By Erika Bassett, PA-C and Alexis Steinberg, MD
When graduating from a nurse practitioner or physician assistant program, an advance practice provider (APP) can launch themselves into a broad range of specialties and subspecialties. So why enter the world of neurology, and specifically, why neurocritical care?
Throughout the years, we have seen APPs come and go in our neurological ICUs (NICU). Some enter neurocritical care, learn the nuances of neurological patients, but ultimately leave and transition themselves into a different subspecialty. Conversely, there are the APPs who stay and immerse themselves in the care of the neurological patient and find purpose and satisfaction in their work.
So, why do some APPs stay and others leave? How do we train our APPs for success, prepare and retain them for a long, accomplished career in neurocritical care?
The demand for APPs in ICUs has increased over the past decade secondary to both ACGME guidelines limiting resident duty hours and fewer physicians subspecializing in critical care medicine. The increase of APPs in ICUs has resulted in exploration of methods and training options to adequately prepare incoming APPs. Currently, there are no specific or standardized training programs for APPs who are pursuing a career in neurocritical care. The training mechanisms for APPs tend to have wide variations of exposure to patients with acute brain injury. We have reached out to three APPs who have taken different pathways to a neurocritical care career for their insight of what has helped their success along the way.
Introductions to the NICU
First, how does one first step foot into the world of neurocritical care?
It seems some are introduced at a point prior to the completion of their advanced practice provider degree. Pat Coppler, PA-C, of University of Pittsburgh, Department of Emergency Medicine and the Post Cardiac Arrest Service, worked in post-cardiac arrest research prior to pursuing his education to be a physician assistant. He felt this made him “gravitate” toward neurological specific units.
“I find the pathology, specifically, neurotrauma and anoxic brain injury both interesting and rewarding to care for,” he says.
For Megan Brissie, doctoral, ACNP-BC, RN of Duke Regional Hospital, “I first became interested in neurocritical care when I was a nursing student at the University of Cincinnati. I had the opportunity to rotate through the Neuroscience Intensive Care Unit when I was a fourth year nursing student. At the time, Dr. Lori Shutter was one of the neurointensivists at The University of Cincinnati. Between the complexity of the patients, uncertainty of their outcomes and opportunity to make a difference in patients’ lives even in the midst of tragedy, I knew that I wanted to work in neurocritical care one day. Therefore, after working in trauma as an emergency nurse for three years, I returned back to the University of Cincinnati and entered into the acute care nurse practitioner (ACNP) program with the ultimate goal of becoming a certified nurse practitioner who would work in the inpatient setting and knew that I would one day work in the neurocritical care.”
Candi Hicks, MSN, AGACNP-BC of Vanderbilt University Medical Center, started her career as a neurosurgery nurse practitioner and developed a relationship with the critical care team through this experience. She credits her continued career in neurocritical care largely to her supportive working environment.
Training and Preparedness
Of the multiple challenges faced when entering the world of neurocritical care, one obstacle is particularly daunting: understanding critical care management and multi-organ support in the setting of the complex physiology of acute neurological illness. So, how are APPs trained for success?
Megan and Pat both had training in other units prior to starting their career in neurocritical care. Pat completed a 12-month APP critical care residency program by rotating through different, diverse ICUs. He stated that “During that time, I was treated as house staff with the expectation to make and carry out a plan of care for established patients, work up incoming patients and perform all necessary procedures. After that year of training, I started practicing in the neurotrauma/neurovascular ICUs without further formal orientations.”
Megan describes her diverse ICU exposure during her orientation, “I had the opportunity to practice in several different ICUs, including the Neuroscience Intensive Care Unit. Our program also allowed for a two-week intensive in the Surgical Intensive Care Unit, where it was the expectation that we, too, worked alongside our medical colleagues and spent 80-hours per week in the ICU. In addition, I had the privilege of working with the Cincinnati Stroke Team and learning more about the acute management of ischemic stroke during my training.”
In contrast, Candi had a more focused orientation process during her transition into neurocritical care. “[I had] 12 weeks of orientation to the unit, each week discussing each patient population on the unit.”
These three APPs gained confidence in their clinical decision making through different experiences. Pat felt his exposure to different patient populations outside of the NICU provided him with a more comprehensive approach to patient care and the confidence to take care of neurocritical care patients. Candi credited a large supported, teaching environment as the reason for her success in the NICU. For Megan, confidence came with time, “Although I felt prepared to enter into clinical practice as an acute care nurse practitioner, it was not until I was several years into my practice alongside a team of fellow APPs that I felt confident in my clinical practice as an APP.”
Obstacles Along the Way
We all have obstacles our everyday lives, but what were the specific neurocritical care obstacles that the APPs have experienced along the way?
Megan explains, “There was no standardized orientation or training specific to neurocritical care for APPs when I entered into neurocritical care in 2011. The majority of specialized training for this complex patient care was received during my clinical practice. Although NP training is geared to train APPs to be competent providers, due to the complex nature of neurocritical care patients, I personally felt that it took me more time to better learn this population to meet their care needs. One that I was fortunate enough to receive and was highly supported by my fellow APPs and attendings in my clinical practice setting.”
Pat felt having to compete amongst fellows and residents for his learning could be frustrating at times. For Candi, her background in neurosurgery started her off strong, but she felt learning the intricacies of neurology was more challenging than she expected.
Room for Improvement
We asked these three APPs about what changes should occur to improve training for APPs interested in neurocritical care?
Pat reiterates the importance of comprehensive training, “It might just be because of my background, but I think neurocritical care APP training should include rotations in a number of other intensive care units. I find it valuable to learn approaches to pathology that we don’t see as often in the NICU (hemorrhage, ARDS, etc.) from units that see a high volume.”
Megan comments on the advancements in neurocritical care education tools.
“Over the years, I have been amazed to watch the development of educational resources by the Neurocritical Care Society (NCS),” she says. “I remember taking part in Emergency Neurological Life Support (ENLS) when it was first offered in Denver. To see how this program has continued to develop and evolve over the years has been amazing. NCS is highly focused on educating all their members and ensuring that all members of the multidisciplinary team are recognized and educational needs are met. This is seen in the development in such products as the Pocket Guide and OnCall. Additionally, the APP Committee has been focused on creating materials geared at supporting APP through the development of webinars geared at neuroimaging and neuroanatomy and the development of an Orientation Guide to assist with onboarding new APPs to the neurocritical care unit by utilizing resources created by the NCS. “
Candi reiterates the importance of having a strong support system to help with learning and supporting one’s career and growth.
“My team was fantastic, so unsure as to how I would change training,” Candi says. “I felt supported and also my training was well organized.”
As more APPs are integrated into the neurocritical care team, the question remains: What is the best method to adequately prepare new APPs who enter the field?
Neurocritical care APPs provide significant value to the ICUs they serve, thus it is important to ensure adequate training and to impart the confidence necessary to provide care for this complicated patient population. Does there need to be dedicated neurocritical care fellowship training programs for APPs? Or should training include focus on a more general critical care population? Should there be guidance from medical societies on the onboarding process for and utilization of APPs?
Regardless, it is clear that the utilization of training tools and exposure to patients outside the NICUs, combined with supportive training staff may be essential for preparing an APP for a long career within this highly specialized but also extraordinary specialty of medicine.