A Day in the Life of an Acute Care NP – Interviews with Two Experts

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The ACNP position is the critical communication and coordination link between all aspects of patient care of the acute and critically ill patients.
Nancy Munro, Senior Acute Care NP, National Institutes of Health (NIH)

Acute care nurse practitioners (ACNP) are integral to the American healthcare landscape. These highly skilled professionals work in a wide range of settings to provide high quality care to patients as part of robust, specialized healthcare teams. The ACNP is trained to make difficult, life-altering decisions that are in the best interest of patients, making it a challenging and rewarding career path.

As their title suggests, acute care NPs work with patients who experience often sudden, critical illnesses or injuries. ACNPs not only serve important roles addressing urgent needs in intensive care units and emergency rooms, but they also embrace other duties, from collecting detailed patient health histories to performing invasive procedures such as placing central lines, performing lumbar punctures, or introducing intubation.

As the ACNP role has grown and diversified, these nurse practitioners have continued to be certified by the American Association of Critical Care Nurses (AACN). The ACNPC-AG certification is a consensus model-based credential for graduate-level educated nurses to “provide advanced nursing care across the continuum of healthcare services to meet the specialized needs of adult-gerontology patients with complex acute and/or chronic health conditions.” To become certified, nurses must submit an verifying their eligibility and sit for a rigorous exam.

Overall, ACNPs play a pivotal role in the care of acute and chronic illnesses and injuries. To learn more about the daily responsibilities of this NP specialization, NursePractitionerSchools.com interviewed two experienced ACNPs—including one of the first professionals certified in this field—and is grateful for their valuable insights into this specialization.

Interviews with Two Exceptional Acute Care NPs

Please note that the following interviews have been lightly edited for length and clarity.

Nancy Munro, RN, MN, CCRN, ACNP-BC, FAANP, Senior Acute Care Nurse Practitioner, Critical Care Medicine Department, National Institutes of Health (NIH)

Nancy Munro is the senior ACNP for the Critical Care Medicine Department at the National Institutes of Health in Bethesda, Maryland, as well as a part-time instructor at Georgetown University School of Nursing in the ACNP program. During her 41 years of critical care nursing practice, Ms. Munro has worked in multiple institutions across the country in addition to completing a three-year term on the national Board of Directors of AACN. She continues to work on advanced practice issues for the organization. Notably, Ms. Munro has spoken regionally, nationally, and internationally and has published extensively on clinical and reimbursement topics.

What is unique about the responsibilities of acute care NPs compared to other specialties?

The ACNP position is the critical communication and coordination link between all aspects of patient care of the acute and critically ill patients. ACNPs can make critical decisions regarding care that can be life-saving. Better patient outcomes are ensured with this important position because the ACNP focuses on the details of care that can make a difference with a patient’s course of therapy.

Please tell me about your clinical environment (e.g., where you work, with whom you collaborate, etc).

I work in the Critical Care Medicine Department in the Clinical Center at the National Institutes of Health (NIH) in Bethesda, Maryland. I collaborate with many attending physicians and critical care fellows, NP colleagues, nurses, and respiratory therapists, as well as different primary teams whose patients have become critically ill. These patients are enrolled in research protocols, and their treatment is very complicated, so communicating the plan of care is imperative.

Do you focus on a specific patient population? 

Yes. My patient population is very specific since I work in a unique research institution. My patients are oncology and hematology patients who come to NIH as their last chance for any type of therapy. They are very immunocompromised and can have very unique disease processes.

Please give me a short description of a typical workday.

I work 13-hour shifts and start the morning with evaluating my patients and setting the plan of care. I present the patient’s assessment and plan in morning rounds and then document that plan. I will then prepare for the surgical patients who will be admitted to the ICU or other emergency admissions. I assess and set the plan of care for these patients and then will present my patients in afternoon rounds to the on-call physician. Throughout the day, I will assist with coordination of care of other patients and serve as the communication link to the primary teams to ensure all aspects of care are clarified.

What are the main legislative challenges for the ACNP community? How can others help?

The main legislative challenge for the ACNP is recognition of the role through the ability to bill for the services that the ACNP provides. Reimbursement for services of all healthcare providers is becoming more challenging, and ACNP services need to be recognized for the important contributions the role can provide to ensure excellent patient outcomes

What do you wish you knew about the profession before becoming an ACNP? Do you have any advice for others?

The ACNP position carries a tremendous amount of responsibility because you now decide the direction of patient care. It is a very rewarding position as you see patients improve but it can be a humbling experience every day which prompts further learning and improvement of skills.

Ellen Prewitt, RN, MSN, ACNP, CPNP-AC, CCRN
Acute Care Nurse Practitioner, Critical Care Transport Department, Cleveland Clinic

Ellen Prewitt is an acute care nurse practitioner and a Cleveland Clinic flight nurse. Ms. Prewitt spent several years as a registered nurse before taking her first flight with Summa Health Systems and “getting hooked.” She noted that Cleveland Clinic flight nurses have traveled to more than 22 countries and across 42 U.S. states to transport patients by helicopter or jet. In addition to her clinical duties, Ellen is a member of AACN’s ACNP Scope and Standards group.

What is unique about the responsibilities of acute care NPs compared to other specialties?

Unlike the primary care nurse practitioner, the adult (or adult-gerontology) acute care nurse practitioner’s education focuses on the management of acute, chronic and critical health care issues. Although traditionally this was handled in the hospital setting, ACNPs are providing this care outside hospital walls. Besides providing care as a flight nurse practitioner (definitely outside of hospital walls!), I also provide care via telemedicine, assisting hospitals and long term acute care facilities that do not have in-house critical care services at night. This may involve ordering further testing and evaluation, directing care, and prescribing medications. We partner with the bedside nurse to evaluate the patient and provide optimum care. We bring both our nursing skills and our advanced medical knowledge, merging the best of both worlds to care for our patients. 

What are the main legislative challenges for the ACNP community? How can others help?

Currently, not all states have full practice authority, which means practicing to the fullest extent of their training and education. Some states mandate an agreement with a physician in order for an ACNP to practice, or they have cumbersome formularies restricting what a nurse practitioner can prescribe. The nurse practitioner must be aware of these restrictions to practice within the regulations of their state. If they hold licenses and work in multiple states, they must be aware of the differences in each. States are now looking at reciprocity among states to decrease this confusion and assist NPs whose area crosses state lines. When an NP relocates, they may face delays in obtaining licensure due to different requirements and restrictions in practice and prescriptive authority from their previous state.

Becoming active members of organizations that advocate for the ACNP role—e.g., the American Association of Critical-Care Nurses (AACN) and the American Association of Nurse Practitioners (AANP)—is a major way to address the challenges to practice for nurse practitioners.

What do you wish you knew about the profession before becoming an ACNP? Do you have any advice for others?

When the first national certification exam for ACNPs became available in 1995, there was not much information about the role. I sat for that first exam along with five others from our city. Our clinicals were side by side with residents and they became comfortable with us providing care. Many of those same physicians ended up being our biggest supporters later when we were looking at credentialing within the hospital systems. We were the first in our geographic area to develop the role. With the six of us already being “seasoned” RNs, we knew what patients needed and knew the impediments to good care. We viewed the patient more holistically. I was very glad to have a strong nursing background that gave me the confidence to state my opinions. We walked into a role that was not pre-formed, but rather one that we could mold to provide better care for the patient.

My advice is to be involved with your health system’s advanced practice committee/department and credentialing committee. Know what is going on. Become active in your state’s nurse practitioner organization. They are your biggest supporter of you and what you do for your licensure. Be involved with your national organizations such as AACN and AANP. They will support you on the national level.

Recognizing the Importance of ACNPs

Becoming active members of organizations that advocate for the ACNP role—e.g., the American Association of Critical-Care Nurses (AACN) and the American Association of Nurse Practitioners (AANP)—is a major way to address the challenges to practice for nurse practitioners.
Ellen Prewitt, Acute Care NP, Cleveland Clinic

It is evident from these interviews that working as an ACNP means making choices that are critical to providing excellent patient care. As the scope of the ACNP role has grown, so too have the healthcare settings in which ACNPs most commonly practice. Whereas the acute care label once applied largely to nurses who worked in hospitals, these days acute care nurse practitioners work in more diverse settings, including:

  • Emergency care
  • Procedurale and interventional settings
  • Home care
  • Ambulatory care
  • Urgent care
  • Long-term care
  • Rehabilitative facilities
  • Hospice
  • Air and ground ambulances
  • Telehealth

In closing, the ACNPs interviewed for this feature touched on two important (and interrelated) challenges in their profession: being able to bill for services and achieving full practice authority. To the first point, Ms. Munro stated that, “The main legislative challenge for the ACNP is recognition of the role through the ability to bill for the services that the ACNP provides.” As it stands, ACNPs and other APRNs are not able to bill directly for services in all states and have varying disbursement procedures. These rules are complicated and can lead to confusion among patients, healthcare providers, and insurers. These convoluted billing regulations are related to the issue of practice authority, which Ms. Prewitt summarized succinctly: “Currently, not all states have full practice authority, which means practicing to the fullest extent of their training and education. Some states mandate an agreement with a physician in order for an ACNP to practice, or they have cumbersome formularies restricting what a nurse practitioner can prescribe.”

NursePractitionerSchools.com has interviewed more than 40 NPs about expanding full practice authority across the country. To find out how to get involved to help ACNPs and others, please check out the FPA legislative toolkit.

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