The Consensus Model for APRN Regulation (2008) states the scope of practice is not setting specific but rather based on the needs of the patient. Advanced nursing programs are designed to prepare individuals specifically for their declared practice. Seeking practice outside of one’s specialty must require formal preparation and certification. APRNs are educated in one of the four roles and in at least one of six population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s health/gender-related, or psych/mental health (Consensus Model for APRN Regulation, 2008, p. 6). Primary and family nurse practitioners (FNP) generally manage chronic health problems and long-term illnesses in the outpatient/ambulatory setting. Acute care nurse practitioners are trained to manage short-term critical problems that often require hospitalization. Even though settings and skills overlap, the full skill set is different, and experience in that setting as anything other than an ACNP can be very helpful but does not confer the full set of competencies needed to practice in that setting as an NP (Gardenier, Knestrick, & Edwards-Tuttle, 2017). Since the FNP’s scope of practice doesn’t include care for patients with acute or chronic illnesses in deteriorating or life-threatening conditions, the AG-ACNP is the go-to credential for NPs looking to serve adult patients in areas like emergency rooms, trauma units, and intensive care units (Nurse Journal, 2019). Studies have shown that ICU teams that include properly trained and supervised advanced practice providers can provide care that is of equivalent quality to that provided by resident staffed teams (Lily & Katz, 2016).
History
The AG-ACNP had not been a formal certification until 2008 when the APRN Consensus Model explicitly changed the competency requirements to address the multidimensional needs of the older adult population (Joel, 2018). Notably, the adult and gerontology foci were merged, and both the adult-gerontology and pediatric foci are distinguished as being primary care or acute care (NONPF, 2016, p. 3). These organizations recognized a demand for adult-gerontology specialists in acute care/critical care settings and began to break down requirements for educational programs. The change in competency requirements forced educational programs across the country to modify their curriculum and integrate specific competencies for the adult-gerontology patient populations. The designation was made to focus the NP's role on the aging patient populations and their growing needs, however, questions emerged about the nature of acute care and primary care practice (NONPF, 2011). The National Organization of Nurse Practitioner Faculties (NONPF) issued a statement in 2011 addressing questions and clarifying the difference between the two roles in adult-gerontology practice. These declarations are used today to distinguish the scope of practice between ACNP and PCNP.
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Program Design
The preparation of an ACNP differs from that of a primary care nurse practitioner (PCNP). The education of competent ACNP intensivists requires a specialized curriculum that provides both robust didactic content and clinical experiences (Squiers et al., 2012). Competencies for the ACNP include independently managing complex acute, critical, and chronically ill adult and older adult patients at risk for urgent and emergent conditions, using both physiologically and technologically derived data, to manage physiologic instability and risk for potentially life-threatening conditions. However, PCNP competencies focus on plans for long-term management of chronic health issues with the ability to provide interventions to prevent multi-system health problems. In addition, AG-ACNP programs provide formal education on therapeutic devices or treatments such as non-invasive and invasive respiratory support, hemodynamic monitoring, line and tube insertion, and lumbar puncture. Primary care NPs in acute care settings are forced to complete on-the-job training for line insertion or circulatory management without formal knowledge from their educational program. The separation of acute care and primary care set forth by the National Organization of Nurse Practitioner Faculties was to provide precision and focused training to each patient care area.
NPS who wish to practice in critical care requires substantial didactic and experiential education to attain confidence and competence as a provider (Donaworth, 2017). To further this case, studies have shown new APRN graduates do not feel confident or prepared for their roles in acute care even if they hold certification in acute care practice. One study issued a 44-item questionnaire to ACNP graduates evaluating the respondents' perceptions of educational preparation for the ACNP role. Of this study, only 19% reported that they were very well prepared for practice (Donaworth, 2017). Thus, making it impossible for PCNPs to be well prepared for a role in critical or acute care.
Practice Outside of Legal Certification
Since a primary care NP’s scope of practice doesn’t include care for patients with acute or chronic illnesses in deteriorating or life-threatening conditions, the AG-ACNP is the go-to credential for NPs looking to serve adult patients in areas like emergency rooms, trauma units, and intensive care units (Nurse Journal, 2019). Licensure and accreditation are granted according to the patient population that is served. If the provider is professionally educated in primary care, he/she will sit for the AG-PCNP exam. If the PCNP then chooses to work in an acute care setting, he/she is not practicing under their formal preparation. This creates an increased liability for the new APRN graduate because they lack the expertise in high-acuity patients and complex life-threatening conditions. According to the Statement on Acute Care and Primary Care Nurse Practitioner Practice declared in 2011, NPs practicing beyond their scope of practice (e.g. PCNPs in acute care) present legal, ethical, and safety issues of which the NP – and generally not the employer - is responsible. State Boards of Nursing grant licensure to providers assuming they will practice in a moral and ethical manner. Licensure can be revoked at any time if the APRN is found liable for alleged acts of negligence including patient negligence as well as professional negligence.
Hiring Personnel and Complexity of NP Certification
Many hiring personnel do not understand the difference between NP certification. Registered nurses are trained to practice in all settings and, because not everyone who hires NPs understands that our training and certification model is different, it comes down to the NP to be sure that skills and credentials match the practice setting (Gardenier, Knestrick, & Edwards-Tuttle, 2017). There are many APRN students obtaining a primary care degree but have experience in acute or critical care as a registered nurses. Because of the previous specialized experience, administrators may be lead to believe that the APRN was formally prepared by their program to provide concentrated acute care. For example, a registered nurse who practiced in critical care and then completes a primary care NP formal educational program is not prepared to practice as an acute care NP (NONPF, 2011).
Since employers may not be aware of different educational preparations or practice settings this creates longer orientation and higher cost to train primary care NPs. ACNP’s curriculum includes training for patients with rapidly deteriorating conditions, line/tube insertion, and short-term treatment. PCNP programs do not require acute care hours or the completion of a critical care rotation. Clinical rotation sites and nursing practice mentors are essential components to clinical preparedness. The PCNP will lack formal education in these skillsets due to their limited curriculum and consequently require more on-the-job training at their health care facility.
Patient Risk
The acute care nurse practitioner works with patients with a higher level of acuity than those encountered in a primary care setting, requiring a skill set that blends the best of advanced practice and acute care nursing (Yeager, 2010). This level of acuity provides a foundation for defining the scope of practice and training requirements that should be used to grant credentials to advanced practice providers who practice in ICUs and raises the question of how the longitudinal educational and professional needs of ICU advanced practice providers should be supported (Lilly & Katz, 2016). Effective use of NPs in critical care becomes compromised when NPs are ill-prepared. Working outside the scope of practice places patients at increased risk for complications where health care scenarios become more complex every day. The National Organization for Nurse Practitioner Faculties (2011) remarked the PCNP does not have the educational preparation to care for the complex acute or critical patients but does have preparation to manage the simple acute patient. Likewise, the ACNP does not have the educational preparation to provide comprehensive, continuous care but does have the preparation to provide preventive services within the context of restorative care (NONPF, 2011). If patients were privy to this information, would it change the amount of confidence they have in their health care provider knowing the APRN has not been graduately-prepared according to their job description?
Conclusion
Concerns arise when providers practice outside of their designated specialty. The role of the NP has evolved over the years, requiring nursing organizations to modernize guidelines and specify settings for which APRNs may practice. The program curriculum for AG-ACNP is targeted at caring for patients with rapidly changing conditions who are often mechanically dependent. Generally speaking, the main focus for PCNPs is continuous care and the main focus for ACNPs is restorative care. Things can be further complicated because employers may not understand the intricacy of different APRN certifications. A continual challenge to the clarity of scope of practice for the ACNP and PCNP is the willingness of some employers to credential NPs to practice beyond their educational preparation and certification (NONPF, 2011). APRNs have a moral obligation to adhere to the guidelines set by State Boards of Nursing to ensure safe practice and problem prevention. Both certifications can agree the main priority is to provide care to the best of one’s ability. Ultimately, the certified ACNP has a stronger educational background and firmer understanding of inpatient specialties, better serving the acute care patient population.
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