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Abstract

Demand for acute care is forecasted to grow in the United States. To meet this demand, nurse practitioners (NPs) are increasingly employed in acute care settings. Yet, there is concern about an adequate supply of acute care NPs given demand. Further, professional nursing organizations recommend aligning an NP's role with their education, certification, licensure, and practice. Given workforce constraints and the policy environment, little is known about how hospitals approach hiring NPs for acute care roles. The purpose of this study was to explore advanced practice provider (APP) directors’ approaches to hiring NPs within the context of alignment and describe factors that influence hiring decisions. We conducted semi-structured interviews with 17 APP directors in hospitals and health systems. Interviews were recorded, transcribed, and coded using an iterative, hybrid inductive and deductive method. Two themes emerged: (1) local factors that inform aligned hiring and (2) adaptive hiring responses to changing environments. Practices around hiring NPs varied across institutions influenced by organization and state policies and regulations, workforce availability, and institutional culture. Most APP directors recognized trends towards hiring aligned NPs for acute care roles. However, they also identified barriers to fully aligning their NP workforce and described adaptive strategies including hiring physician assistants, building relationships with APP schools, and leveraging hospital resources to develop the APP workforce to meet care delivery demands given the current NP workforce supply. Future research is needed to assess widespread practices around acute care NP alignment and the implications of alignment for patient and organizational outcomes.

Keywords

nurse practitioners advanced practice provider acute care hiring regulation

There are nearly 35 million hospitalizations in the United States each year and demand for acute care will likely grow as the population ages and the prevalence of chronic diseases increases (Agency for Healthcare Research and Quality, 2021; Arora & Fried, 2020; VanOosteveen et al., 2015). To meet these demands, health systems are increasingly hiring advanced practice providers (APPs), especially nurse practitioners (NPs). Since 2010, the number of NPs working in hospital settings has more than doubled (Auerbach et al., 2020). Over the next decade, NPs are projected to be the fastest growing provider workforce, underscoring their potential to help meet rising demand for acute care services (Bureau of Labor Statistics, 2022).

The NP role originated in primary care settings before expanding into acute care. Education, policy, and regulations evolved to support these emerging NP roles. NPs receive focused education in specific patient populations guided by the Consensus Model for APRN Regulation, Licensure, Accreditation, Certification, and Education (the Consensus Model) which (1) defined APRN licensure, roles and population foci; (2) standardized education and certification; and (3) outlined a strategy to align education, certification, and licensure with practice roles (APRN Consensus Workgroup & National Council of State Boards of Nursing, 2008). Three of the six population foci align with acute care clinical practice that meets the care delivery needs of patients with changing, acute conditions (1) acute care adult/gerontology, (2) acute care pediatric, and (3) neonatal (National Organization of Nurse Practitioner Faculties, 2013). Aligned NP practice would result in NPs with expertise in these three population foci employed in roles caring for patients with acute and critical health care needs, which is often, but not exclusively, provided in hospital settings. Yet, 88% of the NP workforce have certifications that align with primary care (American Association of Nurse Practitioners, 2022). Therefore, the supply of acute care certified NPs is likely less than demand. In addition, since the introduction of the Consensus Model 15 years ago, few states have fully adopted the model, and hospitals’ implementation of aligned NP practice has been variable (Gigli et al., 2021; Hoyt et al., 2022; Kaplan & Klein, 2020; Martsolf et al., 2020; National Council of State Boards of Nursing, 2023).

This creates a tension for hospitals as they navigate hiring NPs to meet acute care demands when there is an abundance of primary care certified NPs. Professional nursing organizations recommend aligned NP practice, but most states lack regulations requiring it. Without regulatory mandates for aligned hiring, hospitals define their own criteria for hiring NPs (Hoyt et al., 2022; Kaplan & Klein, 2020). Hospital-based APP directors are well positioned to influence these hiring practices. However, little is known about their approach to hiring NPs for hospital roles, including how they view alignment of NPs for hospital roles and how state regulations inform hospital and health system hiring practices. The purpose of this study was to explore APP directors’ approaches to hiring NPs in hospital settings within the context of the Consensus Model and alignment and describe factors that influence their hiring decisions.

Method

Study Design

We performed a descriptive, observational, qualitative study of APP leaders in hospitals and health systems using semi-structured interviews to describe approaches to employing NPs in hospital settings. Data were analyzed using hybrid inductive and deductive coding (Fereday & Muir-Cochrane, 2006). The University of Pittsburgh Human Subjects Protection Office approved this study (STUDY19110294) before participant recruitment started. All participants provided informed consent.

Sample and Recruitment

We used snowball sampling to recruit APP directors who were involved in hospital and health system leadership of APPs. Our participants represented diverse disciplines in APP leadership roles (i.e., NPs and PAs), patient populations (e.g., children's hospitals, lifespan health systems), and geographic and state regulatory (scope-of-practice) environments. We contacted potential respondents via electronic mail and conducted all interviews using a web-based videoconferencing platform (Archibald et al., 2019).

Data Collection

We used a semi-structured interview guide to understand how hospitals and health systems approach hiring, onboarding, and retaining APPs to meet workforce needs. We developed the guide through iterative discussion among the investigators using existing theories of APP practice and regulation that informed our study conceptual framework. The conceptual framework included macro-, meso-, and micro-level factors (e.g., state scope-of-practice, work environment, NP characteristics) that influence APP care delivery and contribute to outcomes (Supplement A). In the context of this study, we sought to understand how factors in each level of the framework influenced APP directors’ approach as they considered the study outcome of interest, NP hiring decision. To refine the interview guide, we conducted two pilot interviews with non-study participants and made revisions for content and clarity based on their feedback. The final interview guide consisted of 15 questions. The full interview guide is available in the Supplemental Materials (Supplement B).

Interviews were conducted between October 2020 and May 2021. We conducted interviews until thematic saturation was reached, which we defined as the identification of no new themes after two consecutive interviews (Hamilton & Finley, 2019). Interviews were recorded and transcribed verbatim, and transcripts were stored in a secure, cloud-based platform (Graneheim & Lundman, 2004). Study team members deidentified transcripts and uploaded them into the NVivo software package (QRS International, Chadstone, VIC, Australia) for analysis.

Data Analysis

We used iterative, hybrid inductive and deductive coding to identify factors that influence practices related to hiring, onboarding, and retention of NPs in hospital roles (Hamilton & Finley, 2019). The codebook included thematic categories and subcategories, each with a unique definition and included code inclusion and exclusion criteria. Three researchers individually coded transcripts; the coders discussed and, through consensus, resolved discrepancies. The results are presented as a series of themes that are based on these codes and, for the purposes of this manuscript, focus on practices related to implementation of the Consensus Model, along with supportive quotes.

Results

Thematic saturation was reached after 17 interviews, with the 16th and 17th interviews adding no additional themes to the codebook. The final sample included 13 NPs and three PAs who served as APP directors within hospitals and health systems and one non-APP recruitment leader. These participants represented five children's hospitals, seven adult hospitals, and five lifespan hospitals and health systems. The hospitals and health systems were in three full, five reduced, and seven restricted state scope-of-practice environments. Two participants worked in health systems with multiple scope-of-practice environments. Interviews averaged 37 min in length.

Themes

Two overarching themes emerged from the interviews: (1) local factors that inform aligned hiring and (2) adaptive hiring responses to changing environments.

Local Factors that Inform Aligned-Hiring Decisions

Many factors influenced APP directors’ decisions regarding the extent to which they required NP alignment including being in a consensus state, local NP supply and substitutes, acute care NP inducements, and local culture.

Hiring in Consensus States

All interviewees reported being familiar with the Consensus Model. If there were clear state policies, those policies informed hiring approaches yet, most participants were from states without regulations on alignment (see Table 1). In Consensus Model states, APP directors simply needed to find acute care NPs without choice. In a state that adopted the Consensus Model, one APP director said,
… early on [we] realized that we, I can’t put a primary care person in the inpatient side … there is no way to be nimble unless everybody's acute care on the hospital side.

Table 1.
Perspectives on Hiring Nurse Practitioners for Aligned Practice in Hospitals and Health Systems.

Theme Quotes

Alignment is a policy recommendation but not required
So, you’re going to have some bigger hospital systems that have a lot of FNPs working for them, and the cost of getting them to acute care certified is so high that their standard for requiring acute care certifications, if it's not mandated by state … partly depends on the organization and their history and how big they are.

We’ve been really flexible because we realized that the candidate pool is very limited. We try our best to accommodate the Consensus Model and get the best fit candidate for the role, and we found that folks that have a little bit broader background … especially that hospital-based nursing experience coming in is helpful because they … can navigate some of those areas.

Current state of alignment
[W]e allow acute care practitioners to work in the ambulatory settings. And there are some primary care practitioners who work in our inpatient setting because the state board of nursing has not yet mandated that [alignment].

Although … the family nurse practitioner training is less suited for acute care roles … the training of the person as a nurse may provide background that's important for the role and therefore, because we’re not yet guided by law in [state], they may be the best fit for a role.

So [state] adopted [the Consensus Model] early, and so we early on realized that we can’t put a primary care person in the inpatient side … there is no way to be nimble unless everybody's acute care on the hospital side.

Informing an institutional framework
An FNP has no business rotating through the PICU. An acute care PNP really does not belong in a primary care clinic.

When we think about the fit, from a board certification standpoint … we really try to illustrate that it's not really the facility, necessarily—that it's an outpatient or it's a hospital—but rather what role are they performing.

APP directors in states that had not fully implemented the Consensus Model demonstrated diverse perspectives on alignment. In many instances, the APP directors described the Consensus Model as ideal but not practical. Each developed, and modified with experience, a framework for how they would align NPs with roles that informed practice in their institution.

Local NP Supply and Substitutes

Participants described an uneven supply of acute care trained APPs across the country (see Table 2). Some interviewees identified a limited availability of acute care NPs. To meet care demands, APP directors in areas with a limited supply of acute care NPs described hiring primary care-trained NPs. Some accepted hospital experience as a registered nurse as an adequate substitute for formal acute care NP education. Further, APP directors discussed substitution of acute care NPs with PAs as a mechanism to diversify the workforce pipeline, increasing the available supply of APPs for hospital-based care roles. Notably, the generalist model of PA education and the ability for an institutions’ physicians to determine the PAs’ scope-of-practice supported hiring PAs. Interviewees also described the perception that, given complex state nursing regulations, PAs are “easier to supervise” than NPs. To mitigate perceived challenges navigating the NP regulatory environment, APP directors increasingly planned to hire PAs. Overall, APP directors reported, with a period of onboarding, perceptions that primary care-trained NPs and PAs provide equivalent care to acute care NPs. One APP director summarized these discussions: “side by side, given the same robust onboarding and orientation, six months later, you probably wouldn’t be able to tell the difference.”

Table 2.
Local Factors That Inform Aligned Hiring of Advanced Practice Providers in Hospitals and Health Systems.

Theme Quotes

Shortage of acute care NPs
… our system has [preferentially hired NPs] across the board. I am trying to diversify the recruitment pipeline by adding PAs to the mix … because the market is so tight, there's just not enough nurse practitioners to go around …

We’ve been really flexible because we realized that the candidate pool is very limited … We try our best to accommodate the LACE and Consensus Model and get the best fit candidate for the role.

The applicant pool is really limited … the FNP programs are really what a large number of people have chosen to go back to …

Comparisons with the PA model of care
The [state] has basically said PAs can practice in any specialty or subspecialty area without additional training above and beyond what [education] they have. But for nurse practitioners, it's a little bit different …

… So the PA and the chair sit down, [go] through a practice agreement to determine what types of services are gonna be provided. Those are not delegated services …

[A] Majority of the providers– the APP providers in [Emergency Departments] are PAs because … they can be generalists and work with the ED physicians.

NP regulations drive shift to PA hiring
In areas where there has been full practice authority, what we have seen … [is] a ramp-up with PA hiring. Because you see that some physicians have been upset by the new legislation. And so I’m not gonna hire more NPs, I’m just gonna hire all these PAs because I can supervise them.

[P]hysicians at other institutions, [are] planning to ramp up more PA hiring because of concerns that these NPs will now be, um, independent. I think a lot of that has to do with the misunderstanding of the legislation … and misunderstanding what full practice authority is meant to do. It is not competition with the physician.

Surplus of acute care NPs
Over the years … we had some challenges early on when there was a dearth of, of acute care PNPs, but more recently, especially with COVID we had lots of candidates, and hiring time is not that difficult in most areas.

We’ve got a good, steady stream of very talented graduates, and … people want to come here [city] and there's still a lot of opportunities, so I get contacted at least once a week from somebody from outside of [state] or someone who just moved here looking for employment.

Local education to change culture
We’ve educated our physicians a lot better so that they’re much more aware of the fact that there are big differences in the way nurse practitioners are educated versus physicians.

There's time where divisions will reach out to me and say, “Well … we have a nurse practitioner who's practiced as a clinical nurse in the CV ICU, as an example, but they just graduated from the family nurse practitioner program last year … we wanna hire them.” I’m like, “Well you can’t because you can’t equate a beside nursing role with a nurse practitioner role.” They’re two different roles.

Acute Care NP Inducements

In other settings, APP directors had an adequate local supply of acute care NPs. Yet, these participants also acknowledged that nationally, there is dynamic and heterogeneous availability of the acute care NP workforce. To summarize the role of acute care NP supply in hiring practice, one APP director said,
So, I think some organizations would be very hard pressed to draw that bright line and require an [acute care] certification [knowing] that they did not have a pipeline, but we’ve got a good … steady stream of, you know, very talented graduates …

Interviewees with adequate acute care NP staff described factors they felt increased the local availability of an acute care workforce. Several APP directors described being a “destination employer” with a combination of location (e.g., coastal, metropolitan area) and practice environment (i.e., formalized onboarding opportunities, full scope-of-practice) that were attractive to potential applicants. Others expressed gratitude to be situated in an area with an abundance of educational programs for acute care NPs and PAs that ensured a consistent pipeline of APP applicants. One APP director described how their institution identified a need for an acute care NP program and subsequently nurtured the development of a program, “… we really wrapped our arms around the acute care [NP] program here, … most of the lectures are given by people from our hospital, and we would also actively recruit from there, and actively provide the traineeships, practicums.”

Local Education to Change Culture

APP directors described their roles changing culture and providing education in their institutions to dispel beliefs that any NP is a qualified NP. One APP director said, “[physicians] are just so used to pulling a nurse off the floor and you train her and she's a nurse practitioner.” To achieve institutional change, APP directors described physicians’ need to understand, and support aligned hiring.

Adaptive Hiring Responses to Changing Environments

Hiring practices are continuously evolving in response to changing practice, educational, financial, and regulatory environments. Given these dynamics, to attain desired APP staffing levels, APP directors adopt strategies to support hiring to meet demand. As a result, APP directors often described approaches that included anticipatory planning and implementation of process changes to positively affect their ability to hire qualified APPs (see Table 3). Many APP directors recognized the limitations of graduate nursing education. One said,
… I think the jobs have changed so much that even with [graduate education] it's just so not adequate to get people ready for where they are. And I do think it's impossible to totally prepare somebody for the diversity of [specialties].

Table 3.
Strategies Adopted by Hospitals and Health Systems’ Advanced Practice Provider Directors to Support Hiring in Response to Educational and Regulatory Environment Changes.

Theme Quotes

Changes to graduate nursing education effect practice readiness
[W]e’re doing students a disservice by growing the number of programs … the new grad quality is going down. And I think it's directly related to this lack of high-quality clinical rotations.

But the other thing that we’re finding is NPs and PAs don’t have a whole lot of experience after their training program by themselves. And so we’re doing more and more—looking at growing our own fellowship programs and things like that—so that they grow in experience under our roof because the clinical training is not adequate for jumping into the role.

[I]t hits their head that, like, “I’ve been going to this online school with no support. And now here I am in this job, and you expect me to be able to perform, and I haven’t had enough feedback or enough experience"… so that is one reason we have a fellowship program at our organization.

Relationships with Stakeholders

APP Schools
[Supporting clinical rotations] makes recruitment easy when we’ve had the opportunity to spend four or six weeks, eight weeks, with a student, and then maybe identify that they are a good match for that team. So it's an easy recruitment mechanism that allows us to have a little more comfort in identifying a candidate because you spend more time with them than a traditional interview.

We try to support their students with preceptor hours and things like that so that we can create a talent pool and a workforce planning initiative in order to seed our talent pool.

So both the PA program and NP program are right here on campus … So really our pipeline is based on the programs that we partner with, both the acute PNP, primary care PNP, and the pediatric PA program.

Board of Nursing (BON)
I had the state board on speed dial … as I was working on this acute care policy and had a lot of conversations about the Consensus Model about, you know, “who's driving the bus” sort of thing. And, essentially, the message from our state board is that our professional organizations define our scope of practice … So, the state board here does not dictate who must have acute care certification.

[The BON] can’t really make law. They would have to propose legislation [to mandate alignment for acute care NPs]. They can make the rules, but … you can’t adopt pieces and parts [of the Consensus Model].

[T]he board of nursing did a really nice job controlling that [alignment] when we had a collaborative agreement. So, if I sent my primary care certification up to the board of nursing for a job in the PICU, they would’ve sent it back very politely and told me to go back to school. But now no one manages that. The board of nursing gives you a license based on your certification. It’ll tell you where to work. So, the hospital med staff and credentials organizations, they need to understand that.

Changing regulatory environment

Process change to be an aligned institution
Oftentimes people will hear, “Oh, go and get your family nurse practitioner because you can do everything.” And, that's not fully correct. We try to get out ahead of that and do a lot of education on the frontend so that nurses that are going back are truly going back to do something that they’ve always wanted to do …

The state board of nursing in [state] has not yet declared that you must have acute care certification to work in an ICU or to work in a hospital-based setting … despite that we have tried to transition to what we see happening in other states … if that mandate [for alignment] comes, it’ll be a grandfathered opportunity and we will have time to send those practitioners back to school.

[W]e gave a deadline, whoever was employed here had to go back and become acute care certified within a year or two from that deadline because we do not hire someone now and let them go to school to be an acute care NP.

Process change to implement full practice authority
I think the requirement for all the collaborative agreements and all of the changes and everything to be on file at the state, it's nothing but administrative barriers. It doesn’t meet any kind of goal of collaborate. We collaborate because it's the right thing to do, not because we have pieces of paper, right.

The regulations in [state] are relatively restrictive and that's really challenging to operationalize in many ways … it's a rather archaic because it no longer really meets the needs of systems which have grown so much. The roles for NPs and the way we work clinically is so different than what it was when those rights were first put into place.

Abbreviations: BON = board of nursing; ICU = intensive care unit; NP = nurse practitioner; PA = physician assistant; PNP = pediatric nurse practitioner.

APP interviewees found the increasing reliance on online, distance education among NP programs particularly concerning. Many viewed a formal onboarding process as an important component of their hiring strategy to facilitate role transition.

Relationships with Stakeholders

APP directors highlighted how relationships with stakeholders informed hiring practices. To ensure an adequate acute care workforce, APP directors emphasized a need for relationships between institutions and schools that educate APPs. APP directors viewed clinical rotations as extended interviews through which they could screen and recruit APPs while in graduate school. Relationships with state boards of nursing were informative for APP directors when developing hiring policies. Yet, boards of nursing took different approaches to providing guidance. APP directors felt some state boards of nursing left interpretation of alignment to institutions while others were “overly prescriptive” and acted “beyond their legislative authority.” As scope-of-practice policies became less restrictive, some APP directors described receiving less guidance from boards of nursing. This was perceived as a challenge, shifting the onus for interpreting and adopting policies related to NP hiring practices solely to the institutions.

Changing Regulatory Environment

As states increasingly mandate alignment in acute care settings, many APP directors acknowledged there will be a future need to move their institution toward alignment. They are preparing for how that transition might impact their hospitals and health systems. For example, some interviewees were working to advise aspiring NPs to match their educational pursuits with their future career goals. Others discussed a practice change to hire only aligned NPs from a certain time onward. Despite the approach used to move towards alignment, they all acknowledged a need for time to adopt policies and grandfather current, misaligned employees.

In addition to mandates for alignment, APP directors anticipated changes to state scope-of-practice regulations and, in some cases, were implementing change in response to the recent passage of full practice authority legislation in their states. Most identified a need for institutional changes related to formal collaboration agreements and paperwork requirements as the primary difference associated with implementing new, less restrictive scope-of-practice regulations. There was a sense that modernization of rules would be beneficial but might not change practice in significant ways because of how hospital NP roles have grown despite “archaic” state regulatory environments.

Discussion

Through the perspective of APP directors, this study explores hospital practices related to hiring NPs for roles in acute care, including barriers and facilitators to hiring aligned NPs consistent with the Consensus Model. Participants identified acute care NP workforce availability, regulatory mandates, and institutional culture as essential elements informing APP hiring decisions. However, ambiguous guidance from boards of nursing and state regulatory changes were barriers to greater alignment of NPs. APP directors reported collaborating with stakeholders and the need for process change to improve aligned hiring.

The findings of this study reveal several insights with implications for NP education, practice, policy, and research. First, local availability of the acute care NP workforce influenced hiring practices around NP alignment. A majority of physicians stay in the geographic location where they complete their training (Boyle, 2021). While it is unclear if NPs have the same pattern, greater availability of local acute care NP education can facilitate hospitals aligned hiring of NPs and is one strategy to ensure future workforce growth. Second, respondents described the effectiveness of mandating an aligned NP workforce. As the nursing community pushes for greater nurse practitioner authority, policymakers considering these policy changes yield significant power regarding concurrent implementation of the Consensus Model. However, APP directors noted that while state mandates for alignment would have desired effects of an aligned workforce it could also have unintended consequences. For example, there were concerns about workforce availability given the relatively small acute care NP workforce compared to primary care NPs (HRSA Dashboard, 2018). As a result, educational capacity and availability of acute care programs would need to be considered if more states mandate alignment (Gigli et al., 2020). Further, policymakers should fund acute care NP programs when mandating alignment to support sustainability and growth of these educational pathways to aligned practice (American Association of Colleges of Nursing, 2023; HRSA, 2021). In addition, if policymakers pass legislation consistent with the Consensus Model, an adequate time frame to complete aligned, population-specific education is necessary to accommodate NPs whose education, certification, and licensure are currently misaligned with their roles, but who wish to continue their current practice. Finally, APP director perspectives diverged on the need for an aligned hospital NP workforce. Notably, many APP directors believed that after a period of onboarding, aligned and misaligned NPs or PAs had similar clinical practice and outcomes. However, to date, no studies examine outcomes associated with aligned or misaligned practice or PA substitution (Hoyt et al., 2022). This gap in empirical knowledge of the role of NP alignment on outcomes often results in APP directors using their gestalt, influenced by institutional culture and historical precedent, when making hiring decisions. Future research is needed to provide evidence of outcomes associated with NP alignment or substitution and should be a priority for funders given the projected workforce growth (Auerbach et al., 2020).

As the NP workforce grows, NPs will play a key and growing role in hospital care delivery (Auerbach et al., 2020). However, challenges in hiring to meet demand may prevent NPs from maximally contributing to hospital care delivery needs. Limiting regulatory barriers can significantly increase the effect of the NP workforce (Frogner et al., 2020). Importantly, hospital and health systems frequently impose additional regulations beyond state scope-of-practice (Bowman et al., 2022; Gigli et al., 2018; Pittman et al., 2020). While policies around alignment may complicate hiring and pose implementation challenges for APP directors, particularly in areas of limited supply, an aligned acute care NP should be better prepared to meet the acute care needs of hospital patients. In turn, aligned NPs would require less regulation of their practice by the hospital (Frogner et al., 2020). Aligned NPs then could be incentivized to seek out employers with less restrictive institutional policies and enjoy increased professional autonomy, drawing NPs to these positions and institutions. These types of positive regulatory changes support hiring needs and help achieve the full potential of the NP workforce.

Limitations

First, this study is qualitative; we describe hiring practices in a limited number of hospital settings. As such, our results may not generalize. However, we sought a diverse sample representing different professional backgrounds, hospital types and practice environments. Second, two members of the study team (KHG, JC) are acute care NPs who practice in hospital settings, and we acknowledge that this may have influenced our interpretation of the data and ensuing recommendations. In response, we sought thick description in data analysis to increase the internal reliability of our findings and collaborated with non-APP researchers (Morse, 2015).

Conclusion

This study examined APP directors’ approaches to hiring NPs. Most APP directors recognized trends towards hiring NPs whose education, certification, licensure, and practice aligned with their role. However, they also identified barriers to full implementation of aligned workforces and described adaptive strategies to meet care delivery demands given the current NP workforce supply. Future research is needed to assess widespread practices around acute care NP alignment and the implications for patient and organizational outcomes.

Supplemental Material

sj-docx-1-ppn-10.1177_15271544231204879 - Supplemental material for The Perspectives of Advanced Practice Provider Directors on Acute Care Nurse Practitioner Alignment and Hiring

Supplemental material, sj-docx-1-ppn-10.1177_15271544231204879 for The Perspectives of Advanced Practice Provider Directors on Acute Care Nurse Practitioner Alignment and Hiring by Kristin Hittle Gigli, Jackie Calhoun, Andrew M. Dierkes and Grant R. Martsolf in Policy, Politics, & Nursing Practice

Theme	Quotes
Alignment is a policy recommendation but not required	So, you’re going to have some bigger hospital systems that have a lot of FNPs working for them, and the cost of getting them to acute care certified is so high that their standard for requiring acute care certifications, if it's not mandated by state … partly depends on the organization and their history and how big they are. We’ve been really flexible because we realized that the candidate pool is very limited. We try our best to accommodate the Consensus Model and get the best fit candidate for the role, and we found that folks that have a little bit broader background … especially that hospital-based nursing experience coming in is helpful because they … can navigate some of those areas.
Current state of alignment	[W]e allow acute care practitioners to work in the ambulatory settings. And there are some primary care practitioners who work in our inpatient setting because the state board of nursing has not yet mandated that [alignment]. Although … the family nurse practitioner training is less suited for acute care roles … the training of the person as a nurse may provide background that's important for the role and therefore, because we’re not yet guided by law in [state], they may be the best fit for a role. So [state] adopted [the Consensus Model] early, and so we early on realized that we can’t put a primary care person in the inpatient side … there is no way to be nimble unless everybody's acute care on the hospital side.
Informing an institutional framework	An FNP has no business rotating through the PICU. An acute care PNP really does not belong in a primary care clinic. When we think about the fit, from a board certification standpoint … we really try to illustrate that it's not really the facility, necessarily—that it's an outpatient or it's a hospital—but rather what role are they performing.

Theme	Quotes
Shortage of acute care NPs	… our system has [preferentially hired NPs] across the board. I am trying to diversify the recruitment pipeline by adding PAs to the mix … because the market is so tight, there's just not enough nurse practitioners to go around … We’ve been really flexible because we realized that the candidate pool is very limited … We try our best to accommodate the LACE and Consensus Model and get the best fit candidate for the role. The applicant pool is really limited … the FNP programs are really what a large number of people have chosen to go back to …
Comparisons with the PA model of care	The [state] has basically said PAs can practice in any specialty or subspecialty area without additional training above and beyond what [education] they have. But for nurse practitioners, it's a little bit different … … So the PA and the chair sit down, [go] through a practice agreement to determine what types of services are gonna be provided. Those are not delegated services … [A] Majority of the providers– the APP providers in [Emergency Departments] are PAs because … they can be generalists and work with the ED physicians.
NP regulations drive shift to PA hiring	In areas where there has been full practice authority, what we have seen … [is] a ramp-up with PA hiring. Because you see that some physicians have been upset by the new legislation. And so I’m not gonna hire more NPs, I’m just gonna hire all these PAs because I can supervise them. [P]hysicians at other institutions, [are] planning to ramp up more PA hiring because of concerns that these NPs will now be, um, independent. I think a lot of that has to do with the misunderstanding of the legislation … and misunderstanding what full practice authority is meant to do. It is not competition with the physician.
Surplus of acute care NPs	Over the years … we had some challenges early on when there was a dearth of, of acute care PNPs, but more recently, especially with COVID we had lots of candidates, and hiring time is not that difficult in most areas. We’ve got a good, steady stream of very talented graduates, and … people want to come here [city] and there's still a lot of opportunities, so I get contacted at least once a week from somebody from outside of [state] or someone who just moved here looking for employment.
Local education to change culture	We’ve educated our physicians a lot better so that they’re much more aware of the fact that there are big differences in the way nurse practitioners are educated versus physicians. There's time where divisions will reach out to me and say, “Well … we have a nurse practitioner who's practiced as a clinical nurse in the CV ICU, as an example, but they just graduated from the family nurse practitioner program last year … we wanna hire them.” I’m like, “Well you can’t because you can’t equate a beside nursing role with a nurse practitioner role.” They’re two different roles.

Theme	Quotes
Changes to graduate nursing education effect practice readiness	[W]e’re doing students a disservice by growing the number of programs … the new grad quality is going down. And I think it's directly related to this lack of high-quality clinical rotations. But the other thing that we’re finding is NPs and PAs don’t have a whole lot of experience after their training program by themselves. And so we’re doing more and more—looking at growing our own fellowship programs and things like that—so that they grow in experience under our roof because the clinical training is not adequate for jumping into the role. [I]t hits their head that, like, “I’ve been going to this online school with no support. And now here I am in this job, and you expect me to be able to perform, and I haven’t had enough feedback or enough experience"… so that is one reason we have a fellowship program at our organization.
Relationships with Stakeholders
APP Schools	[Supporting clinical rotations] makes recruitment easy when we’ve had the opportunity to spend four or six weeks, eight weeks, with a student, and then maybe identify that they are a good match for that team. So it's an easy recruitment mechanism that allows us to have a little more comfort in identifying a candidate because you spend more time with them than a traditional interview. We try to support their students with preceptor hours and things like that so that we can create a talent pool and a workforce planning initiative in order to seed our talent pool. So both the PA program and NP program are right here on campus … So really our pipeline is based on the programs that we partner with, both the acute PNP, primary care PNP, and the pediatric PA program.
Board of Nursing (BON)	I had the state board on speed dial … as I was working on this acute care policy and had a lot of conversations about the Consensus Model about, you know, “who's driving the bus” sort of thing. And, essentially, the message from our state board is that our professional organizations define our scope of practice … So, the state board here does not dictate who must have acute care certification. [The BON] can’t really make law. They would have to propose legislation [to mandate alignment for acute care NPs]. They can make the rules, but … you can’t adopt pieces and parts [of the Consensus Model]. [T]he board of nursing did a really nice job controlling that [alignment] when we had a collaborative agreement. So, if I sent my primary care certification up to the board of nursing for a job in the PICU, they would’ve sent it back very politely and told me to go back to school. But now no one manages that. The board of nursing gives you a license based on your certification. It’ll tell you where to work. So, the hospital med staff and credentials organizations, they need to understand that.
Changing regulatory environment
Process change to be an aligned institution	Oftentimes people will hear, “Oh, go and get your family nurse practitioner because you can do everything.” And, that's not fully correct. We try to get out ahead of that and do a lot of education on the frontend so that nurses that are going back are truly going back to do something that they’ve always wanted to do … The state board of nursing in [state] has not yet declared that you must have acute care certification to work in an ICU or to work in a hospital-based setting … despite that we have tried to transition to what we see happening in other states … if that mandate [for alignment] comes, it’ll be a grandfathered opportunity and we will have time to send those practitioners back to school. [W]e gave a deadline, whoever was employed here had to go back and become acute care certified within a year or two from that deadline because we do not hire someone now and let them go to school to be an acute care NP.
Process change to implement full practice authority	I think the requirement for all the collaborative agreements and all of the changes and everything to be on file at the state, it's nothing but administrative barriers. It doesn’t meet any kind of goal of collaborate. We collaborate because it's the right thing to do, not because we have pieces of paper, right. The regulations in [state] are relatively restrictive and that's really challenging to operationalize in many ways … it's a rather archaic because it no longer really meets the needs of systems which have grown so much. The roles for NPs and the way we work clinically is so different than what it was when those rights were first put into place.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Kristin Hittle Gigli

Andrew M. Dierkes

Grant R. Martsolf

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Kristin Hittle Gigli is an acute care pediatric nurse practitioner and health services researcher. She is an assistant professor at the University of Texas at Arlington College of Nursing and Health Innovation and pediatric intensive care unit nurse practitioner at UT Southwestern, Children's Health. Her research examines nurse practitioner workforce and policies influencing their practice in pediatrics and hospital-based settings.

Jackie Calhoun is an assistant professor and coordinator of Acute Care Pediatric Nurse Practitioner and Neonatal Nurse Practitioner programs at the University of Pittsburgh. She practices as a Pediatric Critical Care Nurse Practitioner in the pediatric intensive care unit at the UPMC Children's Hospital of Pittsburgh.

Andrew M. Dierkes is a registered nurse and a health services and policy researcher studying the nursing workforce at the intersection of cost, quality, and outcomes. He is an assistant professor at the University of Pittsburgh School of Nursing, Department of Acute and Tertiary Care.

Grant R. Martsolf is a professor at the University of Pittsburgh School of Nursing and a policy researcher at the RAND Corporation. He is a nursing health services researcher and public policy expert. His research interests include primary care payment and innovation as well as educational, organization, and regulatory issues related to nurse practitioner practice.

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