When Nurse Practitioners (NPs) begin to work at the R. Adams Crowley Shock Trauma Center in the University of Maryland Medical Center, they are given training that helps integrate them into the ICU. Brooke Andersen, ACGNP-BC, Clinical Program Manager for Shock Trauma and Advanced Practice Provider for the Critical Care group, wrote about this topic for Critical Care Nurse. She took the time to answer our questions about how this process works and why it is important.
What follows is an edited version of the interview.
As opposed to having them begin working directly in the ICU, what kind of preparation is done beforehand? Why is this necessary?
All newly hired NPs attend a 2-day hospital orientation and a 1-day Advanced Practice Provider orientation that includes content on regulatory requirements, computer training, access to systems, and supplies needed for the job. Each NP receives a structured orientation manual and details regarding the orientation plan.
This standardized onboarding phase assists the NPs in completing the necessary requirements to begin work in the ICU and has minimized delays in credentialing and other regulatory requirements while streamlining the process.
What kind of training do they receive before starting in ICU? Why?
We do not provide training before starting in the ICU. The new NPs receive education in conjunction with their clinical training. They participate in weekly 1-day standardized didactic education and bimonthly procedural workshops or simulation sessions throughout the orientation. The weekly sessions provide time off the unit and opportunities for the NPs to obtain knowledge and technical skills while gaining confidence and competency in the critical care setting.
Education sessions include over 30 critical care core topics. The procedural skills lab provides the necessary training for NPs to become credentialed in ICU advanced skills. High-fidelity clinical simulations are failure-to-rescue and rapid-response scenarios that provide training in critical high-stress situations with debriefing.
How has this helped them be better at their jobs when they begin in the ICU? Why? How does this training and integration help the patients?
The weekly education allows the NPs time to network with other critical care providers and develop a support system. Our program evaluation has shown that novice NPs do not feel adequately prepared to work in an ICU immediately after graduation, but at the completion of orientation, they are confident and competent.
This training helps the patients by ensuring that the NPs have had standardized training that promotes success in achieving competency in necessary critical care knowledge and technical skills.
Is this just done for the ICU or other departments as well? Why?
A structured orientation is provided for newly NPs throughout the organization, but is tailored to the specialty areas. The critical care orientation that we have described is specific to the critical care units and has been shown to meet the necessary NP competencies needed in all the ICUs. These competencies are based on the AACN Scope and Standards for adult and pediatric ACNPs.
What else do you think is important for nurses to know about how new NPs are integrated into the ICU?
Newly hired NPs require a depth of knowledge and skills to successfully transition into their new roles. A comprehensive training program that includes standardized educational activities, clinical training, and thoughtful matching of preceptors with new NPs are key elements. Mentorship is especially critical during the orientation period to ensure new NPs receive support and guidance in their learning while fostering independence and autonomy as competencies are achieved—and ultimately builds confidence.
The impetus to address—and combat—the opioid epidemic that is plaguing our country has never been more urgent. Overdose rates have more than quadrupled since 1999, making opioid overdoses now the leading cause of death in Americans under 50. For every person who obtains opioids on the streets, there are many more who abuse prescription drugs that are prescribed to them.
Nurse practitioners (NPs), in primary care and in specialties, can help break this cycle. Nurse practitioners are on the frontline in patient care and have the skill and authority to intervene. As a provider, I have seen firsthand how pain medication can help patients regain control of their lives, when prescribed and taken correctly. I have also seen people become so dependent on these medications that they will do almost anything to get access to them. Part of my role at Columbia University School of Nursing is to oversee the school’s faculty practice, ColumbiaDoctors Primary Care Nurse Practitioner Group, which offers combined primary care and mental health services in New York City.
At the practice, we handle opioid prescriptions with a three-prong approach: comprehensive history and assessment, opioid patient-prescriber agreements, and educating our faculty NPs to engage in Medication-Assisted Treatment, particularly the authority to now prescribe Buprenorphine, an opioid medication used to treat addiction.
Nurse practitioners bring an evidence-based and culturally-competent approach to primary care. I connect with my patients and am able to understand a patient’s needs by eliminating barriers to care. This includes a comfortable environment that allows for ample time to interact with the patients and is focused on building the patient-provider relationship. When it comes to pain management especially, we want patients to feel comfortable sharing the root causes of their problems, so that we can provide the most appropriate course of treatment.
If we feel the problem stems from a multitude of factors, we may refer them to our mental health nurse practitioner, or other specialists before prescribing opioid prescriptions. By taking the time to assess the problem, we aim to ensure that opioid medication is methodically prescribed—and not our first course of treatment.
We know that this alone is not enough, which is why we also ask our patients to sign an opioid patient-prescriber agreement. This helps us to ask for accountability from both the patient as well as the prescriber.
Beyond just promising to take medications at the dose and frequency prescribed, our patients must agree to come in for a random “pill count” whenever asked. They must always bring the original pill bottle with unused pills in to every appointment, and we will even ask for consent for random drug screenings.
The purpose of these precautions is to remind our patients that this treatment modality will be taken away from them at any time if they cannot adhere to our safe practices. It also reminds our prescribers to keep a watchful eye to ensure the patient’s treatment does not become habit forming.
For those who come to us already addicted to opioids, NPs can now legally prescribe Buprenorphine, an opioid medication used to treat addiction, thanks to the Comprehensive Addiction and Recovery Act (CARA), passed just last year. This allows patients to come to us when they need help, and allows us to devise a plan of action from the convenience of our primary care practice. Patients appreciate being able to be treated in the familiar surroundings of our practice, and in the care of an NP who knows their complete health history.
Last year, the opioid epidemic claimed 64,000 American lives. Today, there are more than two hundred thousand nurse practitioners in the country who are prepared to help. Perhaps, this is one of our greatest assets. We offer access to quality and patient-centric care, especially in underserved and underinsured communities across the United States. As we recognize Nurse Practitioner Week, November 12-18, it is important to remember our role in combating this escalating health crisis.