We’ve been profiling various nursing specialties so that you can get more information about what the job entails and what education you would need if you’d like to consider that specialty. Next up—Family Nurse Practitioner (FNP).
According to Miranda “Mandy” Wiggins, CRNP, an FNP with
Main Street Family Care in Alabama, FNPs are responsible for patients from
birth to geriatrics as well as all aspects of that care. They provide
comprehensive treatment and see patients for yearly wellness visits, write
prescriptions for them, order any necessary testing, and follow up to review
results of testing.
In addition, Wiggins says, “We are there for them for acute
illness and management of chronic medical issues.”
She admits that one of the biggest challenges in being an FNP is educating patients. Often, patients don’t understand that FNPs can provide many more services than an RN. They think that nurses and FNPs are the same position.
But there are so many more rewards to this job. “I chose
to be a family practitioner so that I could impact as many demographics as
possible in my practice. I enjoy providing care to patients of all ages and
presentations,” says Wiggins. “I enjoy the interaction with the patients and
the involvement of family members to ensure they are being given the best care
in and out of the office. They will remember that you took time to give them
resources and helped plan for their future needs.”
“The greatest reward is most definitely the continuity of
care we are able to provide from our listening and diagnostic skills to
providing follow-up care and establishing a trusting relationship with those
patients. It’s very rewarding to see them improve in their plan of care and to
be able to care for them over a period of years,” she says.
If you’re thinking of becoming an FNP, Wiggins says that the NP program usually takes two years to complete after earning a bachelor’s degree—if the student attends full-time. This timeframe includes a residency program and leadership/professional practice courses. Certification is also a must.
“If you love your patients and have a desire to serve, go for it!” says Wiggins.
People are often confused by the specialty of progressive care. Isn’t that what ICU is for?
No, not exactly.
Linda M. Bay, DNP, RN, ACNS-BC, PCCN-K, CCRN-K, Nurse Consultant, VA Office of Inspector General as well as a member of the national board of directors, American Association of Critical-Care Nurses (AACN) from 2012-2015, took time to not only explain what progressive care is, but also what PCCN certifications are and how they can help your career.
What is progressive care? What does a nurse in a progressive care unit do?
care is one of the fastest-growing nursing specialties, but remains one of the
least understood. The term “progressive care” describes the increased level of
care and vigilance required by acutely ill patients who are not in an ICU, but
have complex health care needs. These patients are moderately stable with an
elevated risk of instability and are found in settings such as step-down,
intermediate care, progressive care, telemetry, and transitional care.
Progressive care refers more to the acuity and care needs of the patient
population than to a specific location within the hospital.
Many hospitalized patients require complex assessment and
monitoring without the advanced therapies of intensive care. Progressive care
nurses need to have highly developed assessment skills and the knowledge to
monitor and anticipate their patients’ course. This is a specialized patient
population with specialized needs. An experienced progressive care nurse can
intervene and prevent a patient from needing intensive care-level services.
I think of progressive care
nursing as a “gray” area. My experience in hospital settings and conversations
with other nurses indicate that not everyone is familiar with that concept. When
people ask me about progressive care, I ask them to consider the question, “How
can we meet the needs of patients as they progress
through acute or highly acute episodes and steer them clear of needing the
intensity of a critical care unit?”
To me, progressive care
nursing means having enough knowledge of both critical care and acute care to
be agile in our practices to accommodate what happens to patients in the middle.
were the PCCN certifications established? What are they and why are they
- PCCN: AACN has recognized progressive care as a nursing specialty since 2004, when PCCN certification was established to validate the specialized knowledge and competencies needed to provide the best care to acutely ill adult patients in progressive care settings.
- PCCN-K: In 2016, AACN Certification
Corporation launched the PCCN-K credential for progressive care nurses who
influence the care delivered to acutely ill adult patients, but do not primarily or exclusively provide direct care.
AACN Certification Corporation conducts periodic national studies of acute and critical care nursing practice to make sure that certification exams and test plans are grounded in actual practice. These surveys revealed a gap in the care needs of acutely ill patients outside of the ICU. The PCCN credential was created based on the increasing complexity of patients in other areas of the hospital, as well as the need to care for patients who were transferring out of ICUs much sicker than they had been historically.
Adding PCCN-K to the AACN family of nursing certifications reflects evolving roles and changing times in nursing and health care. A growing number of acute care nurses are shifting to positions where they influence patient outcomes by sharing their unique clinical knowledge and expertise rather than providing care directly—essentially becoming nursing “knowledge professionals.” Offering this credential enables a wider range of progressive care nurses to pursue or maintain certification
nearly 20,000 nurses hold PCCN or PCCN-K credentials.
Some of the same types of
patients I once cared for in the ICU are now cared for on progressive care
units. The gap between acute care and critical care continues to narrow, and
the sickest patients are now in hospitals as an inpatient. With hospitals
working at full capacity, the need for the progressive care certification is
even more important today because nurses need the knowledge to care for
patients who are highly acute.
is PCCN-K different from PCCN? How can nurses determine which certification is
PCCN is designed for nurses
who directly care for acutely ill adult patients. These patients are often
found in areas such as intermediate care, direct observation, stepdown,
telemetry, and transitional care units.
PCCN-K is for RNs or APRNs
who influence the care delivered to acutely ill adult patients but do not
primarily or exclusively provide direct care. Nurses working in roles
such as clinical educator, manager/supervisor, director, academic faculty, or
nursing administrator may be eligible.
As a clinical nurse specialist, I worked directly with nurses, patients, and families, which enabled me to obtain PCCN certification. Now in my consultant role, I am doing indirect work, but I want to maintain expert knowledge of progressive care. So, I recently transitioned to the PCCN-K credential.
When nurses want to decide whether the direct care or knowledge professional certification is best for them, they should think about how they care for patients. Does the work they do put them at the point of care, with patients and families? Then PCCN is likely the appropriate credential. Does the work involve influence more than direct care (e.g. educating staff nurses, working with nurses and physicians, indirectly caring for patients)? Then PCCN-K is likely to be the right fit
Nurses who have questions on
which credential is right for them should seek advice from the AACN
certification experts before applying to take an exam. AACN specialists will
help them identify which certification exam is right for them.
did you choose to become PCCN certified?
If I wanted our progressive
care nurses to obtain the PCCN credential, I thought I first needed to “walk
the walk.” PCCN certification gave me pride in knowing that my knowledge and
expertise were validated. Knowing that I validated my knowledge gives me
confidence. My motivation to remain certified is about being recognized for my
expertise and my commitment to the profession by lifelong learning. I feel
connected to others who are certified as well. For me, being certified says to
the world “I know my stuff.”
Nurses who became certified gain a sense of pride—and more importantly, a sense of empowerment—because they have more knowledge. They became more comfortable with advanced cardiac life support, began asserting themselves more effectively with physicians, became more competent in caring for patients who became more critical, and confidently cared for patients right out of the ICU. I am quite proud of those nurses for their courage to get certified and their willingness to grow
can certification help a nurse’s career?
promoting continued excellence in progressive care nursing and helping nurses
stay up-to-date on the latest research and evidence-based practices, certification
as a progressive care nurse acknowledges the valuable clinical specialty
knowledge of these accomplished nurses.
people see that a nurse has board certification and credentials, they see
someone who has exceeded expectations. Certification validates knowledge, but
getting and keeping those credentials shows a commitment to the profession.
Professional journals often
have recruitment advertisements for “certified nurses,” and hospitals are pointing
to their certified nurses as a showcase of nursing excellence. Some organizations
even offer bonuses or raises for certification.
Compassion fatigue and burnout—it’s a popular topic in nursing. It’s tough to know how to maintain a good work/life balance and show compassion for patients while still preserving your own mental and physical health.
Vidette Todaro-Franceschi, PhD, RN, FT, Professor, The College of Staten Island & Graduate Center, both of the City University of New York, is also the author of Compassion Fatigue and Burnout in Nursing. As the second edition of the book recently published, we asked her questions about how things have changed.
What are some of the
biggest changes that you’ve observed regarding compassion fatigue and burnout
in nursing since the first edition of the book?
Since the first edition in 2012, a greater emphasis is being
placed on the relation between nurse well-being and patient care, as evidenced
by the growing body of research and practice literature. There are more studies
being performed in the area of professional quality of life, and the
significance of having a “happy” as well as “healthy” workforce is finally
getting proper attention.
A number of nursing organizations have advanced various programs to foster a healthy work environment and promote work-life balance. For example, in 2013 the American Nurses Association (ANA) launched an initiative with the development of a professional issues panel to address nurse fatigue. Since then other professional issues panels have been formed to focus on moral resilience and workplace violence, among others. In 2017, the ANA began a critical initiative called the Healthy Nurse, Healthy Nation Grand Challenge (HNHN GC), which is geared toward enhancing both nurse well-being and the health of the nation—a win-win for all.
Lastly, years ago I would have been tarred and feathered for
saying that no one coming to work should be asked to leave their baggage at the
door, or that it was ok for a nurse to say, “I need a mental health day” or “I
just cannot do it.” Today, I think,
there is recognition that we—nurses—are human beings; we feel, we hurt, we cry,
and it’s ok.
What are the
biggest challenges for nurses experiencing poor professional quality of life?
The biggest hurdles for nurses who are experiencing professional
quality of life issues (related to: compassion fatigue, moral distress,
incivility, lack of preparedness to care for patients who are dying, death
overload, PTSD, burnout, unhealthy work environment) are: acknowledging that there
is a problem, recognizing that there are choices and actions that they can
take, and lastly, turning toward self and other(s) in ways that foster health and
contentment. These three things form the basis of ART©, a mindful awareness model, which I developed to
assist nurses and other carers to enhance their professional quality of
Mindful awareness is the key to acknowledging how one feels (the A of ART). However, this
can be challenging, since the majority of nurses work in fast-paced, chaotic
places and are not paying much attention to how they feel as they go about their
work. In fact, coworkers, friends, or family members may identify that there is
a problem before the suffering nurse becomes aware. Hence, nurses should engage
in mindfulness at work (and at home) in order to acknowledge both the good and
the bad feelings associated with their work (with the goal to maximize the good
and minimize the bad).
Once a problem has been acknowledged, it is essential to
figure out what choices one has and what actions can be taken to fix whatever
needs fixing. This can be another difficult hurdle for some nurses. A nurse might
think that she/he has no choice(s), or may be fearful of change. Nurses need to
recognize that there are always choices
(doing nothing is a choice), and then intentionally choose and take action to change
their work circumstances (the R of ART).
The last part of ART is turning toward self and other(s) (the T of ART), which entails connecting and/or reconnecting with the things that contribute to health and happiness, whatever those things might be. Nurses need to put the oxygen mask on their own faces first, figure out what makes them happy, and what will contribute to their well-being. Of course, this is easier said than done because nurses are typically self-sacrificing and altruistic. But nothing good can come from self-sacrifice that results in an unhealthy, unhappy person, especially one who is responsible for the health and well-being of others.
Making changes in eating, drinking, sleeping, and
exercise habits can be difficult. Motivating oneself to go out with friends or
family, or even to go out for a walk around the block may seem incredibly daunting
when one is physically or emotionally exhausted and unhappy. Turning towards
self and other(s) has to be taken one small step at a time, mindfully. Eventually,
new good habits can replace old bad ones.
have occurred for nurses who experience professional quality of life issues
such as compassion fatigue and burnout?
With greater awareness of the importance of nurse well-being
for patient care quality, in many settings, health care administration is focusing
efforts on creating a healthier, happier workforce. For example, many
workplaces now have wellness, meaningful recognition, and resiliency programs.
What do you think is
most surprising to people and/or nurses regarding compassion fatigue and
The fact that many individuals are compassion fatigued or burned
out (or other things), without realizing it. Whenever I teach and/or talk about
it, there seems to be this reverberating AHA!
People who work with all
living beings (humans and animals)
should be educated about professional quality of life issues. They should know
how to identify compassion fatigue, moral distress, death overload, PTSD, and
burnout as well as the effects these things can have on their health/well-being,
work productivity, and patient safety.
Sharing personal information with patients sometimes is
just natural for nurses. Working closely with patients while caring for them
and giving them compassion warrants it.
The adage says that you don’t discuss some things with
other people: religion, money, and politics. But is this really true, though?
Mindy B Zeitzer, PhD, MBE, RN, Visiting Assistant Professor of Nursing at the Linfield College, School of Nursing, has worked a lot with self-disclosure—when it’s okay to share information and when it’s not. She took time to answer our questions.
Nurses who work
with patients may practice a particular religious faith or have none at all.
When is it appropriate to share their faith with patients? When is it not
Self-disclosure of any type including religious beliefs and religious practices should or can be done when the purpose benefits the patient. Meaning religion beliefs or practices can/should be shared when its purpose is to either help with patient goals or help develop a better nurse-patient relationship, a therapeutic relationship. For example, if the patient had particular religious beliefs and perhaps felt alone in those beliefs or was struggling with a certain aspect of health and religious beliefs and the nurse shared similar beliefs, the nurse might connect with the patient by discussing those beliefs and expressing empathy through understanding.
It would be inappropriate to share religious beliefs or
practices if the purpose or intent was to serve the nurse’s goals rather than
the patient’s. It also would be inappropriate if the nurse does not feel
comfortable with sharing or divulging such information. When it comes to self-disclosure
of any kind, the nurse should only share information and as much information as
they feel comfortable sharing.
When can talking
about their faith actually help patients?
Many patients turn to faith in difficult times with health. For some patients, turning to faith may be “new” to them, and they may not feel totally comfortable with it. As nurses, we are often at the bedside at those vulnerable times. Expressing empathy and understanding through shared beliefs—or even if they are not shared—can help a patient feel understood and talk about their current feelings, emotions, and experience. It can also help “normalize” the experience of thinking about faith at these difficult times, if that is what the patient needs.
Are there instances
in which expressing their faith can get nurses in trouble?
Anytime a nurse discusses information pertaining to themselves (self-disclosure) to fulfill the nurse’s own goals such as trying to convince a patient to receive a certain treatment or refuse a certain treatment—based on the nurse’s beliefs—could be considered coercive. The nurse, rather, should try to help the patient understand/recognize their own beliefs and values so the patient can make an informed, well thought-through decision based on their own values and beliefs in order to make the best decision for the patient—rather than what is best for the nurse.
What advice would you give to nurses about sharing their faith in general—whether it’s with patients, families, or coworkers?
First, only share information about your beliefs if you
feel comfortable doing so.
Second, before discussing your own beliefs, think about
what will be accomplished by doing so. Does it help meet patient goals or personal
Should they ask
patients about their beliefs in a way to be cross-cultural?
An important aspect of being culturally sensitive is to make sure we meet [the] patient’s need related to cultural and religious beliefs. In order to do this, it’s important to ask if patients have a particular belief system, particular beliefs, or religious or cultural practices. Perhaps they would like to see a particular clergy member or have various care aspects modified—in particular: diet, modesty, the way we approach medical treatments, aspects pertaining to death and dying, pain control, etc. If we don’t ask about these needs, we likely will miss an important aspect of the patient and won’t be able to help the patient holistically.
When transplant cardiologists at the Debakey Heart and Vascular
Center at Houston Methodist Hospital, began to use percutaneously placed
axillary intra-aortic balloon pumps (PAxIABPs) in 2007, there was one problem.
Not with the procedure, which would act as a bridge to heart transplants. But
rather, with the nursing care that would take place after. When CICU nurses
searched for literature on the subject, there was one problem.
There wasn’t any.
The procedure was so new, so no patient care protocols existed. So they developed them. And now an article about the problems and solutions developed by the nurses is out.
Frederick R. Macapagal, BSN, RN, CCRN, RN, Cardiac Intensive Care Unit, Houston Methodist Hospital, was a part of that team and is a lead researcher on the article. What follows is an edited version of our interview with him
Q: Were you on the original team that discovered that no nursing literature existed on PAxIABPs in 2007?
I was part of the team at Houston Methodist Hospital that
searched the literature in 2007 and did not find any nursing articles about
caring for patients with PAxIABPs. Medical journals had a few articles about
similar procedures, but they focused on the surgical intervention with nothing
about nursing care.
Since this was a relatively new procedure, the lack of
nursing articles was not surprising. Our protocols were developed over time,
using evidence-based nursing care and lots of “learning by doing.” After about
10 years of developing, reevaluating, and taking care of more than 100 patients
with PAxIABPs who are awaiting heart transplant, our staff has become more
competent and comfortable taking care of these patients.
Q: Explain how the
nursing and medical teams collaborated to develop these protocols. Did you work
together to determine what to try and what not to? Please explain.
The cardiologists informed us about the new procedure and
what the change meant for the patients. They gave us parameters and guidelines
on what to do and not to do to take care of the balloon pump and the insertion site.
Overall, the doctors trusted the nursing staff to figure out how to walk these
patients safely and provide the care needed at the bedside. The
multidisciplinary team of nurses, doctors, physical therapists, and ancillary staff
collaborated to devise interventions to mitigate the problems that arose and
incorporate them into the standard of practice.
Q: How did you decide
how to develop and implement clinical practice guidelines if there was no
previous literature with evidence-based practice backing it?
We did not have a choice. Our patients with intra-aortic
balloon pumps needed us to find a way to get them moving. Our patients needed to
walk to keep up their strength while waiting for a transplant, and we had to
develop our own nursing care protocols based on existing evidence-based
practices in order to safely incorporate walking and mobilizing into their care.
Q: What are the
resulting clinical practice guidelines that reflect nursing care practice and
The mobility guidelines we developed address issues such as where
patients walk within the cardiac care unit, for how far, and how long. We
defined the number of staff who need to walk with the patient, based on each
one’s individual strength. The guidelines also cover how often laboratory tests
and x-rays need to be completed. For example, laboratory tests such as complete
blood count and basic metabolic panel are obtained every other day to minimize
blood loss and the need for blood transfusions. On the other hand, chest
radiographs are obtained every day to determine the PAxIABP position.
Our nursing team also developed a PAxIABP repositioning kit so
that transplant cardiologists can perform simple repositioning of the PAxIABP
at the bedside as needed. This kit
contains sterile gloves, masks, surgical cap, stabilization device adhesive,
CHG scrub stick, and a prepackaged central catheter dressing kit. The kit,
stored in a clear plastic bag, is hung on a pole attached to the IABP console
for easy access.
Q: The article lists
some really interesting morale boosters used. Why are these so important to patients
in these situations?
Our pre-heart transplant patients with IABPs wait anywhere
from a few days to months for a donor heart. Anyone would get depressed with waiting
for so long under such stress. So the nursing staff came up with different ways
of helping our patients cope.
We consider these patients part of the CCU family and treat
them as such. We call them by their first names, chat with them about anything
and everything whenever we pass by their rooms, and get to know their family
and other visitors. We celebrate birthdays, anniversaries, holidays, and other
special occasions. We’ve found ways for patients to enjoy the occasional
home-cooked meal, have their pets come for a visit, and more, in an effort to
keep their spirits lifted.
Our patients from 10 years ago regularly come to our unit
when they are in town, chat with us, and offer to visit with current patients
who might need a pep talk and some cheering up. Patients appreciate the extra
effort we put into making their stay with us enjoyable.
Q: What else is important
about the nursing protocols for patients with PAxIABPs?
We started with existing evidence-based practice, but our journey didn’t end there. Whenever a challenge arose, we found solutions to address the situation. We documented each lesson learned and worked through the unique challenges encountered with our patients. We gained confidence throughout this process in our ability to innovate and improve the care we provide to all of our patients. We hope that this article helps other nurses who are caring for patients with PAxIABPs or who may do so in the future. In addition, we hope it inspires nurses to trust in their abilities to be innovative and courageous as they strive to provide the best care for their patients.
To learn more about the protocols, visit https://www.aacn.org/newsroom/nurses-develop-protocols-for-patients-with-paxiabps.