as a primary criterion for APN practice (see Chapter 21). In addition, Medicare regulations stipulate completion of a national certification examination as a requirement for ACNPs to obtain reimbursement. ACNP certification examinations are offered by the American Nurses Credentialing Center (ANCC, 2012) and the American Association of Critical-Care Nurses (2012). Although it is evident that the content of a certification examination should not drive educational standards or curriculum development, the topics and content for the ACNP certification examinations have been validated by role delineation studies and are consistent with the other documents delineating ACNP practice scope (ANCC, 2009). As such, they serve to further articulate the scope of ACNP practice.

State Level (Government)

Each state’s government provides the second mechanism whereby the ACNPs professional scope of practice is defined. The nurse practice statute for each state governs nursing practice. NP practice rules and regulations that are intended to define NP practice vary from state to state (Kleinpell, Hudspeth, Scordo, et al., 2012; NONPF, 2012).

In all states, APN regulation for practice is based on basic nursing licensure, but many states have additional rules and regulations that delineate specific requirements and define and limit who can use a specific advanced practice nursing title with protection (see Chapter 21). Although at the state level it is relatively easy to define limitations in scope of practice based on the age of the patient population, it is more difficult to determine scope based on patient acuity and practice setting. Regulations relative to acuity and setting are not well defined and vary considerably by state (Kleinpell, Hudspeth, Scordo, et al., 2012; NONPF, 2012).

Institutional Level

As noted, most ACNPs provide patient care in health care institutions. Institutions may further delineate the ACNP’s scope of practice within that facility by identifying the patient population that the ACNP serves and the process for collaboration with other health care providers in the institution (Kleinpell, Hudspeth, Scordo, et al., 2012; Magdic, Hravnak, & McCartney, 2005). Further specification of the ACNP’s practice scope may be set forth in job descriptions, in hospital policy, or through the health care agency’s credentialing and privileging process.

Employers and hospitals have the right to define a specific health care provider’s scope of practice within the employment situation. Documentation of initial training and ongoing provider competence in the application of specific skills is needed. This scope of employment may not exceed the scope of practice specified by the state’s nurse practice act but may be curtailed based on the needs and mission of the employer. The institutional scope of employment may take the form of a job description, hospital policy, or both. In settings in which the ACNP role is being newly introduced, a job description may not exist. In general, the job description should include ACNP performance standards and responsibilities as they relate to patient care, collaborative relationships, professional conduct, and professional development; these institutional performance standards can provide a template for ACNP performance evaluation.

When providing care within a health care institution, the ACNP will also need to undergo the process of provider credentialing and privileging by the institution whether the ACNP is an employee of the hospital or an employee of a hospital-affiliated or private practice plan (see Chapter 21). The ACNP is required to provide proof of licensure, certification, educational preparation, (generally) malpractice insurance, and skill performance (training, numbers performed, proof of competence). Institutional credentialing is necessary for the ACNP to provide care to patients within the institution, although the ACNP may or may not hold a medical staff appointment.

Once an individual is credentialed, a determination is made regarding the clinical privileges that may be granted and is the process whereby the institution determines which medical procedures may be performed and which conditions may be treated by physician and nonphysician providers (Magdic, Hravnak, & McCartney, 2005). Although an appropriately educated provider may be permitted by statute to perform certain acts or skills, the hospital is not bound to grant the provider this privilege. The clinical privileges of the ACNP are based partly on the ACNP’s professional license, certification, and inherent scope of practice, documented training, experience, competence, and health status. For example, the ACNP who has received educational preparation for performing invasive diagnostic procedures (e.g., insertion of central line catheters, endotracheal intubation) may request that these privileges be a part of his or her institutional scope of practice if he or she can provide proof of training and competency along with documentation that the skill is required for the job. An ACNP may periodically request new privileges based on evolving mastery of skills, further training, and changes in services needed by the patient population and institution. ACNPs must understand that although they may be qualified to perform certain procedures, privileges to perform these acts may not necessarily be granted or renewed (usually on a biannual basis) if the patient population that the ACNP serves does not require these skills, or if ongoing application and competency in the skill during the renewal period cannot be documented (Table 16-1). A number of specific institutional examples of ACNP role development, including discussion of formal orientation programs, are available that further outline considerations for competency assessment, credentialing and privileging considerations, and ongoing professional practice evaluation (Bahouth & Esposito, 2009; D’Agostino & Halpern, 2010; Farley & Lathan, 2011; Foster, 2012; Goldschmidt, Rust, Torowicz, et al., 2011; Kapu, Thomson-Smith, & Jones, 2012; Kilpatrick et al., 2010; Kirton, Folcik, Ivy, et al., 2007; Pascual, Holena, Vella, et al., 2011; Shimabukuro, 2011; Yeager, 2010).

Service-Related Level

The functions of the ACNP are also adjusted according to the needs of the specialty patient population served or of the care delivery team (i.e., service) in the organization with which the ACNP is affiliated. This may be inpatient- or outpatient-based. This service-related scope outlines the clinical functions and tasks that may be administered by the ACNP specific to the service team with which the ACNP works and the needs of the specialty patient population served, which may include the following:

Therefore, service-related scope may vary among ACNPs affiliated with various services or specialties within the same institution and even among those who function under the same generic job description. The service-related scope outlines a more detailed and specific description of the types of activities that the ACNP will perform as a member of the practice.

In states in which physician collaboration is a requirement, or in cases in which the health care organization has collaborative guidelines, the ACNP’s institutional and service-related scope of practice and clinical privileges may be determined collaboratively by the physician and ACNP and set forth in a written agreement. This written agreement for collaborative practice then provides the source document on which the hospital makes privileging decisions (see Chapters 20 and 21). Written agreements, often formatted as a checklist, are frequently helpful because the detail included in a written agreement cannot be spelled out in a job description. Job descriptions, by their very nature, tend to be more general to cover ACNPs working in a variety of settings within the institution. In addition to outlining the specific activities that the ACNP performs, the agreement might also specify the level of communication or degree of supervision between the ACNP and physician that is required before the performance of a specific function (D’Agostino & Halpern, 2010; Kleinpell, Buchman, & Boyle, 2012). An ACNP with novice skills in central line insertion may require direct supervision for a specified period or number of successful attempts but, as the ACNP approaches expert status, the level of supervision may be decreased to minimal or none. Eventually, as the ACNP’s expertise continues to advance, she or he may supervise medical trainees or novice ACNPs in these skills. As skills progress, the written agreement, if required, will also need to be modified. In some cases, the written agreement may be used to communicate the ACNP’s scope of employment to other members of the health care team, such as staff nurses and pharmacists.

When negotiating the written agreement, the ACNP and collaborating physicians need to ensure that no function is in conflict with the individual state’s nurse practice act and the policies of the particular institution. Nevertheless, the agreement should not serve as a barrier to practice but should be written as broadly as reasonable to allow for practicality, flexibility, and optimization of practice within the context of experience and safety.

Individual Level

The final determinant of scope of practice is role individualization by each ACNP. Experience, specialization, interest, motivation, self-esteem, personal ethics, personality traits, and communication style affect the employment opportunities, clinical specialties, skills, practice arrangements, and degree of autonomy that the ACNP will seek out and/or apply in her or his uniquely personal enactment of the role (Kapu, Thomson-Smith, & Jones, 2012).

Acute Care Nurse Practitioner Specialty Competencies

In addition to the core APN competencies, each of the NP specialties has unique competencies that differentiate practice. The Nurse Practitioner Core Competencies (NONPF, 2011) outline those competencies that are relevant to NP practice, regardless of population focus. ACNP entry-level competencies are illustrated in the AACN national adult gerontology acute care nurse practitioner competencies (AACN, 2012) and the Scope and Standards of Practice for the Adult Gerontology Acute Care Nurse Practitioner (American Association of Critical-Care Nurses, 2012). A discussion of how these ACNP competencies are carried out within the framework of the APN core competencies in Chapter 3 follows.

Advanced Practice Nurse Central Competencies of Adult Gerontology Acute Care Nurse Practitioners

Direct Clinical Practice

Direct clinical practice, the central competency of ACNP practice, is the function that consumes the greatest percentage of ACNP practice time. Prior clinical nursing expertise is essential for the ACNP role, because even the novice ACNP cares for acutely and critically ill patients who may precipitously manifest life-threatening conditions that mandate an immediate response. These situations demand a strong clinical practice foundation.

The specialty practice of ACNPs consists of short-term goals (stabilize patients, minimize complications, promote physical and psychological well-being) and long-term goals of care (restore maximum health potential, evaluate risk factors) (AACN, 2012; American Association of Critical-Care Nurses, 2012). ACNPs achieve these specialty practice goals through the performance of cognitive skills common to all APNs, such as patient assessment, critical thinking, diagnostic reasoning, case management, and prescription of therapeutic interventions. Assessing and intervening in complex, urgent, or emergency situations are key components of ACNP specialty competencies.

The central competencies of direct clinical practice as they apply to ACNP specialty practice can be broadly characterized as those related to diagnosing and managing disease and to the promotion and protection of health (see Box 16-1).

Diagnosing and Managing Disease

For ACNPs to achieve the specialty competencies to diagnose and manage disease in their specialty patient population, they must demonstrate mastery of advanced pathophysiology, completion of a prioritized health history and comprehensive and focused physical examinations, rapid assessment of unstable and complex health problems, implementation of diagnostic strategies and therapeutic interventions to stabilize health care problems, demonstration of technical competence with procedures, modification of the plan of care based on a client’s changing condition and response to interventions, and collaboration with other care providers to facilitate positive outcomes (AACN, 2012; American Association of Critical Care Nurses, 2012). The varied practice settings of individual ACNPs across the continuum of acute care delivery services result in associated variance in some of the competencies that they perform (Kapu et al., 2012). Most ACNPs practice in acute and critical care settings that include subacute care, emergency care, and intensive care settings. These include but are not limited to acute and critical care neurology, pulmonology, transplantation, presurgical and perioperative care, emergency care, pain management services, and cardiac surgery (Goolsby, 2011; Kleinpell & Goolsby, 2012). A growing number of ACNPs also practice in specialty-based practice settings, such as clinic, medical rehabilitation, home care, long-term care, sports medicine, holistic medicine, occupational medicine, employee health, mental health services, and medical flight program settings (Goolsby, 2010; Kleinpell, 2005; Kleinpell & Goolsby, 2012). Individual elements of the ACNP role differ, depending on these varied practice settings and on the specialty patient populations served, but the basic elements necessary to function as a generalist ACNP remain.

The performance of patient procedures, some of which are invasive, also constitutes a portion of ACNP’s direct clinical practice. Technical procedures most commonly performed by ACNP respondents to the AANP 2008 to 2010 national sample survey are listed in Table 16-1. The literature corroborates ACNP technical skill performance that includes the following: endotracheal intubation, central line placement, pulmonary artery line placement, needle thoracotomy, chest tube insertion and removal, and cricothyrotomy for the trauma critical care focus; nerve block, joint needle aspiration, diagnostic peritoneal lavage, needle decompression of the chest, lumbar puncture, chest tube insertion, cricothyrotomy and tracheostomy, suturing of lacerations and wounds, and splinting of injuries for the emergency care focus; endotracheal and nasotracheal intubation, chest tube insertion and removal, arterial puncture, and insertion of central lines for the critical care focus (Kleinpell & Goolsby, 2012). (Kleinpell, Hravnak, Werner, et al., 2006). A NONPF publication, Integrating Adult Acute Care Skills and Procedures into Nurse Practitioner Curricula (NONPF, 2011), outlines a number of advanced procedures performed by ACNPs, including the following: monitoring intracranial pressure; 12-lead electrocardiogram (ECG) interpretation; defibrillation and cardioversion; pacemaker interrogation; hemodynamic monitoring; central venous line insertion; arterial puncture or cannulation; interpretation of a chest radiograph; performing thoracentesis for pleural effusions; chest tube insertion and removal; airway management for the nonanesthesia provider and sedation for procedures; spirometry and peak flow assessment; paracentesis; local anesthesia application; and cutaneous abscess drainage.

It must be understood that procedural skill performance is not limited to the task itself but also includes knowledge of the indications, contraindications, complications, and skill in managing complications. When performing a procedural skill to derive physiologic data, such as mean arterial pressure, pulmonary artery pressure, or lumbar cerebrospinal fluid pressure, the ACNP must be able to use this information skillfully for patient evaluation. ACNPs are also compelled to collect their individual practice data related to procedure performance, including number and type of complications, and use these data to document ongoing skill competence, to attain positive patient outcomes, and to facilitate patient safety. The practice of an ACNP in a cardiothoracic surgical ICU, which illustrates the integration of technical skills within the context of diagnosis and management of disease, is provided in Exemplar 16-1.

Exemplar 16-1   Adult Gerontology Acute Care Nurse Practitioner Practice in an Intensive Care Unit

In the cardiothoracic ICU (CTICU), Marie, the ACNP, functions collaboratively with the critical care provider team consisting of the ACNP, attending physician (intensivist), one or two critical care medicine fellows, clinical pharmacist, and other members of the delivery team, including bedside nurses, primary care nurses, and respiratory therapists. The team works in collaboration with the surgeons, surgical fellows, and residents on the cardiac, thoracic, transplant, vascular, and trauma services. As the CTICU ACNP, Marie manages the patient from admission to discharge from the unit.

The day begins with a report from the team members who provided care during the previous night, highlighting changes in patients’ conditions and providing information on new patients. Marie participates in dynamic patient-focused rounds, during which each patient is examined at the bedside and interviewed, when possible. A wealth of other data is reviewed, including vital signs, hemodynamic data (pulmonary artery pressures, central venous pressures, cardiac outputs), ventilator settings, and results of previous weaning trials, chest radiographs, diagnostic testing, laboratory and culture data, and a complete list of medications, continuous infusions, and fluid balances. Based on the clinical examination and review of data, and with input from members of the provider and delivery team, a comprehensive plan of care is devised for the patient. Marie assumes varying roles during these patient-focused rounds (e.g., presenting and reviewing data, doing the physical examination, writing orders, calling consultants). During this time, Marie is noting issues to be addressed later, treatment outcomes to be evaluated, planned procedures, culture and diagnostic test results to review, family conferences, and expected admissions and discharges. Once rounds are complete, Marie will begin to address some of the specific issues on her work list.

Marie begins by seeing the four patients who are to be transferred out of the CTICU care unit that morning. She briefly examines each patient and reviews their data to ensure that the patients’ responses to interventions are appropriate. She verifies that these patients have been weaned from their vasoactive medicines and removes their chest tubes. Marie reviews each patient’s history and physical (H&P) and restarts home medications that are appropriate to the patients’ cardiac conditions and comorbidities. She writes transfer orders and collaborates with the bedside nurse to ensure that all patient care issues have been addressed in the orders. One patient has a history of active smoking, and Marie discusses the relationship between smoking and heart disease with the patient, as well as smoking cessation strategies. One patient needs to maintain a central IV access on the hospital ward. Marie converts the 16-gauge introducer in the patient’s right internal jugular vein to a triple-lumen catheter using a rewire technique. One patient has developed an arrhythmia with some hemodynamic instability and Marie initiates appropriate treatment, cancels the patient’s transfer to the floor, and informs the intensivist of the change in condition. One patient is being transferred to a subacute care facility. Marie collaborates with the unit case manager to finalize transfer plans, speaks with the patient’s family before discharge, and speaks with the receiving team in the subacute care facility to ensure continuity of care. During the course of the day, Marie might perform other invasive procedures, such as inserting arterial lines, central venous lines, dialysis catheters, chest tubes, and nasoduodenal feeding tubes and performing thoracentesis, endotracheal intubation, and removal of intra-aortic balloons. Health promotion and protection assessment and intervention are integral to Marie’s role but in different areas than one might expect in the primary care setting. For example, in the CTICU, Marie addresses stress ulcer prophylaxis, preventing complications from immobility, promoting skin integrity, and optimizing nutritional support.

Marie will continuously monitor the patients on the unit throughout the day and provide problem-focused care in response to changing patient needs and condition. She will be contacted by the nurse who is providing bedside care for the patient to address patient problems such as hypotension, hypertension, low cardiac output, low urine output, bleeding, low oxygen saturation, fever, difficulty with ventilation or ventilator changes, agitation and delirium, mental status changes, inadequate pain management, arrhythmias, electrolyte abnormalities, and problems with lines or catheters. She will see patients multiple times throughout the day in response to these concerns, each time assessing possible causes, performing directed physical examinations, formulating a treatment plan, and reassessing clinical findings to evaluate response to therapy. Marie initiates some treatments independently, but other, more complex situations may require her to consult with the intensivist and/or surgeon to review the management options. Marie will communicate with consultants from other teams, such as cardiology, renal medicine and infectious diseases, to coordinate care and treatment plans.

During the day, Marie also participates in the care of patients newly admitted after surgery. As patients arrive from the operating room, Marie receives a brief report from the anesthesia care provider and surgical fellow. She reviews the chart, examines the patient, and reviews initial laboratory results, electrocardiographic results, and chest radiography results. She reviews the plan of care with the critical care nurse and respiratory therapist, targeting hemodynamic management and ventilator weaning. She documents a progress note, writes orders, and then returns frequently to reassess the patient’s status and adjust the plan. One postoperative patient is bleeding severely. Marie alerts the surgeon, orders and reviews a coagulation profile, and ensures that the patient is being rewarmed. She orders blood products to correct the abnormality and monitors the patient to determine whether this therapy is effective or whether the patient will have to return to the operating room for mediastinal exploration.

At the end of the day, the team makes rounds again, seeing the new patients, evaluating the progress of and plans for other patients, and developing a plan for the next 12-hour period. The dynamic environment of the CTICU and the changing CTICU team members require the ACNP to assess and reassess patient conditions frequently, remain flexible and responsive to subtle changes, and to carefully organize and manage time.

As a permanent member of the critical care team, Marie provides needed continuity to care. She is instrumental in developing clinical protocols and communicating care expectations to other members of the team. She is available to interact with social services, case managers, physical and occupational therapists, and nutritional consultants. She is able to participate in discharge planning. She is readily available to the nursing staff for questions or problem solving. She participates in the CTICU’s continuous quality improvement activities. She participates in research protocols, screens patients for eligibility criteria, and educates others concerning the research initiatives. Marie plays an important role in communication with patients and families and has a unique opportunity for teaching and reinforcing teaching.

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