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Acute Care Nurse

A Spotlight on Acute Care NP Skills and the Privileging Process

I have been blessed with the opportunity of traveling to many schools and teaching nurse practitioner students about the didactic and clinical/procedural skills which nurse practitioners need for entry to practice in their first acute care role. Many times, there are opportunities to provide this training as the first pass before going to clinicals, or perhaps it may be as a final touch to guarantee they had exposure before entering their final hours of clinical before graduation. One of the hardest things to do as a student or new grad acute care NP is to keep documentation of everything you’ve learned to prepare for your first hiring hurdle: the credentialing committee.

Here are four simple recommendations to simplify life during the transition from student to a practicing acute care nurse practitioner.

Acute Care Skills Workshop

1. Decide your list of potential jobs early.

Think to yourself what you really want to do once you graduate, then consider three other possible roles you would be willing to do. Now that you have several different possible areas you might find yourself in, investigate each role to create a master list of the procedural skills which you might need for those different roles. Seek out the training in those areas that overlap the most, to make sure that you have qualified yourself for many of the roles you would be interested in whether in clinical time, or in your own individual skills training endeavors.

This is such a big psychological step that many people forget. You must validate your willingness and your flexibility because you will not know what positions will be hiring down the road when you are in the job hunt. I’ve known many people say that they were only going to go into the specialty of “X”, so they don’t need to know skill “Y”, then graduate and realize there are no jobs posted in specialty “X” and had to choose something else that they were not at all prepared because they self-sabotaged their training. My point here is don’t over commit your mind until you have a signed contract. You also may find you like a specialty you have not spent clinical time in until you do so.

2. Plan to develop your skillset early in your schooling.

Caution: not every NP program is created equal. Not every school prioritizes the hands-on skill set of every practicing nurse practitioner; some will focus entirely on didactic and rely on preceptors for the skills. This may be due to the institution’s financial, expertise, or curricular shortfall, while some programs offer a considerable benefit of providing you access to sim labs, skills workshops, and specialty training. Ideally, the baseline criteria for your certification will be met by your school, known as NONPF criteria, but that doesn’t necessarily mean those criteria are met at the SCHOOL, they may be met in your clinical time instead and somewhat managed by your PRECEPTOR.

Nevertheless, you as the practitioner need to decide how much investment you make to become an expert in each of these skills while you are student if you anticipate truly being successful in your transition to practice. Don’t waste your clinical time. This is specifically meant to give you access to learn these skills, but YOU must be invested.

3. Documentation is not optional, it is everything.

Many schools will utilize software to help you track your clinical experiences and hours, with one specific purpose in mind: prove that you have met the minimum requirements for safe practice entry. This is the same for your procedures, which can also be tracked and electronic software programs, but not every school uses. In fact, when I went to school, which was not that long ago, my logs were done on paper and if I lost those, that would be disastrous. With the advent of electronic clinical software, now it’s much easier for students asked to show proof of training for clinical hours, types of patients, ages, disease pathology, etc. Once you enter practice as a NP, however, you should do this also. Create your own spreadsheet that would be a living, breathing document for your skills and procedural count as they occur in real-time.

When I started in practice, a very smart nurse practitioner with many years of experience told me to keep a file of all the procedures of privilege-specific skills so that when it comes time to be re-credentialed (which is every two years at this institution), I could simply provide a log of the procedures which you’ve performed. She was on the credentialing committee of that institution, so she spoke from expertise and advice. Ideally, it should be possible to do this within the healthcare systems electronic record, but there are plenty of providers who leave healthcare systems for greener pastures, and when you do this, you lose your ability to access that information, and the last thing you want to do when you’re trying to be credentialed at a new facility is hunting down the proof you have done 10 central lines, arterial lines, intubations, etc.

Bottom line: Keep track of your procedures performed. I would highly recommend that you include the date procedures performed, last four of a medical record number, or something specific that can be tracked should you have to prove in an audit, but make sure how you document is not a violation of HIPAA.

4. Train like you mean it.

Yes, your school and clinical time are meant to be your training grounds, however as I mentioned above sometimes students don’t uniformly get everything they wish they saw in the training process, whether from poor sampling of a certain patient population during your clinical time, your clinical site being shut down due to pandemic restrictions, your school not providing a sim lab, etc.

The bottom line is you are responsible to be skilled in what you are saying you are skilled in when you apply for a job, and that’s where the companies like Skills On Point come in to play. Receiving a formalized initial education through either your school or through an accredited program like Skills On Point will give you a piece of paper that you can take to the credentialing body to show initial training, and although you may be seeking independent privileges, most new providers will not have independent privileges until proving their skill set under observation. The issue is you will not even have the ability to practice with supervision until you hold the specific privilege.

Most hospital privileging works by applying for a privilege (arterial line insertion, for example), and once you’ve shown 10 successful arterial line insertions without complication, you can then submit a request to the credentialing committee to have your supervision removed and request independent privileges for that privilege. This is true of most non-core privileges, with core privileges rarely involved in this, such as history and physical exams, prescribing medication, ordering and interpreting lab work, discharge summaries, etc.

Taking the time to be proactive in the thought experiment of “what would I need for this role versus that role” when you are early in your training, perhaps in your first clinical or second clinical, is not only a recommendation; it is a requirement if you want to be fully prepared for jobs that you are looking into (even if they are just skills required on your back up job list).

Hopefully this helps put some thoughts together for you and get your wheels turning in the right direction as you prepare for clinicals, practice, and keeping up with your requirements of documentation so that you don’t find yourself two years into your first job and surprised when a piece of paper shows up at your desk asking for proof of all your procedures and you don’t have any prepared documentation of what you’ve done.

One of the courses which Skills On Point offers to both students and practicing providers is the Acute Care Skills Workshop, which is a hospital medicine–based course including skills such as intubation, ultrasound use, vascular access, central line placement, chest tube insertion, thoracentesis, and procedural suturing/hand tying. The continuing education course for nurses also includes self-paced online content in medical imaging, antibiotic selection, and other selected courses designed to make sure your proficiency in your skills matches your expertise and the didactic content that your school has provided. And yes, it includes the paperwork you will need to successfully pass the credentialing committee.

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