New Emergency Nurse Practitioner Certification Rolled Out

Certification Offers Nurse Practitioners Head Start in Emergency Department Practice
      Nurse practitioners (NPs) have worked alongside emergency physicians for decades, but only in the past year has the profession gained a specialty certification. Now, by passing the Emergency Nurse Practitioner (ENP) Certification examination, NPs may add ENP-C to their list of credentials.
      The Emergency Nurse Practitioner Certification examination was spearheaded by the American Academy of Emergency Nurse Practitioners in collaboration with the Academy of Nurse Practitioners Certification Board, with a grant from the American College of Emergency Physicians (ACEP), and first offered in January 2017. The examination consists of 135 questions covering medical screening, medical decisionmaking and differential diagnoses, patient management, patient disposition, and professional, legal, and ethical practices. So far, 355 people have passed it to become board-certified emergency NPs.
      The certification hasn’t brought any radical change to the emergency department (ED); hospitals and practices are still hiring NPs and physician assistants (PAs) to fill similar advanced practitioner roles, working as part of a team alongside physicians, emergency nurses, technicians, and others. New advanced practitioners will spend their first few years on the job honing their skills with procedures and evaluating patients of varying acuity; certification offers NPs a head start, advocates say.
      “If you have emergency-specific skills, then your employer will be quicker to onboard you, and onboarding is expensive,” explained Dian Dowling Evans, PhD, ENP-C, a nursing professor at Emory University and coordinator of the school’s ENP program.
      As patients continue to stream into EDs and urgent care facilities in record numbers, the demand for NPs and PAs is strong, observed Kirk Jensen, MD, an emergency physician and chief innovation officer at the staffing firm Envision Physician Services.
      “This has been on the upsurge for at least the last 10 to 15 years,” Dr. Jensen said. “The demand is growing…as there is a projected shortage of physicians over the next 20 to 25 years.”
      In the past, NPs working in the ED came from a variety of backgrounds, usually through surgical or primary care certification and then gaining emergency care experience on the job, Dr. Jensen noted. He’s now seeing the newly certified ENP-Cs entering the market.
      “The certification is important, but it’s a relatively new development,” Dr. Jensen said. “There are a number of employers that aren’t that aware of it.” However, he expects the ENP degree will soon be recognized and understood by managers making hiring decisions.
      “What you want in the ED is a highly qualified, competent professional with a fair amount of compassion, and how do you best vet for that?” he said. “Certifying NPs in a knowledge base that’s based on the types of patients seen in the ED is a coherent way to [indicate] critical intellectual and procedural skills. It’s a quick way to get this done.”
      There are approximately a dozen training programs leading to the emergency NP specialization. To gain the certification, applicants must already be certified as a family practice NP. From there, there are 3 paths to ENP board certification:
      • accumulate at least 2,000 direct, emergency care clinical practice hours as a family NP (in the 5 years preceding certification) and have 100 hours of continuing education units in emergency care, of which 30 hours must be training in emergency care procedural skills;
      • complete an academic emergency care NP program from an accredited nursing program or complete a dual family nurse practitioner/ENP graduate/postgraduate program (this usually takes 2 years of full-time study to complete, or 3 years part time); or
      • complete an approved emergency fellowship program (usually 12 months long).
      To be accredited, the ENP graduate programs have to meet standards including didactic content, clinical training experiences in emergency care, and dedicated procedural skills training. Some NPs who have been working in EDs for decades had to go back to get continuing education unit credits to get their certification, including Dr. Evans, who has been practicing since the early 1990s and is a leader in the field.
      “I still had to demonstrate that I obtained emergency-specific continuing education, including completing a cadaver-based procedure course, to demonstrate I met the eligibility criteria to sit for that exam,” Dr. Evans said.
      Training programs have been around since the 1990s but are expanding because of demand to fill critical workforce gaps, Dr. Evans said. “Now we have a certification exam, which provides a better mechanism for employers to evaluate the knowledge and clinical proficiencies of NPs who are applying to work in emergency care settings,” Dr. Evans said. “There won’t be enough ENPs to meet demand for some time, so employers are likely to be hiring family practice NPs and supporting them to get emergency-specific continuing education unit.”

      Who Becomes an Emergency NP?

      Ali McCray, MSN, MPH, ENP-C, is using her certification in a fast-paced ED in Salem, OR. She grew up in a medical family: her grandfather was a vascular surgeon, her father a geriatrician, and her mother a nurse. She married an emergency physician.
      “I like taking care of people; it runs in the family,” Ms. McCray said. “I’m also a bit of an adrenaline junkie. As a kid, I did gymnastics and snowboarding. So I gravitated to the ED.”
      She went to nursing school and worked as a registered nurse, but before long she was looking for something more. “I wanted more decisionmaking and autonomy, a little bit more independence than what the [registered nurse] role would afford me,” Ms. McCray said. The natural next step was to enter an NP program, and as she looked at her options, she saw that Emory had an emergency medicine specialization. The program also allowed her to get a master’s degree in public health at the same time, giving her a dual perspective in caring for the health of communities along with hands-on care of patients.
      Ms. McCray then spent a very busy 3 years in school, one of them while taking classes for the public health degree while still putting in clinical hours in the ED. The Emory emergency NP program requires 53 credit hours in a full-time 4-semester schedule. Like the other ENP programs, Emory’s clinical portion includes training in advanced procedural skills, including airway management; ultrasonography for vascular access and trauma evaluation; suturing; wound care, including incision and drainage; invasive procedures such as chest thoracostomy; management of precipitous delivery; orthopedic fracture and dislocation management; 12-lead ECG interpretation; and radiologic skills.
      Having Dr. Evans as a mentor was a big help in gaining a wide array of clinical experiences. “I’d say, ‘Can I do a toxicology rotation or hang out in interventional radiology?’” Ms. McCray recalled. “She’d go through her contacts and find me a great educational experience.”
      After school, Ms. McCray spent 3 years working in Massachusetts. Her job there was at an academic medical center where she was given freedom to treat higher-acuity patients while working collaboratively with emergency physicians.
      “They let you ask a lot of questions,” she said. “I got very lucky with that. I was given a lot of leeway to explore the role.”
      After that, she spent 1 year in North Carolina and then 2 years in Oregon. Her diverse experiences have helped her realize that some physicians are uncomfortable with expanding roles for NPs because there is no standardized pathway for them, and various NPs—and PAs—can have highly variable clinical experience in procedures and evaluating patients. She has found that those kinds of details are sussed out by potential employers during the job application process; for her most recent job, she listed specific skills on her curriculum vitae and also was asked by her employer to go through a checklist of ED capabilities. But she believes that her ENP education and certification are becoming helpful indicators of her ED-specific skills for prospective employers.
      Mark Lamb, MSN, MPH, ENP-C, another graduate of Emory’s ENP program, worked as a nurse for 6 years before deciding to go back to school for his master’s degree in nursing, along with an MPH. He was drawn to emergency care because he likes treating a broad variety of patients and he enjoys the fast pace. Mr. Lamb’s first job post–ENP certification has been at an Indian Health Service facility in Chinle, AZ.
      Although the facility is remote, it is staffed with multiple NPs, PAs, and both locum tenens and permanent physicians. It maintains both an outpatient clinic and an ED, and Mr. Lamb alternates shifts on both sides. The work is both challenging and collaborative.
      “I like working closely with other clinicians and having someone else to bounce things off of,” he said.

      NP Independent Practice Worries Physicians

      There is friction between advocacy organizations for NPs and physicians over a high-profile policy issue: the American Association of Nurse Practitioners’ push to get more states to allow independent practice for NPs without a formal collaboration agreement with a physician. (Currently, 22 states allow some form of independent practice for NPs, although the specific permitted scopes of practice vary from state to state.) The campaign is alarming to some physicians and has prompted ACEP to take a position against it alongside most other physician advocacy groups.
      The emergency NPs’ group has not taken a position on independent practice legislation, mainly because it isn’t seen as relevant to emergency medical practice, in which advanced providers work closely with physicians on a multidisciplinary team. Sandra Schneider, MD, director of emergency medicine practice for ACEP, said NP independent practice is a concern in the ED even though employers will likely vet advanced practice providers before assigning them to an ED team. ACEP’s concern, Dr. Schneider said, is for smaller emergency or urgent care settings in states where NP independent practice is legal and where a provider could step beyond his or her training, with little oversight.
      “Although there are some people who have extensive experience, there are some graduating today who have none. You could literally have someone who has been a psychiatric NP for the last 15 years and today wants to work in emergency medicine,” Dr. Schneider said. “Those states say an NP can go to an [ED] and take the place of a physician the day after they finish their degree, without any specialized training in emergency medicine.”
      Simultaneously, Dr. Schneider emphasized that NPs and PAs both have important roles in the ED, particularly in caring for lower-acuity patients, whereas physicians manage more complex cases. Mr. Lamb works in an independent practice state but said he works collaboratively with other providers, regularly checking in with those with greater experience. A physician doesn’t have to sign off on his notes, but some of his notes are reviewed by the ED director, as well as the PA who is his direct supervisor.
      The amount of leeway Mr. Lamb gets in caring for higher-acuity patients often depends on his relationship with a given physician. “Some attendings like me to run every patient with them, which I have no problem with as a new provider,” Mr. Lamb said. “I’ve gotten a sense of which provider wants me to be more detailed in my presentations on the patients for whom I have questions, and which feel fairly comfortable with my plans.”
      Physicians ask him his comfort level with specific procedures, many of which he learned at Emory (eg, lumbar punctures, intubation, placing central lines). Typically, unless the procedure is a simple laceration repair or an incision and drainage of an abscess, the physician will show him how the procedure is done and then ask him the next time to do it under supervision.
      Both Ms. McCray and Mr. Lamb said they appreciate having physicians—and other practitioners—to consult with.
      The level of collaboration really depends on the culture of a given practice setting, Ms. McCray said. She has worked both in highly team-oriented settings and ones in which physicians, PAs, NPs, and nurses were encouraged to work as independently as possible and do their jobs without a lot of consultation. She prefers an environment in which she can work to “the top of her license” without taking on patient issues she’s not prepared to handle.
      But knowing where those lines are—and recognizing when you’re in too deep—is challenging for any health care provider, physicians say, which is why many worry about independent practice for NPs. “You don’t know what you don’t know,” Dr. Schneider said. Procedures such as suturing can be taught, she said, but more challenging for nonphysicians are the diagnostic skills to work through a vague symptom such as lower back pain or chest pain. Those are nuanced skills physicians get through 3 or more years of residency and other clinical training in which close supervision is required.
      Dr. Schneider sees emergency medicine as a profession eventually needing to address the question of where the lines are drawn between physicians, PAs, NPs, nurses, and other hospital workers. She cited the work done years ago by obstetrics and gynecology that resulted in a set of guidelines describing the scope of practice for practitioners such as physicians and nurse midwives.
      “That same type of scope-of-practice discussion probably needs to be had in emergency medicine,” she said, adding that ACEP officials are now talking about how to approach that in the near future.

      Future of the Profession

      Dr. Evans noted that both the NP role and the specialty of emergency medicine were launched about 50 years ago. She’d like to see the professions continue to work side by side and is encouraged by the participation of emergency physicians in the development of the emergency NP certification examination.
      “The essence of emergency care is collaborative and team based,” Dr. Evans said. “Hopefully, as more NPs are supported to become ENP specialists, the proficiency of NPs providing care throughout the country will increase.”
      Six months into his new career as an ENP, Mr. Lamb figures he’s made a safe choice. “The ED and urgent care are the safety net, the place of last resort for all unscheduled health issues, and sometimes the place to manage primary health issues,” Mr. Lamb observed. “That’s not going away anytime soon. It’s important to have good training to prepare NPs and PAs for that role.”