Postgraduate Residencies and Fellowships in Neurocritical Care for Advanced Practice Providers
Published on: July 10, 2024
With the growing aging population, healthcare leaders are increasingly concerned that the demand for services will soon exceed supply, especially in the realm of critical care. The physician shortage is well documented, as is the shortage of board-certified critical care physicians, especially neurointensivists. While many health systems have turned to advanced practice providers (APPs), many of these APPs are new graduates or are new to the specialty. New graduates often face disorganized orientation and onboarding processes. Preceptors, overwhelmed with their own clinical demands and work requirements, have limited time to train new graduates adequately. Evidence suggests that many new graduates feel they are not sufficiently prepared to practice in their first year (Hart & Bowen, 2016). The onboarding processes for APPs must become more robust to ensure their adequate preparation to care for critically ill patients. One promising solution is the optimal use of the APP workforce through postgraduate training programs like residencies and fellowships.
The APP workforce continues to grow. Many states have revised practice authority laws and regulations, allowing APPs to practice to the fullest extent of their license. Some states grant full practice authority to APPs, regardless of experience, while others require a period of supervised experience. These trends indicate that as APP numbers increase, their clinical responsibilities will expand, leading to more autonomy and complex duties. I emphasize that collaboration with physician colleagues in the ICU remains crucial.
As the APP workforce evolves, examining how to prepare APPs for the complexities of more acutely ill patient is paramount. The Institute of Medicine (2011) recommended transition-to-practice programs for nurses completing prelicensure or advanced practice degrees or transitioning to new clinical areas. I believe this recommendation can be broadened to both APRNs and PAs. Many healthcare organizations have developed APP residency and fellowship programs that provide additional training beyond formal graduate education. National accreditation for these programs has become available in recent years through a few different organizations.
However, these programs lack standardization in organization, management, and structure. There also remains quite a limited understanding of the content, implications, and value of these programs for APP education and practice. A standardized curriculum is needed according to the specialty of the program. And while I do not (yet) recommend mandating residencies or fellowships yet – given that more research is needed – I can attest to their value in strengthening clinical skills and easing the transition into practice. I strongly encourage new graduate APPs to consider such programs to increase their competency, confidence, and readiness for the APP role.
It is an unfortunate fact that clinical training programs in several disciplines do not provide much focused education on neuroscience, much less neurocritical care. For this reason, as it relates specifically to neurocritical care, there could be an especially significant benefit to academically oriented neuro ICUs to offer such postgraduate training programs. It is imperative that any such program be a true educational program. It should not be a program that merely seeks to utilize these APP residents or fellows as a cheap labor alternative.
Programs must ensure that there is protected educational time, assigned readings, and meaningful clinical rotations in the neuro ICU and a variety of other settings to augment learners’ development. Such rotations might include medical, trauma, and cardiac ICUs, the emergency department, acute stroke unit, radiology, anesthesia, and procedural rotations. In this way, neuro ICUs can develop home grown APPs to staff their units long-term, with likely much greater patient outcomes, something which could be studied alongside the development of such programs. Indeed, the next frontier in advanced practice provider inclusion in the neuro ICU should be a rigorous examination of APPs who received on-the-job training versus residency or fellowship trained APPs, with specific aims addressing knowledge, clinical competency, confidence with clinical decision making, anxiety, and readiness to practice.