Nurse practitioners (NPs) are certified within a population-focused specialty area, practice in a variety of settings, and treat a wide range of patients. Little is known about what agreement exists between certification obtained and actual site of practice. - Keough, Stevenson, Martinovich, Young, and Tanabe (2011, p. 195)
There is an ongoing debate about which qualifications are necessary to work in emergency care settings.
BACKGROUND
Statistics
There are currently more than 205,000 NPs in the United States and 9,000-12,000 are employed in emergency departments (EDs) and related areas (e.g., urgent care centers; American Association of Nurse Practitioners [AANP], 2015). Last year NPs cared for approximately 4% (5.4 million) of the 136 million patients seen in EDs in the United States (Centers for Disease Control and Prevention, 2015).
Consensus Model
In 2008, the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education developed by the American Nurses Credentialing Center (ANCC; 2008) became the framework for NP licensure, accreditation, certification, and education. The model delineates advanced practice nursing based on role (NP, clinical nurse specialist, nurse midwife, or nurse anesthetist) and population-focused competencies (family/individual across the life span, adult-gerontology, pediatrics, neonatal, psych/mental health, and women's health/gender specific; ANCC, 2008). Specialty practice encompasses additional competencies, and it is at the specialty level within the Consensus Model that concerns about scope of practice reside.
Primary Certification
Upon graduation, primary certification for NPs is achieved by the successful completion of the board examination at the population level:
* Family nurse practitioners (FNPs) are awarded board certification as a Family Nurse Practitioner, Board Certified (FNP-BC), through the ANCC or the American Academy of Nurse Practitioner Certification Program that awards an FNP-C;
* Acute care NPs are awarded an Acute Care Nurse Practitioner Certification from the AACN Certification Corporation or an Acute Care Nurse Practitioner, Board Certified (ACNP-BC) from the ANCC;
* Pediatric NPs may have ANCC certification as a pediatric primary care nurse practitioner or certification by the Pediatric Nursing Certification Board as a pediatric acute care nurse practitioner.
Once certified, a pediatric, family, or an adult-gerontology NP may be hired to work in an ED. Because the educational preparation of pediatric and adult-gerontology NPs does not include the care of patients across the life span and because many EDs see patients of all ages, the pediatric and adult-gerontology NPs are limited to practicing in EDs within larger metropolitan areas that see only older adults or children.
Competencies/Specialty Certification
Competencies for emergency nurse practitioners (ENPs) were initially published by the Emergency Nurses Association (ENA) in 2008 in the Nurse Practitioner Delphi Study: Competencies for Practice in Emergency Care (ENA, 2010). In conjunction with the AANP, individuals on this committee led stakeholders to develop entry-level competencies for NPs in emergency care. The competencies were also endorsed by the American Nurses Association and by the National Organization of Nurse Practitioner Faculties. These competencies are the basis of ENP curricula in the United States.
The ANCC established emergency nurse practitioner board certification (ENP-BC) via portfolio in 2013 (ANCC, 2013). To obtain ENP-BC, the NP applicant must have obtained certification in a population focus, 2 years or 2,000 hr of emergency care practice (within the past 3 years), 30 hr of continuing education in emergency care, and exemplary performance in two of five professional development/leadership areas. Submission of self- and peer performance evaluations is also required. Finally, the applicant must complete a written exemplar demonstrating expertise as an emergency care provider.
REQUIREMENTS TO WORK IN AN ED
The ability of an FNP and/or ACNP to work in an ED is based on the (1) regulatory agency (state board of nursing [BON]), (2) academic preparation, (3) additional preparation, and (4) credentialing.
Regulation
The BON in each state determines the scope of practice and is the final authority on whether an NP can work in an ED. Currently, there is limited consensus among state BONs on the interpretation of the Consensus Model related to the scope of practice for NPs providing care within EDs.
Academic Preparation
Formal educational programs to prepare NPs to work in EDs have been available since the 1990s. The domains in emergency care include critical care, urgent care, primary care, behavioral medicine, public health, and social medicine (Chan & Garbez, 2006).
Nurse practitioners prepared as primary care providers have competencies different from those prepared for acute care roles. These unique educational differences govern an NP's scope of practice (American Academy of Emergency Nurse Practitioners, 2015). Recently, several FNP programs have revised their curricula to incorporate didactic and clinical content in emergent and urgent care. Nurse practitioners educated as acute care providers are prepared with didactic and clinical practice in acute care settings; they do not have the academic preparation to care for pediatric patients in emergency care settings.
Additional Preparation
Emergency Care Fellowships
Both FNPs and ACNPs may obtain additional education in emergency care by completing an emergency care fellowship program. Pediatric and adult-gerontology ACNPs who receive additional educational preparation in emergency care and acute stabilization and resuscitation of medically unstable patients across the life span are prepared to provide safe, high-quality care in their respective EDs. Emergency trained FNPs or ACNPs graduating from academic ENP programs and fellowships should be recognized as having the knowledge, skills, and competencies to practice in the ED and be considered board-eligible for ENP certification. FNPs can obtain knowledge and skills in the acute resuscitation and critical skills required for safe practice in an ED either by completing an ENP graduate program or by attending a structured emergency fellowship program.
Continuing Education/On-the-Job Training
Continuing education is one method of obtaining the competency, knowledge, skills, and behaviors necessary to practice in an ED setting. On-the-job training can also teach NPs valuable skills (e.g., ultrasound technique).
Credentialing
Regardless of each state BON's authority to regulate practice or the educational preparation of an FNP or ACNP, the ability to work in an ED is ultimately granted by the medical staff of the hospital through a process called credentialing. Credentialing or obtaining privileges is the process of establishing the qualifications of an individual to work in a specific environment. This generally includes a background check along with an assessment of academic and certification credentials, work history, recent continuing education, and current licensure.
FNPs OR ACNPs IN THE ED?
In a study conducted by Keough et al. (2011), FNPs, adult NPs, and ACNPs were surveyed regarding certification, demographics, practice setting, routine responsibilities, and additional preparation (2011). The FNP, adult nurse practitioner (ANP), and ACNP respondents (5%, 7%, and 42%, respectively) reported practicing in a nontraditional practice setting. Of the NPs practicing in a nontraditional setting, 74% were ACNPs, with 90% of those ACNPs practicing in a nontraditional, ambulatory care setting. Sixty-five percent of the FNPs who were practicing in a nontraditional setting worked in a high-acuity ED, whereas 56% of the ANPs working in a nontraditional setting were employed in intensive care units. Additional training and education for these NPs included, but were not limited to, pharmacology, laboratory interpretation, and the ordering of diagnostic tests. The authors concluded that "while greater than 90% of ANPs and FNPs practice in settings consistent with their certification, a proportion of NPs practice in nontraditional settings may benefit from additional education (formal, on-the-job, and continuing education) and mentoring" (Keough et al., 2011, p. 195).
Among NPs working in emergency care, a snowball sample of 164 NPs surveyed found that 78% reported were certified as an FNPs whereas only 10% reported certification in acute care (E. Ramirez, oral communication, August 20, 2015). Current initiatives to help prepare NPs to attain the ENP core competencies include establishing educational standards for graduate education of ENPs and appropriate postgraduate continuing education. Other important activities to support and promote ENP practice include updating the ENP core competencies and exploring partnerships with nursing and medical organizations to improve continuing education, recruitment, and retention of qualified ENPs.
Nurse practitioners will continue to work in EDs, whereas state BONs strive for congruence with the Consensus Model. Ultimately, all NPs working in emergency settings must demonstrate ENP competencies because certification for ENPs is in the best interest of patient safety. That's the bottom line.
-K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN
Emergency Nurse Practitioner
St. Mary Medical Center
Long Beach, CA
-Jean A. Proehl, RN, MN, CEN, CPEN, FAEN
Emergency Clinical Nurse Specialist
Proehl PRN, LLC
Cornish, NH
REFERENCES