Dear Editor,

After being certified as an acute care nurse practitioner (ACNP) for 5 years, educated at a nationally ranked (eg, top 25) public university, and with 3 years of critical and progressive-care registered nurse (RN) experience, I have yet to secure an ACNP position consistent with my goal of practicing as an advanced practitioner in an intensive care unit (ICU); instead, I maintain active practice by working in a correctional health care setting. But because my commitment to maintain commensurate skills and knowledge in critical-care is so great, I regularly attend conferences, have successfully completed the Society of Critical Care's "Fundamental Critical Care Support Course," am currently enrolled in a PhD program where my research interests involve critical illness and high-acuity patients, and consistently read relevant journals. Over the last 5 years, I have applied and interviewed for a number of ICU ACNP positions. The main reason I have not been hired has been that I have "limited current clinical experience." While these experiences have been disheartening and frustrating, I have also been puzzled by the absence of constructive criticism and advice despite my requests.

Recently, I was interviewed by a dynamic ACNP/MD medical director team, after which an interview team member phoned to let me know I was the "runner-up." I was told that my critical-care skills were "rusty," and I should consider returning to the ICU as a staff RN to "brush up." While I appreciated the feedback, it further stimulated my concerns about current interviewing and hiring practices. I wondered how common the experiences of ACNP interviewees without a "current" critical-care background were to mine? Definitive data are not available to determine whether others' experiences are similar to mine; however, I hope nursing leaders and their organizations will evaluate their hiring practices and consider 2 areas that I find particularly important. The first is the hiring teams' knowledge of the multiple educational ACNP pathways currently in place. For at least 2 decades,1 direct entry into practice (non-nurse graduates) programs have not required a previous Bachelor of Science in Nursing (BSN)/Master of Science in Nursing (MSN) or RN experience prior to matriculation, which leads to certification as an advanced practice nurse (APN). If these individuals are not hired because of lack of experience, then they are prevented from securing a role commensurate with their education and training. In addition, one might consider why these potentially excellent candidates are interviewed at all; especially since reviewing their resumes would likely identify those who do not fit the qualifications desired by the interview team. The second issue that bears some consideration is the importance of providing constructive criticism surrounding the reasons for a candidate's nonselection. It seems such advice may be extremely beneficial to the applicant, and in keeping with being a fellow professional colleague. The advanced practice nursing environment continually evolves,2 and an overview of contemporary and future dynamics is necessary if institutions are to hire and integrate ACNPs as valuable health care providers positively influencing patient outcomes.

Annually, the American Association of Colleges of Nursing collects and compiles enrollment data from US Schools/Colleges of Nursing with baccalaureate and/or graduate programs. In 2012, a significant increase in master's and doctoral degree programs was observed with an 8.2% rise in master's program enrollment. In 2011, 6.3% of practicing nurse practitioners (NPs) were ACNPs compared to 18.9% and 48.9% of practicing adult and family NPs.3 Even though the number of practicing ACNPs remains small, the reduction of resident physicians' work hours, and an explosion of the aging patient population leave a wide gap in the continuity of patient care. Because of these dynamics, ACNP educational preparation and professional role are well positioned to assume the care of high-acuity, hospitalized patients. Multiple institution-specific ACNP hospital-based models have been implemented4-11 and do appear to provide support for the ACNP role in acute and critical-care patient management, as well as active members of the multidisciplinary health care team.

The terms critical and intensive care are used synonymously and by convention connote dire situations for hospitalized patients. Registered nurses practicing in environments that encompass high-acuity and critically-ill patient populations where advanced health care technologies facilitate sustaining life require a substantial level of specialty knowledge and competencies.12 Conceptually defining competence in intensive and critical-care nursing is multidimensional, challenging and lacks coherence.13 Conventionally, competence has been defined as a set of skills and attitudes, but it is currently defined as workers' comprehension of their work.14 In a study by Lindberg,14 a qualitative approach was used to describe how critical-care unit staff understands competence development.14 The study suggests that key foundations for a competent nurse in intensive care were personal maturity and the right kind of attitude.14 Despite competence transcending a set of skills, the idea of "experience" being a key requirement is still a commonly held belief; therefore, an overview of the science examining experience among professional APNs and critical-care RNs will be presented.

Because some Schools/Colleges of Nursing prepare students to be advanced practice nurses without requiring previous nursing experience, some researchers have sought to determine the relationship of RN experience to NP clinical skills competence in professional practice.15 Rich investigated whether a relationship existed between length of prior RN experience and clinical skills demonstrated following employment as an NP. Areas of NP practice in this study were primary, inpatient, and emergency department and nursing home care settings. Study findings noted that length of RN experience did not correlate with the competency of NP professional practice skills, and greater duration of previous RN experience was associated with lower competency-based NP skill evaluations by the NP collaborating physicians.15 Another study attempted to elucidate the conventional belief that increased knowledge leads to enhanced clinical-based performance. In this study, Whyte et al16 investigated novice and experienced critical-care nurses' knowledge by comparing knowledge levels with their performance in a patient-simulated acute respiratory distress scenario. Experienced critical-care nurses' knowledge levels were significantly higher than novice nurses, but no difference in clinical performance between experienced critical-care nurses (16.52 years) and novice (0.58 years) nurses was found.16

To date, studies that focus on the interaction of nursing knowledge, competence, and years of experience do not illuminate how these key qualities interact to construct a model profile from which to select a high-potential job applicant. It may well be that the "experienced critical-care RN" will not result in a better ACNP in the ICU setting. The experienced critical-care RN, who is a new ACNP, in fact may have an ingrained theoretical base, knowledge, clinical perspective, critical thinking skills,17 and cultural norms from previous workplace environments that preclude evolution into a fully competent ACNP. Thus, ACNP interviewing and recruitment teams may benefit from an evaluation of how potential prejudices related to "experience" might be affecting their hiring practices. Conversely, interdepartmental and human resources may benefit from acknowledging their requirements for hiring so that level of experience is clearly defined for potential applicants. Doing so would preempt the time and commitment that less experienced, high-potential candidates would have to undergo. Instinctively, institutions that wish to hire ACNPs may consider focused, comprehensive orientation programs to support less experienced ACNPs.

Harris calls for nationwide postgraduate residency programs "to provide specialized training to better prepare new ACNPs for the workplace."18^(p335) While the idea is intuitive, there are some housekeeping issues that surface when conceptualizing novel postgraduate residencies for new ACNPs. First, postgraduate ACNP residencies pay lower in salary. It is often not ideal for a candidate to take on a significantly lower salary than she or he could make outside of residency training; not all ACNPs have a second salary to fall back upon. Unlike physician residencies, ACNP residencies do not come with the perk of having educational loans deferred while committed to residency; this would place greater undue burden on a new graduate making a lower salary. Second, if approximately 25 very competitive ACNP residencies offering 1 to 2 vacancies per year are currently available, and "have been slow to proliferate",18(p335) the future and real commitment to ACNP postgraduate training appears grim. Compounding this dynamic is the additional burden placed on practicing ACNPs who serve as clinical mentors and preceptors. While the commitment to clinical practice, teach, and mentoring are essential to advance our profession, not all applicants may hold these imperatives dear-such professional responsibilities are important to be addressed during ACNP interviewing processes.

The theme of "needing more experience" has been common following my applications for critical-care ACNP roles. If we continue to use that as a reason for not hiring qualified applicants, I believe we are doing our profession a disservice. Each of us remembers the difficulty and anxiety associated with entry into practice as a new nursing graduate, and the knowledge that experienced RNs imparted upon each of us to use, build upon, and to carry with us. This same commitment is important to our ACNP role, practice, and professional development. It's highly concerning to suggest that a certified ACNP return to the clinical setting as an RN to "brush up" on skills when the science does not support the need to do so. It also discounts the accomplishments of the ACNP applicant and what s/he is potentially capable of once integrated and mentored into professional practice.

Finally, the time and commitment to interview is nothing short of arduous. Hiring should also consider the applicant ACNPs' maturity and a positive attitude, as these attributes speak well to potential contributions and effective practice. When an applicant falls short, we owe it to our colleagues to provide them with instructive feedback. These practices are not only ethical and humane but also are supportive of individual nurses and the profession as a whole.

Sincerely,

-Shay K. Mitchell, MSN, ACNPC, APRN

Lexington, KY

[email protected]

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