The elderly, who frequently have multiple complex health problems, are the leading consumers of critical care services. As reported by the United States Census Bureau, the number of persons over the age of 65 years is projected to increase from 40 million in the year 2010 to an estimated 88 million by the year 2050. The elderly, who frequently have multiple complex health problems, are the leading consumers of critical care services (Angus et al., 2000). The Centers for Medicare and Medicaid Services (CMS) expects that Medicare enrollment will exceed 92 million Americans by the year 2050; an increase of 50 percent over the next 35 years (CMS, 2013).

Ewart et al (2004) described critical care as highly skilled, complex patient care provided by multidisciplinary teams of nurses, respiratory therapists, pharmacists, and others, under the direction of a critical care trained physician. Utilization of critical care medicine hospital beds continues to escalate in the United States despite the overall decrease in number of acute care hospitals (Halpern & Pastores, 2010). A shortfall of available, qualified critical care healthcare providers is poised to generate a critical care workforce crisis in the United States (Ewart et al., 2004).

The cost of providing critical care in the United States (U.S.) escalated 44 percent (from $56.6 to $81.7 billion) between the 2000 and 2005 (Halpern & Pastores, 2010). Improved clinical outcomes in critically ill patients, as well as decreased length-of-stay (LOS), were directly related to increased utilization of staff trained specifically in critical care (Pronovost et al., 2002). Although management of critically ill patients by intensivists has demonstrated reduced morbidity and mortality and healthcare costs, physician intensivists manage only 37% of all intensive care unit (ICU) patients in this country (Logani, Green, & Gasperino, 2011). The goal of increased critical care trained physician staffing is likely unattainable, given the current and projected increased need for critical care services (Kelley et al., 2004)

The expanding complexities of the critically ill patient population mandate the development of a critical care focused, interprofessional critical care residency. The growing disparity between the numbers of critical care providers to the numbers of patients has precipitated the increased need for adult-gerontology acute care nurse practitioners (AG-ACNP) in critical care arenas. However, many specific critical care competencies are not integrated into the AG-ACNP’s core curriculum. The transition from novice AG-ACNP to a proficient and competent critical care provider requires a steep learning curve and an extended orientation period. The expanding complexities of the critically ill patient population mandate the development of a critical care focused, interprofessional critical care residency. AG-ACNPs who wish to practice in critical care require substantial didactic and experiential education to attain competency as a provider. A post-graduate AG-ACNP residency is the ideal setting to attain proficiency as a critical care provider.

A recently published statement by the NP Roundtable has recommended the title of fellowship, rather than residency. The previous title acute care nurse practitioner (ACNP), and current title, adult-gerontology acute care nurse practitioner (AG-ACNP), are frequently used interchangeably and both will be utilized in this article according to the term employed in the referenced publication. Also, the terminology of nurse practitioner residency and fellowship are found in the literature when describing post-graduate NP clinical education. The most commonly utilized term, residency, was described in the document published by the Institute of Medicine (IOM), The Future of Nursing: Leading Change, Advancing Health (IOM, 2010). A recently published statement by the NP Roundtable has recommended the title of fellowship, rather than residency (NONPF, 2014b). This reflected the medical model of fellowships as optional, while residencies are mandatory. This position has been endorsed by numerous NP associations including: American Association of Nurse Practitioners (AANP), Gerontological Advanced Practice Nurses Association (GAPNA), National Association of Pediatric Nurse Practitioners (NAPNAP), National Association of Nurse Practitioners in Women’s Health (NPWH), and the National Association of Nurse Practitioner Faculties (NONPF).

Development and implementation of NP critical care residency/fellowship programs is congruent with many recommendations from the IOM. In October 2010, the RWJF Initiative on the Future of Nursing at the IOM released the blueprint: The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine of the National Academies, 2010). The report endorsed specific recommendations for improvements in healthcare delivery systems by utilizing the skills and competencies of nurses (Table). Development and implementation of NP critical care residency/fellowship programs is congruent with many recommendations from the IOM. NP residencies could offer a viable solution to the current and projected critical care workforce shortage. This article will explain that the current AG-ACNP curriculum and clinical practicum is sufficient for general hospital-based acute care, but may be inadequate preparation for entry into complex, multiple subspecialty critical care practice settings. Additionally, practice transition from critical care nurse to critical care NP in advanced practice would be optimally facilitated by experiential learning in a structured, critical care residency/fellowship program.

Table. Summary of IOM Recommendations (2010)

The Critical Care Workforce Crisis

The looming workforce crisis was described at length in a landmark study by the Committee on Manpower for the Pulmonary and Critical Care Societies (COMPACCS). Angus et al. (2000) sought to estimate the projected requirements for physician adult critical care providers in the United States. The outcome of the analysis established the trend of rapid growth in the demand for critical care services, while the supply of critical care physician providers is expected to remain stable. This pattern produces an escalating deficit of providers estimated at 22% of demand by 2020 and 35% by 2030. Subsequent studies by numerous authors have validated this conclusion with regard to both the difficulty to achieve optimal critical care provider staffing patterns; the current and projected significant shortage of available critical care providers; and the worsening shortage due to growth of the elderly population (Angus et al., 2006; Ewart et al., 2004; Krell, 2008).

As expected, larger hospitals and academic medical centers had more critical care trained staffing availability than smaller community hospitals (Angus et al., 2006). Notably, only 4% of all the adult ICUs in the United States demonstrated full adherence to established standards of attending physician coverage during daytime and nighttime hours. (Angus et al., 2006). Innovative critical care training pathways for physicians and multidisciplinary critical care fellowships are recommended (Krell, 2008).

Advanced practice nurses are broadly educated as generalists and current curriculums do not encompass specialty training within their educational programs. The growing numbers of AG-ACNPs can help alleviate the growing disparity between numbers of providers to numbers of patients. There are more than 234,000 NPs licensed in the United States; approximately 20,000 are acute care NPs (AANP, 2015). However, some specific critical care competencies are not integrated into the AG-ACNP core curriculum. Advanced practice nurses are broadly educated as generalists and current curriculums do not encompass specialty training within their educational programs (American Association of College of Nurses, 2011). The transition from AG-ACNP to an expert provider in the specialized critical care arena requires substantial didactic and experiential learning to attain competency as an autonomous critical care advanced practice provider. Development of post-graduate critical care residencies is a reasonable approach to facilitate this transition. Currently, the lack of research examining the effects of nurse practitioner residencies on NP competence and patient outcomes represents a significant gap in the literature (Kleinpell, 2005).

NP Education, Certification, and Licensure

The Advanced Practice Registered Nurse (APRN) Consensus Work Group, composed of representatives from leading professional organizations and the National Council of State Boards of Nursing, developed a framework of requirements for licensure, graduate program accreditation, professional certification, and education for APNs, including NPs. This collaboration resulted in the publication of the APRN Joint Dialogue Group Report (APRN Consensus Work Group, 2008). The APRN regulatory model was a wide-reaching, although generalized structure for standardizing APN education. The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education serves to identify the role and foci for APRNs (Figure 1). Specialty certification is outside the scope of the APRN educational framework and requires specific certification specified by the professional nursing organization of the particular specialty (Stanley, 2009).

Figure 1. APRN Regulatory Model

[View full size]

American Association of College of Nurses (2008). Reprinted with permission.

The APRN Curriculum Consensus Model provides a framework for standardizing NP education in a generalist approach... The standards for NP educational programs were the result of a collaborative effort between the American Association of Colleges of Nursing (AACN) and the National Organization of Nurse Practitioner Faculties (NONPF). These standards are outlined by the AACN as the Essentials of Master’s Education for Advanced Practice Nursing Graduate Core Curriculum (AACN, 2011) and by NONPF as the Nurse Practitioner Core Competencies (NONPF, 2012a; NONPF, 2014a). The APRN Curriculum Consensus Model provides a framework for standardizing NP education in a generalist approach as established in the published diagram (Figure 2). Furthermore, Adult-Gerontology Acute Care Nurse Practitioner Competencies have been established by NONPF; delineating entry-level competencies for graduates of master’s and post-master’s programs preparing AG-ACNPs (NONPF, 2012b; NONPF, 2016). These additional competencies augment the core competencies established for all nurse practitioners.

Following successful completion of an accredited NP program, the graduate is eligible to sit for a nationally recognized certification examination. Currently, there are two organizations that provide national certification as an AG-ACNP. The American Nurses Credentialing Center (ANCC), which is part of the American Nurses Association (ANA), and the American Association of Critical-Care Nurses (AACN). Successful completion of either national certification examination enables the graduate to apply for licensure to practice in any state.

Figure 2. Competencies

American Association of College of Nurses, 2008. Reprinted with permission.

Theoretical Frameworks and Professional Development

Evolution to expertise requires expansion of practical knowledge and is best accomplished through clinical experience. The role adjustment from novice to expert is aptly described by Patricia Benner. Benner’s theory is based on the premise that practice disciplines like medicine and nursing require real world experience and application of knowledge to attain an expert level of competence (Benner, 1984). Evolution to expertise requires expansion of practical knowledge and is best accomplished through clinical experience. A NP critical care residency would offer adequate mentorship and clinical experiences essential for growth in self-confidence and development of clinical expertise, enabling a successful transition from novice to expert NP.

Kolb’s Experiential Learning Model (Kolb, 1984) aligns with Benner’s model and has served as a practical framework for both nursing education, as illustrated by Laschinger (1990) and for medical education, as described by Curry (1999). Because the NP critical care residency would be collaborative between professional nursing and physicians, the model would be appropriate for an interprofessional program.

Focused training for specialty practice is beyond the scope of the standard NP education. NPs practicing in complex specialty and subspecialty practices require extensive post-graduate clinical training and didactic information to achieve practice competency. Focused training for specialty practice is beyond the scope of the standard NP education. Most post-graduate education takes place informally between novice NPs and physician and NP mentors. Currently, formal post graduate educational opportunities for the NP are extremely limited both in number and in variety. The transition process from staff nurse to APN involves internal and external socialization and requires adequate educational preparation and a supportive environment to enable a successful transition (Fleming& Carberry, 2011). The desire for formal professional development opportunities was substantiated by a recent study (Doerksen, 2010). Development of NP post-graduate residencies/fellowships for specialty practice may better serve the educational needs of novice NPs entering a complex specialty and facilitate the transition from RN to the advanced practice role.

Perception of Preparedness

Kleinpell (2005) completed a five-year longitudinal study of ACNP practice related to role perception and role preparation. Distributed after the initial year of ACNP certification, a 44-item questionnaire evaluated the respondents' perceptions of educational preparation for the ACNP role. Only 19% reported that they were very well prepared for practice. Recommendations for ACNP educators were solicited from respondents. The foremost recommendation offered by 66% of respondents was additional clinical or residency hours; 56% of respondents suggested additional time with practicing ACNPs.

Hart and Macnee (2006) evaluated self-perception of preparedness following completion of fundamental NP education by NP conference attendees, utilizing a cross-sectional descriptive study method. Analysis of the questionnaire data revealed that 10% of respondents felt very well prepared for NP practice and 51% reported feeling somewhat or minimally prepared. There was no significant difference in responses among varying age groups of respondents. The study supported the assertion that many NPs do not feel adequately prepared for practice upon graduation from educational programs. Of note, 87% of respondents reported interest in a NP residency program, if such a program had been available.

Additional data collected in a follow-up national survey conducted by Hart (2013) was presented at the NONPF 39^th Annual Meeting in 2013. A total of 723 NPs completed the survey with 90% having completed master's level NP programs. Survey results revealed that after initial NP education, 3.1% felt very well-prepared; 38.6% generally well-prepared; 43% somewhat prepared; 11.5% minimally prepared; and 3.8% very unprepared. Considering their first year of practice, 75% indicated having formal or informal mentors, 25% reported having no mentors, and 48.75% indicated never feeling like they had practiced outside of their competence level. In this follow up study, 90% indicated interest in a formal NP residency program, had one been available (Hart, 2013).

NP Residency/Fellowship Development Trends

Successful nursing practice residencies have been in place for post-baccalaureate registered nurses (RNs) in critical care; these are typically offered by sponsoring hospitals for the novice nurse. Krugman, et al's. (2006) study determined that novice nurses who participated in residency programs demonstrated improved employee retention, increased satisfaction, and enhanced organizational skills when compared to nurses who were not residency participants (Krugman, et al. 2006).

An NP critical care residency could facilitate interprofessional collaboration between colleges of nursing, medicine, and pharmacy within academic medical centers. The development of advanced practice residencies is a priority established in 2010 by the IOM (2010). An NP critical care residency could facilitate interprofessional collaboration between colleges of nursing, medicine, and pharmacy within academic medical centers. As a result of the IOM endorsement, there is a rapidly escalating number of innovative, more formalized educational offerings.

Margaret Flinter spearheaded the first NP residency for family nurse practitioners in primary care at a multi-site, federally qualified, health center (FQHC) in Connecticut in 2007 (Flinter, 2012). The process of NP resident selection and the model of didactic education and clinical training were detailed, as well as an examination of program costs and program evaluation. Endorsement of the value of NP residencies as a bridge to successful practice competence was affirmed. Additional research is needed to specifically explore measurable outcomes of NP residency/fellowship training related to practice effectiveness, quality of care, and costs and benefits.

Specialty-focused, post graduate NP residencies/fellowships are available throughout the United States, but there is no standardization or consensus on structure, content, or duration. Specialty-focused, post graduate NP residencies/fellowships are available throughout the United States, but there is no standardization or consensus on structure, content, or duration. Some examples include: trauma/ surgical critical care (St. Luke’s, 2012); oncology (University of Texas, 2014); dermatology (University of Southern Florida, 2011); primary care (Flinter, 2005; Flinter, 2012); neurovascular critical care (Alexandrov et al., 2009; University of Texas MD Anderson Cancer Center, 2011); cardiology (Mayo Clinic, 2012); and critical care medicine (University of Pittsburgh, 2015; University of Maryland, 2015). Each program has individual acceptance criteria, curriculum resources, and experiential learning strategies and most are affiliated with academic medical centers. An evaluation of the literature and survey (Brown, Poppe, Kaminetzky, Wipf, & Woods, 2015) results has revealed essential characteristics for successful residency/fellowship programs :

1. interprofessional training
2. a leadership/ policy component
3. a quality improvement and scholarship dimension
4. diagnostic skill honing and special skill readiness (e.g., electrocardiogram readings)
5. dedicated mentorship and role development

Clinical rotations include multiple critical care units at various hospitals within the Emory system and an online didactic curriculum. Two well established, critical care, post-graduate programs of note are offered at Emory’s Center for Critical Care and Vanderbilt University. The Emory program is a multidisciplinary, one year, didactic and clinical program for both NPs and physician’s assistants (PAs) (Emory University, 2012). Clinical rotations include multiple critical care units at various hospitals within the Emory system and an online didactic curriculum (Emory University, 2012). The Vanderbilt program is an NP Intensivist Fellowship program run jointly by Vanderbilt University School of Nursing and the Department of Anesthesiology-Division of Critical Care Medicine. This program is unique as the critical care focused fellowship is in conjunction with the Vanderbilt School of Nursing Doctor of Nursing Practice (DNP) program (Vanderbilt University, 2012).

NP Role Integration in Critical Care Teams

In 2008, Kleinpell and colleagues conducted an evidenced-based review regarding the role of nurse practitioners and physician assistants in the intensive care (Kleinpell, Ely, & Grabenkort 2008). The authors concluded that the evidence supported positive patient outcome trends related to nurse practitioner and physician assistant practice in critical care. Additional comprehensive research is needed to determine best practice models for multidisciplinary care, specifically to assess patient outcomes and potential financial impact.

...there has been insufficient evidence to endorse an ideal method to integrate the NP role in the ICU. Optimal methods to incorporate acute care nurse practitioner into academic multidisciplinary ICU teams has been the focus of many investigators. Studies have supported the consensus that the process of integration of NPs into the multidisciplinary ICU team can be challenging and requires clarification of role expectations between NPs, fellows, and attending physicians (Farley & Latham, 2011; Goudreau et al., 2011; Shimabukuro, 2011; Yeager, 2010). Additional research is recommended as there has been insufficient evidence to endorse an ideal method to integrate the NP role in the ICU.

NP Role Expansion in Critical Care

Historically in the United States, an increased mismatch between the number of available providers and the public demand for care has been addressed with modifications in healthcare delivery systems. Expansion of the roles and responsibility of nurses has often been the response to a perceived crisis in healthcare delivery (Asubonteng, McCleary & Munchaus, 1995; Coombs, Chaboyer & Sole, 2007). NPs have repeatedly been called upon to fulfill healthcare needs among those underserved patient populations most vulnerable to the shortage of healthcare providers (Asubonteng, McClear, & Munchus, 1995). The need for critical care-proficient NPs increased throughout the country following work hour restrictions for resident physicians set forth by the Accreditation Council for Graduate Medical Education (ACGME, 2012), although lifting these restrictions is currently under consideration.

The expansion of nursing practice among NPs has been met with some opposition in the medical community. NP provided care is purported to be unwanted by patients and likely care of inferior quality when compared to physician care, although the evidence suggests otherwise (Pioro et al., 2001; Roblin, Becker, Adams, Howard, & Roberts, 2004). Researchers found no statistically significant difference in outcomes for patients cared for by NPs or physicians. In addition, increased patient satisfaction was identified in the NP interactions when compared to attending physicians (Pioro et al., 2001; Roblin et al, 2004)

The American College of Critical Care Medicine Task Force on Models of Critical Care Delivery sought to establish critical care medicine guidelines that defined the intensivist and critical care practice (Brilli et al., 2001). The report recommended critical care delivery via intensivist physician-led multidisciplinary teams. The benefit of this collaborative approach was validated in a retrospective study by Meyer and Miers (2005) who examined the impact of collaborative care between cardiovascular surgeons and nurse practitioners in postoperative cardiovascular surgery patients. A reduction in hospital length-of-stay (LOS) was identified, which resulted in an estimated cost savings of over 5,000 dollars per patient.

International Considerations of Advanced Practice Nursing Roles

Identified barriers to role development abroad are congruent with those experienced in the United States... While the NP role was introduced in the United States and Canada in the 1960s, many other countries are now seeking to improve healthcare delivery and reduced healthcare costs by expanding the roles of nurses (Delamaire & Lafortune, 2010). The impetus for role development is primarily a concern for access to care in the environment of limited physician supply, but also considers quality of care (Delamaire & Lafortune, 2010). There are variable education requirements to become an NP, with most countries requiring a graduate degree. Identified barriers to role development abroad are congruent with those experienced in the United States including: opposition of physicians; negative influence on health policy and reform; infrastructure and funding challenges of healthcare systems; and the impact of legislative and regulatory procedures (Delamaire & Lafortune, 2010). The International Council of Nurses (ICN) has recognized advanced practice nursing and recommended a Master’s degree as entry level preparation (ICN, 2008).

Implications for Research

Both the number and variety of NP residencies has continued to accelerate following the 2010 IOM recommendations. Consideration must be given to the quality of those residencies and of nurse practitioner post-graduate education. Future research strategies should be prioritized to examine outcomes resulting from NP residencies regarding the effects on nurse practitioner education, competencies, and practice. Studies are needed to consider how patient outcomes are affected by an interprofessional team approach to patient care.

Conclusion

Integration of the NP into the critical care team has been identified as an effective method of healthcare delivery in critical care. NPs can help to alleviate the growing disparity between numbers of providers and numbers of patients. Collaboration between critical care trained NPs and critical care physicians can expand the range and availability of services for critically ill patients. The expanding complexity in caring for critically ill patients validates the need for interprofessional, critical care residency programs. NPs who wish to practice in critical care require substantial didactic and experiential education to attain confidence and competence as a provider.

Successful completion of a critical care residency/fellowship that incorporates interprofessional practice and competency benchmarks could enable the NP to function at the full scope-of-practice necessary to care for the most complex patient populations. Successful completion of a critical care residency/fellowship that incorporates interprofessional practice and competency benchmarks could enable the NP to function at the full scope-of-practice necessary to care for the most complex patient populations. Proficiency and confidence attained may empower NPs to facilitate and lead interprofessional, collaborative practice teams. Implementation of NP residency/fellowship programs could also improve patient access to competent, highly skilled critical care providers. Advanced practice nurse residencies can benefit not only novice NPs but also NPs entering a different and unfamiliar specialty practice. In sum, increased availability of NP residencies/fellowships can provide additional opportunities for lifelong learning in advanced nursing practice.

Author

Sherry Lynn Donaworth, DNP, ACNP-BC, FNP-BC
Email: donawosh@ucmail.uc.edu

Sherry Lynn Donaworth is an Associate Professor of Clinical Nursing at the University of Cincinnati, College of Nursing where she is lead faculty for advanced pharmacology and clinical management of adult health problems. Holding board certifications as both an Adult-Acute Care Nurse Practitioner and a Family Nurse Practitioner, her extensive clinical practice experience has included critical care, cardiology, geriatrics, and primary care.