Crit Care Nurs Clin N Am 14 (2002) 315 – 326
Challenges of advanced practice nursing in pediatric acute
and critical care: education to practice
Judy Verger, MSN, RN, CRNP*, Tara Trimarchi, MSN, RN, CRNP,
Jane H. Barnsteiner, PhD, RN
The Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
School of Nursing, University of Pennsylvania, 420 Guardian Drive, Philadelphia, PA 19104, USA
Pediatric advanced practice nurses (APN), CNSs
and NPs are instrumental in shaping the care that’s
delivered to patients and families using a skill set
that includes history and physical examination, dia-
gnostic reasoning, therapeutic interventions and
expertise in clinical teaching, research, and lead-
ership [1]. With approximately 150,000 APNs prac-
ticing and 90% of pediatric hospitals employing
NPs, APNs have become crucial to the delivery of
healthcare today [2,3].
Patient care is viewed as increasingly complex
and fragmented. This complex healthcare envir-
onment underscores the need for an APN with a skill
set that focuses on the pediatric acute and critical care
patient. Our current healthcare system supports more
than 20 million children with chronic illness and
increasing numbers of acutely ill infants and children
that require specialized care [4]. The changing reim-
bursement policies, shortened lengths of hospital stay,
and the number of patients rapidly passing through
the healthcare system have resulted in the need to
reevaluate traditional ways of healthcare delivery.
The economics of healthcare are highlighted by a
system that produces 14% of the gross national
product [5]. With the added pressures of delivering
cost-effective high quality care, new models of care
are now being implemented in the United States and
throughout the world [6].
* Corresponding author.17 Ridings Way, Chadds Ford,
PA 19317, USA
E-mail address: jtv@nursing.upenn.edu (J. Verger).
0899-5885/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 8 9 9 - 5 8 8 5 ( 0 2 ) 0 0 0 1 4 - X
In 1999, The American Academy of Pediatrics
(AAP) Committee on Hospital Care formally sup-
ported the role of the NP in the care of hospitalized
children. The AAP cited 30 years of successful
implementation of neonatal NP practice as evidence
of successful inpatient NP practice. The AAP encour-
aged the continued growth of NP collaboration with
physicians in the advanced management of acutely
and critically ill children as well as in posthospital-
ization follow-up [116].
APN is an umbrella term denoting four different
roles: NP, CNS, nurse anesthetist, and nurse midwife.
APN roles have evolved over the past 50 years and
contributed richly to nursing [7]. Historically, the
goal of the NP has been to provide direct patient
care, whereas the goal of CNS is facilitation of patient
care and attendance to systems of care [8,9]. APNs in
pediatric acute and critical care generally carry the
title of NP or CNS.
Recently, many have come to appreciate the
overlapping nature of these roles and have come to
realize that the goals of the CNS and NP are not
mutually exclusive [10 – 13]. Much of the knowledge
and many of the skills are shared by all APNs
[14 – 16]. As both roles are supported by undergrad-
uate nursing education and are derived from the same
science, it makes sense that the perspectives of these
nurses have similar roots and therefore should be
more similar than different [17]. The literature illus-
trates this point by describing CNSs in direct patient
care activities and NPs as providing education to
nursing staff [18 – 21].
Schools of nursing are now designing curriculum
at the graduate level that includes education on all
316 J. Verger et al. / Crit Care Nurs Clin N Am 14 (2002) 315–326
components of advanced practice, including edu-
cation, leadership, healthcare policy, and research
utilization in addition to advanced clinical decision
making [22]. Increasingly, APN bring to their work a
combination of the ability to perform physical assess-
ment, diagnostic and therapeutic intervention, and the
consultative specialty nursing practice and clinical
teaching traditionally emphasized by the CNS. In
more traditional APN roles there continue to be dif-
ferences in time spent in using various skills. Cur-
rently, the scope of the APN role is dictated by the
setting, the clinical situation, and the experience and
specific interests of the clinician [23].
This article describes the evolution and the future
of the APN in pediatric acute and critical care.
Current education and practice models of the CNS
and NP are detailed. Issues that face APNs in the
acute and critical care environment are described and
recommendations given.
Historical perspective
NPs and CNSs have a history of effective use in
pediatric settings [11,24,25]. In 1965 the first NP
program, a pediatric primary care program, was
started by Ford and Silver as a certificate program
[26]. The initiation of this program is attributed to the
perceived shortage of primary care physicians.
Reports of CNSs working in pediatric specialty
practices began in the 1970s in an attempt to defrag-
ment patient care and provide expertise at the bedside
[11,27,28]. With a boost from the nurse training act of
1964 and the resulting explosion of CNS master’s
degree programs in schools of nursing, CNSs became
commonplace for many institutions. As CNSs were
being employed in hospitals, NPs were working in
pediatric specialty areas [29]. The neonatal NP role
was introduced into neonatal ICUs in the 1970s [30].
By the mid 1980s APN programs to prepare CNS in
acute care pediatrics were established at Yale Univer-
sity, the University of Pennsylvania, and the Univer-
sity of California, San Francisco.
Beginning in the mid-1980s CNSs were asked to
carry out some of the traditional NP functions, and
some argued that the roles of CNS and NP were
converging [31 – 34]. The CNS was challenged to
plan and manage patient care in some specialties and
some believed that they were not as well prepared for
these responsibilities in certain areas, for example,
physical assessment and interpretation of lab studies
[35]. By 1990 recognized programs to educate APNs
for this purpose were initiated. The University of
Pennsylvania, School of Nursing began its graduate
program in pediatric acute care and critical care in
1992. In addition, graduate programs at Rush Uni-
versity and Loma Linda University and a post-mas-
ter’s program at Primary Children’s Medical Center
in Salt Lake City formalized programs to educate the
pediatric acute and critical care NP. Unlike the
primary care NP and the neonatal NP programs,
pediatric acute care programs were initially driven
by the need to support an already existing role of the
CNS in the pediatric acute care arena.
Shortly after the initiation of these acute care
nurse practitioner (ACNP) programs an explosion in
interest for alternative models of care occurred as a
result of the public agenda for healthcare reform [36].
Healthcare consumers and payers realized that prim-
ary care and health maintenance issues needed more
attention from the medical profession and that frag-
mented care, in the face of unimproved outcomes,
was costly and could no longer be tolerated [37,38].
This realization precipitated changes in medical res-
idency programs and reimbursement influencing the
upsurge of NPs in tertiary care [39].
Since the early 1990s, APN roles in acute and
critical care have increased exponentially.[40,41]In
the current healthcare environment APNs are ex-
pected to demonstrate a high level of competency
with a variety of skills [5]. APN roles are often
configured according to the needs of the patients,
interests of the APN, and needs of the unit or
specialty. The number of APNs trained as CNSs and
NPs increased 88% since 1996 [40]. CNSs and NPs in
pediatric acute and critical care work with attending
physicians in university and community settings.
APNs that work with specialty services often have
outpatient as well as inpatient service responsibilities.
In pediatric acute care, traditional CNSs provide
guidance and nursing expertise at the bedside, whereas
NPs spend more time involved in patient management
[44 – 46]. Some APNs spend much of their time in
direct patient care, whereas others are more involved in
education and other leadership activities [42,43,47].
Review of literature
Research into advanced nursing practice (ANP) in
the acute setting has focused on role definition, quality
and cost, knowledge, and perceptions of care provided
[48]. In these reports APNs are described as being
involved in physical and technical aspects of care,
engaging in critical thinking and decision making,
providing continuity of care, and participating in
direct care with an educational, research, and lead-
ership component [20,42,49 – 55]. Early articles
 J. Verger et al. / Crit Care Nurs Clin N Am 14 (2002) 315–326
exploring NP practice compared NPs to physicians
and focused on evaluation of practice including
patient satisfaction, patient compliance, and know-
ledge equivalence [56 – 63]. These studies have com-
pared APNs favorably to physicians assistants and
physicians in training [55,64,65]. Cost savings includ-
ing reduced length of stay with positive patient out-
comes also were highlighted [66,67]. Published
studies from the 1970s and early 1980s led to a
congressional report from the Office of Technology
Assessment (OTA) supporting the APN as instru-
mental in provision of healthcare [68].
In acute care the ACNP and CNS practice have
been described [49,69,123]. The role of the CNS in
the acute care environment has been comprehensively
described by time allocation, functions of the CNS,
impact on care, and compared to other care providers.
The role components of the CNS have also been
characterized in detail [49,70 – 73]. CNS practice has
been documented as improving compliance, contri-
buting to shorter lengths of stay, improving out-
comes, and improving staff nurse clinical judgment
skills [43,74 – 79]. In studies examining the role
development of ACNPs, Kleinpell has reported that
the ACNP role has evolved from working predom-
inantly in teaching hospitals with residents and fel-
lows to other areas including subacute care, urgent
care, and specialty-focused settings [42,52,80]. Con-
tinued surveys with ACNPs reveal that the ACNP
role involves direct NP functions such as conducting
histories and physical examinations, prescribing treat-
ment, therapeutic procedures, and interpreting labo-
ratory data. Additionally ACNPs are actively involved
in patient and family teaching, discharge planning,
consultation, and nursing staff education [52,80].
Other descriptions of APNs in acute care settings
highlight the variety found in the role. For example, in
1997, Knaus and colleagues described a model of care
in a university teaching hospital that uses NPs [81].
These NPs were responsible for generating, reviewing,
and implementing plans of care with a physician team
and for conducting rounds on complex patient cases
with the nursing staff. In this setting the NPs assist
attending and resident physicians as well as the bed-
side nurses on a daily basis. The NPs were instru-
mental in the development of multidisciplinary rounds
and routine standing orders that facilitate the roles of
both disciplines. The authors report time delineation as
39% direct patient care, 31% indirect patient care, 13%
administrative activities such as protocol develop-
ment, committee meetings, and product evaluations,
and 12% educational endeavors.
Research demonstrates that APNs have a positive
impact on children with acute and chronic conditions
317
[24,25,28,43,82 – 85]. Since the 1980s studies have
documented the satisfaction, safety, efficacy, and cost
effectiveness of NPs in pediatric primary care
[2,86,87]. One of the most widely reported studies
involving neonates was done by Brooten and col-
leagues [25]. These researchers examined and de-
scribed CNS practice after discharge of very low
birth weight infants. Brooten and coworkers noted
that in the early discharge groups with APN support,
hospital charges were 27% less and physician charges
were 22% less then the control group while there were
no significant differences in rehospitalizations, acute
care visits, or growth of infants in either group [25].
In the neonatal arena APN practice has been
described thoroughly [53,88 – 92,124]. Hunsberger,
Mitchell, and Blatz surveyed 655 health professionals
in Canada and the United States to describe the role of
the CNS/NP in the NICU [91]. With 70% to 75% of
their time devoted to clinical practice, the role of the
neonatal NP encompassed all facets of direct care
including assessment, diagnosis, planning, interven-
tion, and evaluation. In addition, the neonatal NP role
includes clinical education, research, and administra-
tive responsibilities. These skills were typically per-
formed in collaboration with a neonatologist with the
APN assuming the major role for developing the plan
of care. The impact of care delivered by neonatal NPs
on patient survival, length of stay, hospital costs, and
provider knowledge has been compared to physicians
in training. Studies find comparable patient care
between models of care that include neonatal NPs
and those that include physicians in training [53,
89,92]. Bissinger calculated a quality index by using
weighted values for mortality, length of stay, days on
ventilator, days on oxygen and morbidity for retinop-
athy of prematurity, sensorineural hearing loss, and
intraventricular hemorrhage and found no significant
difference between groups [89]. A cost effectiveness
ratio for each provider group was also determined with
average cost of the patients cared for by neonatal NPs
as 25% less than house staff. Mitchell et al compared
the knowledge and problem solving communication,
clinical skills of graduating neonatal NPs and pediatric
residents in a 33-bed NICU [93]. Graduating neonatal
NPs scored similarly to the pediatric residents on the
multiple-choice questions, radiographs, oral examina-
tion, communication skills, and clinical skills.
The first published study examining the NP role in
pediatric critical care was undertaken in 1988 as part
of a Society of Critical Care Medicine manpower
study by DeNicola and associates [50]. One hundred
and forty-eight institutions were surveyed. Twelve
pediatric ICUs (PICUs) and 51 neonatal ICUs
(NICUs) were identified as employing nursing practi-
318 J. Verger et al. / Crit Care Nurs Clin N Am 14 (2002) 315–326
tioners and physician assistants. Of those12 PICUs,
approximately two thirds employed PNPs, with the
majority being university affiliated hospitals, and
95% employed pediatric residents and intensivists.
The NPs performed various invasive procedures
including lumbar puncture (50%), endotracheal tube
intubation (50%), central line insertion (41.7%),
arterial line placement (75%), and thoracotomy tubes
(66.7%) Physician and administrator respondents
described the NP’s and PA’s clinical decision making
skill as similar to the ability of second- to third-year
residents. A major limitation to this study is the type
of information collected. This questionnaire con-
tained 6 items directed solely at medical management
with an additional 16 items looking at the procedures
performed. Activities other than direct patient man-
agement were not solicited.
APN practice in pediatric critical care has been
described [94]. NPs devote approximately 75% of their
time in direct patient management with the remaining
25% in other leadership activities including education,
research, and consultation [94]. Those that work in
smaller ICUs tend to have a larger role in patient
management. Leadership activities such as providing
unit education, developing standards of care, and
participating in unit research increase with years of
experience and the number of ICU beds. Practitioners
in the critical care arena also report performing a
variety of technical skills including arterial line place-
ment and endotracheal intubation. Lack of time to
perform job responsibilities, mentors, independence
in writing orders, and admission and discharge privi-
leges were identified as limitations to practice [20].
Using a retrospective chart review to evaluate the
role and impact of two pediatric critical care nurse
practitioners (PCCNPs) in the PICU, Martin made
comparisons to a model of care that included residents
[95]. Satisfaction with the NP role was solicited via
questionnaire using a convenience sample of parents
and staff nurses over a 6-month period. Results
demonstrated parents and staff nurse satisfaction with
NP care and support for the NP role. Documentation
of discharge planning was initiated earlier and with
greater frequency by the PCCNP as compared to the
medical resident staff. No significant differences in
the nutritional management of the children cared for
by residents and PCCNPs were noted.
Issues facing APNs in pediatric acute and
critical care
The issues of the APN in pediatric acute and
critical care are complex. According to Joel, ‘‘nurse
practitioners and clinical nurse specialists have grown
up in a cross fire of issues. They are seen as either a
frill or a staple of practice’’. [7(p.7)] Addressing
issues facing APNs in pediatric acute and critical
care are essential as the role continues to expand.
These issues include standardizing educational pre-
paration; role definition; reimbursement for services;
recognition of practice; supervision, scheduling, and
staffing; integration of the APNs into the nursing
leadership; and continuing education support
Consistency in educational preparation
As pediatric acute and critical care APN programs
developed in the early 1990s, the traditional models
used in graduate nursing education were reformulated
based on an analysis of clinical practice [16]. Com-
ponents of CNS and NP curricula as well as aspects
of neonatal NP education were blended to construct
programs to meet the needs of patients and families
in a complex healthcare system. Assumptions were
questioned and an emphasis was placed on providing
knowledge and skill that could be used across prac-
tice settings [96].
Although controversial, broadening the scope of
the pediatric acute care programs and converging the
education of the CNS and NP offered more flexibility
for the students, a common knowledge base, cost-
effective education, and a validation of the consistency
in the APN content [1,10,22,97]. Most programs also
believed that a model educating APNs in all the
traditional roles of both the CNS and NP was impor-
tant because of the belief that an understanding of each
component enhances the APNs ability to perform
other roles of ANP. In 1998, five acute care pediatric
master’s programs, six acute care pediatric post-mas-
ter’s programs, and three pediatric critical care mas-
ter’s programs were in existence. Students typically
admitted to these programs are experienced nurses
who are familiar with the acute care environment.
The curricula for the pediatric acute care and
critical care programs at the University of Pennsyl-
vania, School of Nursing (UPSON) include didactic
instruction and clinical experiences in the many APN
roles used in providing healthcare to sick infants and
children. The Essentials of Masters Education for
APN document provides a foundation for the pro-
gram’s development and recommended content
including research; policy; organization and fi-
nancing; ethics; professional role development; the-
oretic foundations of nursing practice; human
diversity and social issues; health promotion and
disease prevention; advanced physical assess; ad-
vanced physiology and pathophysiology; and ad-
 J. Verger et al. / Crit Care Nurs Clin N Am 14 (2002) 315–326
vanced pharmacology [98]. Guidelines have also
been recently published by the National Organization
of Nurse Practitioner Faculties (NONPF) [99]. Along
with required courses in embryology and physiology,
human development, research, and pharmacology, the
UPSON program is constructed to move the student
from the well infant and child to the acutely and
critically ill child. Critical thinking and clinical
decision-making skills with a focus on rationales
supported by science, theory, and research are the
cornerstone of ANP and of the education and training
provided to pediatric acute and critical care APN
students [96,100]. Specialty content is presented and
experiences are offered in a building block fashion.
Concurrent with securing a strong foundation in the
physiologic sciences and theories of psychosocial
development and family systems, students develop
competency in physical assessment, case presenta-
tion, clinical decision-making, interpretation of diag-
nostic tests, advanced therapeutic management,
change theory, research dissemination, and teaching.
The program includes specialized workshops to teach
clinical knowledge and technical skills such as lum-
bar punctures, advanced EKG and radiograph inter-
pretation. Written assignments include exercises in
protocol development and designing job descriptions.
Cultural and ethical considerations are integrated
throughout the curriculum as threads.
Students are required to complete a minimum of
600 clinical hours in environments that care for crit-
ically, acutely, and chronically ill children. In addition,
case based classroom learning is used as a method of
introducing students to common clinical scenarios and
management of emergency situations in conjunction
with hands-on clinical rotations. To provide the oppor-
tunity for comparative analysis of the APN role outside
of the region, some programs offer students the oppor-
tunity to engage in clinical experiences at sites
throughout the United States and Canada.
The limited availability of pediatric acute care
programs adds to the challenge of implementing the
role of the pediatric acute care APN. The hiring of
APNs with varied training and experience presents
challenging issues for planning the initial orientation
as well as implementation of the role. Although there
are currently more acute care trained NPs, job oppor-
tunities continue to outnumber the APNs being edu-
cated in graduate programs in pediatric acute care.
This has resulted in primary care educated NPs being
employed in positions that demand skills the APN
has not yet developed [113]. Prospective employers
may have a limited understanding of APN prepara-
tion and be challenged by the varied familiarity with
acute care practices and technical skills on the part an
319
NP unprepared for the acute care setting. The intro-
duction of other APN roles may further complicate
role expectations.
Role definition
Defining the role of the APN in the current
healthcare environment is a challenge in any setting.
NPs and CNSs come to their positions from a variety
of master’s programs with different philosophies
toward CNS and NP practice. Many of the roles are
new for the institution and new for the APN. Pro-
viders, administrators, patients, and families remain
confused about the role differences of the APN in
acute care pediatrics [101,102]. The APN in speci-
alized practice delivers care within the collaborative
framework. To define the APN only in terms of
particular roles limits the concept of the ANP [18].
The complex needs of hospitalized patients and the
increasing number of patients requiring continuing
special needs demand that APNs work in a team
complete with attending physician services, phar-
macy, social work, respiratory therapists, and others.
Nurse physician collaboration is integral to the effec-
tiveness of this model and uses collaboration to make
a positive impact on patient outcomes [20,103]. In
practice often authority can rest with professional
competence. This same perspective can be used in
considering the responsibilities of an APN hired as a
CNS and NP. Although these roles may have a
different focus, working together to meet the needs
of patients and families is critical [104].
When considering a practice model for APNs, it is
of benefit to think of APNs as a distinct group. Nurses
bring a different and unique combination of skills to
their practice. Although some APNs perform the same
tasks and fill some of the same work functions as
physicians, they are not the same by training or
experience [105]. Using the role of the primary care
NP as a barometer for designing and tracking the
pediatric acute care NP role is also a mistake. Avoiding
these characterizations and clarifying the complemen-
tary nature of the APNs role to other healthcare
providers benefits the entire system. The APNs pre-
vious experiences in pediatric acute care helps shape
their abilities and interest when managing patients and
carrying out other APN functions.
During the past decade, much has been made of the
role overlap between NPs and physicians. Although
some have argued that physicians and NPs have equal
interests in the science and the caring of medicine,
APNs come to the care of acutely ill children from a
different perspective and with a set of skills that
distinguishes them from physicians [106]. Science
320 J. Verger et al. / Crit Care Nurs Clin N Am 14 (2002) 315–326
and caring are not exclusive to either nursing or
medicine and by virtue of the two separate tracks for
education and training, the ‘‘weightedness’’ with
which each profession enacts their role tends to vary.
Daly suggests that we have two options to fit ACNPs
into this strange and dysfunctional system [107]. One
choice is to make efforts to integrate into the strange
system adopting dysfunctional customs. The other
choice is to direct efforts to ensuring that ACNPs
remain a stranger, ‘‘resist attempts to take on the habits
of those around them, and refuse to accept norms that
no longer make any sense.’’ [107 (p. 95)] Daly
suggests that ACNPs continue to use a holistic
approach, typical of nurses; the moral development
that typifies a profession still predominately female
and the perspective of nonscientists. We would argue
that nurses do (in general) have a stronger appreciation
for holism as a foundation for practice. Some physi-
cians have expressed a fear of competition from NPs.
According to Raphaely, APNs are the third challenge
to physicians in critical care medicine as they compete
for payment of services [108]; however, in 1995 it was
reported that there were only 3500 NPs entering the
workforce as compared to 16,000 physicians coming
out of residency programs [109]. In addition, most NPs
do not prefer to practice as independent clinicians.
Instead, most would rather work on teams of profes-
sionals with varied talents and skills [110].
Today the initial worry regarding NPs from other
healthcare providers over turf has been replaced with
a genuine interest in a model of care that includes
APNs. In the current healthcare environment many
physicians view NPs as enhancing the care delivered
to infants and children [111]. Physicians educated
within the past 20 years seem to appreciate findings
that NPs attract more patients to the practice, provide
a different yet positive dimension, and can safely
prescribe commonly used drugs [112]. In pediatric
critical care, physicians identify continuity and con-
sistency in care delivery, enhanced patient care, staff
support and nursing, and resident education as bene-
fits to working with NPs [113]. These same physi-
cians identify challenges working with NPs as
integration of the NP into the traditional care model,
variability of NP preparation and skill level, and
scheduling expectations. Raphaely also comments,
‘‘comprehensive patient care is a formidable
endeavor that should be shared by both physicians
and nurses and advanced practice nurses have found a
role in the critical care team’’ [108 (p.8)].
Institutions may hire NPs with the intent of using
them interchangeably with physicians in training.
NPs, however, have more experience with hands-on
patient care than residents and fellows, possess nurs-
ing knowledge and skills in addition to an under-
standing of patient management, and plan to stay
within the hired setting as a career, rather than as a
stepping stone in their training. Employers will bene-
fit from designing a unique role that integrates the NP
into the preexisting healthcare team in a fashion that
facilitates and includes them in direct patient care
while utilizing their skills as leaders in the realm of
nursing, The experience of working similarly to and
closely with physicians in training, makes NPs well-
prepared to mentor and provide education for training
physicians. In addition, NPs should be considered a
stable and essential part of the faculty and nursing
leadership of a unit.
Recognition of practice
The scope of practice of an APN is defined by
practice acts dictated by state boards of nursing and in
some cases, state boards of medicine, the American
Nurses’ Association (ANA), specialty organizations
such as the American Association of Critical Care
Nurses (AACN), and hospital regulations. The nature
of a NPs role is also dependent on an individual’s
educational background, certifications, and national
cognitive and skills evaluations such as Pediatric
Advanced Life Support (PALS) and is typically
commensurate with years of experience and the
unique characteristic of the practice setting.
In 1994, AACN and the ANA defined the scope
of practice and standards for advanced practice in
acute care [114]. This document was not intended to
specifically represent the practice of pediatric APNs
but serves as a useful guide for supporting the roles of
all NPs working in acute care. In addition, AACN
and the American Nurses Credentialing Center
(ANCC) jointly developed the Adult Acute Care
Nurse Practitioner Certification (ACNP) certification
examination and the Pediatric Critical Care Clinical
Nurse Specialist Certification (CCNS) examination.
In addition to written examination, criteria for ACNP
certification includes completion of a program of
study that includes general APN curriculum with an
additional focus on physiology and that includes
clinical practicum in acute care/critical care settings
At this time, a pediatric acute care NP examina-
tion is under development. Presently, NPs are cer-
tified by graduating from an approved course of
study and via general pediatric examinations spon-
sored by both the ANCC and The National Cer-
tification Board of Pediatric Nurse Practitioners and
Nurses (NCBPNP/N). The ANCC and NCBPNP/N
examinations, however, were designed to assess
knowledge of pediatric primary care. Both ANCC
 J. Verger et al. / Crit Care Nurs Clin N Am 14 (2002) 315–326
and NCBPNP/N currently require a master’s degree
for all nurses sitting for the board examination. In
the case of certification as a neonatal NP by the
National Certification Corporation for the Obstetric-
Gynecologic and Neonatal Nursing Specialties
(NCC), post-master’s practice hours are required
before sitting for the examination.
State boards typically award certification in addi-
tion to licensure as an RN or an additional license as
a generic NP. Some states do grant certification or an
additional license as a provider of specialty services
and acknowledge the APN as a pediatric acute or
critical care NP. Requirements for certification and
licensure vary from state to state but typically include
a master’s degree in nursing from an accredited
school and passing score on a certifying examination.
Some states also require proof of specific educational
experiences, postgraduate practice hours, and addi-
tional pharmacology education before prescriptive
authority is granted. CNSs and primary care pediatric
NPs can complete training requirements necessary
for designation as a pediatric acute or critical care NP
via post-master’s certification as a pediatric acute/
critical care NP offered by schools of nursing hous-
ing such programs.
Often, the state practice act will require both a
collaborative agreement between the NP and a physi-
cian colleague before the NP engages in the role and
a state-regulated list of drugs that NPs can prescribe.
The use of a title and the scope of practice of APNs
must be in compliance with the laws established by
state boards of nursing. The position statements of
professional organizations serve to guide the devel-
opment of state practice acts and generate standards
for education and can be used to support legislation
proposing changes in laws governing ANP [115].
Individual institutions also grant an APN the
authority to function as a NP and to carry out specific
roles and responsibilities within the institution. The
roles and responsibilities defined by an institution
cannot deviate from those outlined in state practice
acts. Hospitals typically grant authorization to prac-
tice via the awarding of credentials or privileges. The
granting of credentials is the process by which the
professional and technical competence of a licensed/
certified provider is recognized by an institution and
includes background checks investigating any actions
affecting licensure/certification, terminations, and
malpractice claims. The granting of privileges is the
process by which the credentialing committee of an
institution (typically a branch of medical staff affairs)
evaluates and recommends that an individual
licensed/certified provider be permitted to provide
specific services within the institution [115]. Hospi-
321
tals often require additional education, passing of
cognitive and skills evaluations (PALS), prior experi-
ence, on the job training and serial assessments of an
NP’s competence for credentialing and privileging
purposes. According to Buppert, the NP must be
prepared to present the following before eligibility
for credentials and privileges are granted [115]:
 Proof of education
 Copy of RN license and state issued document
granting the title as an APN
 Proof of certifications (including life support)
 Drug enforcement agency (DEA) number
 Clinical practice experiences and references
 Continuing education
 Professional activities
State practice acts and individual institutions may
require practice standards and protocols that outline
APN practice. Practice standards and protocols fur-
ther define ANP and should be based on or use
nationally recognized standards of practice and are
directly linked with the job description. It is also
imperative that practice standards and protocols are
evidence based. Recommendations for developing
and using standards and protocols include avoiding
detail that limits practice styles, documentation of any
deviations from the standard or protocol, and frequent
revisions to reflect changes in practice. As documents
are created, language consistent with the state prac-
tice act should be used, nurse-physician collaborative
agreements should be referenced, and the procedural
skills should be specified [114 – 116]
Reimbursement for services
Most APNs in pediatric acute care are reimbursed
for their services through the hospital budget. Salaries
for pediatric acute and critical care APNs are on
average above other APN groups in primary care
practices [Verger J, Marcoux K, Madden M, Bojko
T, Barnsteiner J. Nurse practitioner practice in the
pediatric intensive care unit; under review (p.8)].
The Balanced Budget Act of 1997 with clarifications
from Health Care Financing Administration (HCFA)
gives some structure to direct reimbursement for
APNs [117,118]. These new guidelines addressed a
major impediment to NP practice [119] For the
pediatric acute care APN employed by a hospital
rather than a physician practice plan, direct reimburse-
ment is not allowed [120]. Those APNs receiving a
salary from a hospital based nursing service are
already receiving Medicare Part A funding. NPs,
CNS, and PAs employed by physician practice plans
322 J. Verger et al. / Crit Care Nurs Clin N Am 14 (2002) 315–326
may be reimbursed at a rate of 85% of the prevailing
rate or 80% of the actual charge. Medicaid covers
services of pediatric NPs for infants and children who
qualify on the basis of poverty [115]. The federal
government has given most of the rule making for
Medicaid to the states. The states, however, must
follow HCFA rules and regulations. NPs need to apply
to their state agency administering Medicaid for Med-
icaid provider numbers. Medicaid pays NPs 70% to
100% of the fee-for-service rates for physicians.
Supervision, scheduling, and staffing
CNSs are typically supervised by a nursing
administrator, whereas the NP often reports to a
medical and/or nursing administrator. For NPs in
pediatric acute care, a formalized joint reporting
arrangement to both medical and nursing administra-
tors is recommended. Formal direction and super-
vision from a physician and a nurse benefit the NPs.
In this administrative model the physician supervisor
typically has the lead for clinical practice evaluation
and the nursing supervisor takes the primary role in
evaluating nursing leadership activities. A unit nurse
manager, a nursing director, or an experienced APN
with an appropriate leadership role and title may
provide nursing supervision. The unit medical di-
rector or department chair of the specialty is often
identified as the physician supervisor. Another physi-
cian with sufficient influence in the organization
could also serve as supervisor.
For NPs, a formalized scheduling system that
incorporates both direct patient care time and nursing
leadership/off service time is preferred within the
context of ensuring adequate staffing for patient care.
A schedule that includes consecutive days (or nights)
offers patients an opportunity to be consistently
assigned to one NP. A regular pattern of assigning
patients including giving priority to caring for the
same patients day to day is a critical step that leads to
the successful implementation of the NP program in
acute and critical care. Continuity of care may benefit
patients and families as well as assist the NPs clinical
mastery and confidence in the care they provide. In
acute care an NP team approach to patient care can be
considered. In the long term, offering more consist-
ency with scheduling will benefit the unit or service
by increasing the NP’s job satisfaction, an important
goal given the importance of their commitment to the
unit or service and their expected longevity as staff
members. Protected time for continuing education,
clinical research, and other activities need to be
considered in designing schedules. Unit based NPs
find a monthly or weekly rotation permits them to
meet the leadership components of the APN’s role,
whereas a specialty based NP can often accommodate
a daily change in focus.
Although difficult, hiring NPs with comparable
backgrounds and training will assist in moving any
program forward. The more similar NP experiences
are before they are hired, the easier it is to identify the
group’s learning needs, establish uniform expecta-
tions, and develop educational programs. To develop
a core group of staff, several institutions have estab-
lished their own training programs or sent several
staff members to existing acute and critical care
graduate programs. This is a significant financial
commitment but one that has had long-term benefits
to those institutions by limiting staff turnover and
improving the NP’s ability to function in the unit.
Given the extended learning curve of APNs working
in acute care environments it is not recommended that
APNs be hired without acute care experience in the
specialty if hires are graduates of primary care NP
programs. Benner’s model supports 3 to 5 years as a
bedside pediatric critical care nurse for success in this
role in a pediatric critical care environment [44].
Integrate APNs into the unit leadership
In some circumstances NPs may appear peripheral
to both the nursing and medical leadership group.
This results in disconnectedness between the NP and
the service or unit leadership. Although minor to
some, subtle occurrences such as issues over office
space and minimal involvement in unit leadership
meetings and educational programs may contribute to
a feeling of being undervalued. The NP needs
assigned responsibilities such as mentoring experi-
enced staff, chairing task forces, organizing journal
clubs, and leading quality improvement initiatives.
Meetings should be scheduled to accommodate NP
attendance. Attention needs to be paid to consider-
ations such as office space, business cards, access to
computers, and administrative support.
Support for continuing education
It takes a minimum of 1 to 2 years of experience
before a NP has the necessary knowledge and ability
to function independently. Competencies (once estab-
lished) as well as individualized learning needs
should guide the content for orientation and ongoing
learning needs. Each new employee should be
encouraged to identify their own learning needs and
describe activities to support these learning needs.
This helps with programming for future APNs as well
as helps to direct any continuing education.
 J. Verger et al. / Crit Care Nurs Clin N Am 14 (2002) 315–326
A systematic matching of educational needs with
formalized programming helps to retain current and
future APNs. Joint education with fellows and
residents is encouraged. The knowledge and skill
necessary for APNs to understand the care of sick
infants and children is often similar to the informa-
tion already presented in teaching hospitals to res-
idents and fellows. This does not mean the caliber
of the educational offerings should change but
rather it will enhance the learning for all. Attend-
ance at local and national meetings is also essential
to promote continued education as well as profes-
sional networking.
Summary
The APN role of the future is dependent on our
ability to document through research that NPs, CNSs,
and the consolidated role of the NP/CNS plays a
critical role in the delivery of high quality cost-
effective care. Further information is needed regard-
ing how the APN contributes to and enhances the
care delivered by the healthcare team. Cost effective-
ness and quality outcome studies are needed includ-
ing those that describe morbidity and mortality rates,
patient satisfaction, and cost effectiveness of models
of care that includes APNs [44]. Brooten and Naylor
suggest the inclusion of sensitive nursing outcomes,
including functional status, mental status, stress level,
satisfaction with care, caregiver burden, cost of care
[83]. Defining and clarifying the APN functions and
qualities of scope of practice is imperative. Perhaps
there are populations best served by APNs. Contri-
butions such as continuity, consistency of care, atten-
tion to issues such as immobility, skin integrity, and
health promotion may have a value added effect
[121]. Time motion studies and process logs may
add to the information about APNs in pediatric acute
and critical care.
Professional certification validating competence is
essential for the practice of APNs caring for sick
children and their families. A disparity exists between
the primary care examination now available and the
practice of NPs in pediatric acute and critical care. A
certification examination is needed with content con-
sistent with the practice of pediatric acute care NP.
APNs must possess sufficient knowledge and skill
to meet the needs of patients and families in the
changing healthcare environment. According to
Strodtbeck and colleagues, flexibility, ability to be a
self directed learner, critical thinking, relationship
skills, and leadership skills including interpersonal
insight, interpersonal competence, and ability to
323
stimulate group discussion will serve APNs well as
they move into the century [122]. Transitioning brings
exciting opportunities along with challenges. Using a
blend of abilities, the pediatric acute care APN can
provide optimal care to sick children and families.
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