''Training Up'' Advanced Practice Professionals

Dear Colleague,

Leaders at a community hospital recently asked me whether they could train a nurse practitioner (NP) employed by a group of private practice orthopedists to serve as an RN first assistant to assist with their surgical procedures. She had completed the didactic portion of her RN first assistant training through a formal training program and now needed to complete her clinical hours. Both she and the orthopedists wanted her to complete the clinical hours at their hospital. This process, sometimes referred to as “training up,” is common with advanced practice professionals (APPs) across multiple specialties. APPs will increasingly need to be trained up as the physician shortage worsens over the coming years. For all the right reasons it seemed the hospital should be able to offer this training up experience, but developing an approach to make this happen proved more complex than first appeared.

At the outset, let us be clear on our use of terms. The term APP refers to practitioners who must be granted privileges, such as advanced practice registered nurses and physician assistants.  According to The Joint Commission, these are practitioners who provide a medical level of care. The term allied health practitioners (AHP) is a broader term that includes APPs as well as disciplines for which the Joint Commission does not require holding privileges, such as nutritionists, audiologists, and, yes, RN first assistants.

The decision to grant privileges is the first complex issue to address in this situation. According to The Joint Commission, RN first assistants typically do not require privileges. However, as previously stated, an NP will require privileges to practice, including when he or she serves in the role of first assistant. As with any privileges, these privileges should be granted once the NP has demonstrated the requisite competence. The question is what authorization, if any, is needed that will allow her to undertake clinical training in this hospital prior to achieving the required level of competence.

Some at the hospital raised the concern that the hospital is not accredited as a training program. Is accreditation required to train up APPs? It turns out there is no legal, regulatory, or hospital accrediting standard that maintains this requirement, so this concern can be set aside.

The next concern is what status the NP should have during the training period. Here several options should be considered. The first is to grant her privileges to provide RN first assistant services under direct supervision and a preceptorship.  The delineation of privileges would spell out the nature of the required supervision during the training period. The problem with this approach is that the decision to grant privileges should follow a process of determining competence. Is the NP competent to exercise RN first assistant privileges at the outset of her clinical training period? Not at all. The thought of granting privileges to a practitioner for something she is not competent to do doesn’t sit well with most credentialers, and it shouldn’t. Granting temporary privileges during the training period does nothing to alleviate this problem. Rather medical staffs should determine whether the NP is competent to perform RN first assistant privileges under direct supervision.  If yes, then she could be granted this privilege, and follow the requirements for supervision (a notoriously difficult challenge). If no, then the hospital may decide that training up is not possible (an unfortunate outcome), or it may chose to pursue other approaches.
The next option is to authorize the NP to participate in RN first assistant clinical training under direct supervision as outlined in a hospital policy and procedure. The procedure would spell out the criteria for eligibility for training up activities, what constitutes adequate supervision, how the training experience should be proposed, and who has the authority to authorize the training. This is done every day with medical students and residents, including in community hospitals that do not have formally established residency programs but where trainees get some of their clinical experience. A similar arrangement could be established to authorize the training up of APPs. Concerns may be raised by the supervising physician’s or hospital’s liability carrier which would need to be addressed, but such concerns are unlikely to create an absolute barrier to this approach.

Another option is to consider the analogy of a learner’s permit for new drivers. The state authorizes a student driver, who is clearly not yet competent, to drive under the direct supervision of someone who is competent. Here the subtleties of language may be important. The student is granted a learner’s “permit,” not a “license.” Is a similar distinction possible for our NP? Might she be “permitted” to undergo training without being granted “privileges” to do so?

Having reflected on the request of this hospital, it now appears the question raised does not have a simple answer. An RN who is not an APP could undergo such training with appropriate hospital HR policies and procedures in place. This situation is more complex because the individual wishing to train up is an APP authorized to practice within the hospital only through granted privileges. This person would likely begin training at an even higher level of competence than the RN who is not an APP. Will quality patient care be protected any less during this NP’s training period than for an RN undergoing similar training? Obviously not. There should be an elegant means for authorizing this to occur, especially in the face of the growing physician shortage. The credentialing field has not yet developed such an approach.  It’s time we do.

The Greeley Company offers this analysis of the issues surrounding training up APPs to promote healthy dialogue in the field with the goal of achieving thoughtful consensus on how best to meet this important patient care need. We are interested in hearing from any hospitals that have adopted an APP training up policy. We are seeking benchmarked better practices for this process. If you have implemented an APP training up policy and are interested in receiving feedback on your policy, please send a copy of your policy to my attention at rsheff@greeley.com, and I will be happy to review it and provide feedback.

All the best,

Rick  Sheff, MD
Principal and Chief Medical Officer
The Greeley Company, a division of HCPro, Inc.